Early Childhood Bereavement ELLIOT M. KRANZLER, M.D., DAVID SHAFFER, M.D., GAIL WASSERMAN, PH.D., AND MARK DAVIES, M.A.
Abstract. Acute bereavement responses in preschool children were prospectively assessed. Parentally bereaved subjects (26, 3- to 6-year-olds) were compared with matched, nonbereaved controls (N = 40). Bereaved subjects, particularly boys, were significantly more symptomatic (Child Behavior Checklist - Parent). On a newly standardized affect interview for preschoolers , bereaved children reported feeling more scared and less happy than controls. Bereaved children , especially girls , reported significantly more sadness when thinking about their parents . The ability to report these grieving emotions correlated significantly with improved functioning . Children from families experiencing a drop in income after the death were more symptomatic . Disturbance among subject parents and children was highly correlated . Issues of developmental capacity to grieve and the impact of environmental mediators are discussed. J. Am . Acad. Child Adolesc. Psychiatry, 1990, 29, 4:513-520. Key Words: parental bereavement , preschoolers, acute, grief. Interest in the developmental and clinical effects of early loss of a parent is reflected in both the psychoanalytic and epidemiological literature . Evidence for an association between childhood parental bereavement and later psychopathology has been contradictory . Most studies have been retrospective. Childhood parental loss has been associated with later depression (e.g., Beck et al., 1963; Dennehy, 1966; Birtchnell, 1972; Brown et al., 1977) personality disorder (Barry and Lindemann, 1960; Felner et al., 1975; Birtchnell, 1978; Dietrich, 1979) and with cognitive and functional impairment (Markusen and Fulton, 1971; Lifshitz, 1976). An almost equal number of studies have failed to find increased risk (e.g., Granville-Grossman, 1966; Gregory, 1966; Hopkinson and Reed, 1966; Roy, 1979). Methodological disparities, including sample and control differences , the lack of consistent consideration of potentially important mediators such as sex of child and parent, age at time of loss , circumstances of death, preexisting relationships, and available supports, probably account for the inconsistent findings (Tenant et al., 1980; Krupnick, 1984). Two recent, retrospective studies present evidence for the importance of the environmental consequences of a parent's death. Harris et al. (1986) found that the quality of postloss childcare determined risk for depression in adulthood. Adults with a history of insufficient care following their bereavement were at risk, whereas those left in a stable, adequate parenting environment were at no greater risk than controls . Breier et al. (1988) concluded similarly that the quality of the home life after early parental loss was critical to the development of adult psychopathology. There have been surprisingly few acute or prospective
studies of bereaved children (Bendikson and Fulton , 1975; Shepard and Barraclough, 1976). Thus, it is not known whether bereaved children who show depressive or other psychiatric disorders as adults develop them after an interval of normality (' 'sleeper effect' ') or whether their disturbance is a continuous one . This question would be best addressed prospectively. Studies of acutely bereaved children have either used small samples or did not include interviews and observations of the children, relying instead on parent and caretaker reports (Kaffman and Elizur, 1979, 1983; Van Eerdewegh et al., 1982; Raphael , 1983). Conclusions drawn from case reports of children in treatment are not representative (Wolfenstein , 1969; Furman , 1974). A number of retrospecti ve studies that have examined age at loss concluded that bereavement before age 8 increases risk for later psychopathology (Barry and Lindemann, 1960; Greer, 1964; Haworth, 1964; Jacobson and Ryder, 1969; Lifshitz, 1976). Explanations for the particular vulnerability of the young child include cognitive and affective developmentallimitations and their effects on the child's capacity to grieve, increased susceptibility to disruption in the family environment, and greater need for emotional and practical sustenance (Krupnick , 1984). Despite the interest in younger children, in the few studies of acute bereavement, this age group has not been studied . Perhaps this is due to the lack of developmentally appropriate rating instruments and interviews . This study reports on the acute bereavement reactions of a cohort of preschool-aged children who experienced the death of either their mother or father ; The aims of the study were to describe the children's acute state, to examine developmental influences that might impact on their vulnerability, and to identify important outcome mediators. Bereaved children were compared with a nonbereaved, matched, control group. Criteria of major depressive disorder such as mood, concentration, and self-esteem were assessed in an age appropriate way . A direct interview with the children, designed for this study, obtained their affective self-reports. Other measures assessed children's behavioral disturbance and the impact of potential mediators on bereavement reactions.
Accepted October 3, 1989. From the Department of Psychiatry, Columbia University, College of Physicians and Surgeons , New York State Psychiatric Institute. Reprint requests to Dr. Kranzler, Division of Child Psychiatry , Columbia University, New York State Psychiatric Institute, 722 W. 168 si.. N .Y., N.Y. /0032 . 0890-8567/90/2904-0513$02 .00/0© 1990by the American Academy of Child and Adolescent Psychiatry.
513
KRANZLER ET AL.
Method
Subjects: Twenty-six 3- to 6 year-olds, whose mother or father had died within the previous 6 months were studied. Families were either self-referred, in response to media descriptions of the study (N = 15), or were referred by schools (N = 5) , health practitioners (N = 4), or police and fire departments (N = 2). In order to be included in the study, both the decedant and surviving parent had to have lived at home or to have had daily contact with the child before the death or before the precipitating illness. The 26 subjects (11 boys and 15 girls; 12 3- to 4-yearolds and 145- to 6-year-olds ; mean age 4.9 years old) came from 23 families. Sixty-six percent of bereaved families were Caucasian, 19% were black and 15% were Hispanic . The families were from predominantly professional and business social strata (Hollingshead socioeconomic status (SES) classification: 41% category V, 49% IV, 10% II or I). Seventeen children had experienced paternal deaths and nine had experienced maternal deaths. An equal proportion of children had lost an opposite (N = 14) and a same-sex parent (N = 12). Children and their surviving parent were seen for three to five assessment sessions within a 1 month period at the New York State Psychiatric Institute . All families who contacted the project, met study criteria, and agreed to come in, completed the assessment. Families were offered therapeutic intervention at the conclusion of the assessment. Controls , who were drawn from three preschool programs, were children from nonbereaved, intact families . Program administrators identified 3- to 6-year-old children from intact families and all were contacted by letter. Parents of 62% of eligible controls consented to participate. Thirtyseven control children were assessed (18 boys and 19 girls; 25 3- to 4-year-olds and 125- to 6-year-olds; mean age 4.2 years; 64% were Caucasian, 19% black, 16% Hispanic; SES categories-49% V, 44% IV, 7% II or I) . They were interviewed at their program sites, on two or three occasions, within a 2-week period. Measures . The psychiatric status of the child was measured with the parent completed Child Behavior Checklist (CBCL-P) (Achenbach and Edelbrock, 1983) and the revised Children's Manifest Anxiety Scale (CMAS) (Reynolds and Richmond, 1978). Teachers and childcare workers completed CBCL teacher form (CBCL-T) (Edelbrock and Achenbach , 1984). CBCL-P norms for 4-year-olds were used for 3-year-olds . On the CBCL-T, only total symptom scores for bereaved versus controls were compared. Surviving parents' mental status was assessed on the Beck Depression Inventory (BDI) (Beck et aI., 1961) and the Symptom Checklist-90 (SCL-90) (Derogatis et aI., 1974). A semistructured interview was designed to obtain information from the surviving parent about demographics , prior psychiatric history, events leading up to the death, and changes in financial and childcare arrangements after the death. Bereaved parents' current levels of emotional , childcare, and financial supports, as well as prior and current childcare involvement were assessed using questionnaires adapted from Hetherington et al. ' s (1985, personal communication) study of children of divorce. Scales included measures of how 514
frequently each caregiver does basic childcare tasks (e.g ., giving the child meals, measured in counts of childcare activities) and of emotional involvement (e.g., giving and receiving hugs). A direct evaluation schedule was devised for the children to assess analogs of important clinical features of depression, i.e. , mood , self-esteem, and concentration. Because of the age of this sample and the significant developmental advances made between 3 and 6 years, the children's cognitive and affective development are factors that might have been expected to influence outcome. A concept of death interview was therefore administered. Results from this interview will be described in a separate report . Self-esteem was assessed on the Pictorial Scale of Perceived Competence and Acceptance for Young Children (Harter and Pike, 1980). Using an age appropriate picture format , this measures four domains of self-esteem: physical and cognitive competence and maternal and peer acceptance. Concentration was assessed on the Preschool Embedded Figures Test (Coates, 1972). It is a timed, repetitive operation which, although influenced by visual-spatial capacity, is attention-demanding and measures persistence, impulsivity, and response accuracy . The Preschool Affect Interview (Kranzler et aI., 1987), a self-report measure developed for this study, assesses the child's present mood state as well as his emotions while thinking about the deceased parent. Psychometric data regarding this instrument will be presented in a separate report. Initially , affect recognition and labelling were tested , using sex and black/white matched facial drawings of a happy, sad, angry, scared, and neutral child. If the subject gave any incorrect labelling responses , he was trained and retested until all responses were correct. Next, children were asked to describe situations in which they felt each of these emotions, in order to confirm their understanding of emotion labelling and of the task. In the ensuing interview, children looked at the pictures while they were asked to describe their affective response to various situations. They chose the affect that best described their feelings. Items on the interview (Appendix) are divided into two scales: Scale 1: Everyday Affect Range (EAR)-how the child feels in 10 common, daily situations, subdivided into groups of positive or neutral situations (e.g . , while playing with best friend), and stressful or separation situations (e.g ., going to bed at night); and Scale 2: Thoughts about Parents (TAP)-four thoughts or memories about the deceased parent, or about the sex-matched parent in controls were elicited. The child was asked to identify his feeling while thinking about these experiences. Means for frequency of affects chosen on each of these scales are reported. Data Analysis. To identify differences between bereaved and control children , univariate analyses for differences (using z-tests or chi-square tests where appropriate) were applied (Snedecor and Cochran, 1967). Two-way analyses of variance (ANOVA) (age or sex by group) were conducted on factors that exhibited a significant univariate effect with age or sex to eliminate possible confounding by these two demographic variables. For the CBCL and affect interview, three-way (age x sex X group) analyses of variance were l .Am.Acad. Child Adolesc.Psychiatry, 29 :4, July 1990
EARLY CHILDHOOD BEREAVEMENT TABLE
1. Behavior Disturbance in Bereaved versus Control Children Boys
Totals
Girls
Bereaved X ± SD
Controls X ± SD
Bereaved X ± SD
A. CBCL total scores 1. CBCL-P (parents) 2. CBCL-T (teachers )
45.0 ± 22.2 38.8 ± 31.7
20.8 ± 12.6*** 9.0 ± 9.9**
26.5 ± 13.4 16.3 ± 18.3
B. CBCL-P factors 1. Internalizing 2. Externaliz ing
17.0 ± 8.5 21.6 ± 10.1
7.7 ± 9.7 ±
5 .6** 7.9**
15.3 ± 7.1 ±
7.9 5.2
9.3 ± 8.0 ±
7.1* 4.6
C. DSM III symptom clusters 1. Disruptive behavior 2. Depression 3. Anxiety
14.1 ± 10.3 ± 12.1 ±
7. 1 ± 3.4 ± 5 .0 ±
5.1 ** 2.8*** 3.7***
6.9 ± 6.5 ± 9.1 ±
5 .0 3.6 4 .6
6.3 ± 4. 3 ± 4.6 ±
3.2 2.9* 3.4 **
* P :
Abstract. Acute bereavement responses in preschool children were prospectively assessed. Parentally bereaved subjects (26, 3- to 6-year-olds) were compared with matched, nonbereaved controls (N = 40). Bereaved subjects, particularly boys, were significantly more symptomatic (Child Behavior Checklist - Parent). On a newly standardized affect interview for preschoolers , bereaved children reported feeling more scared and less happy than controls. Bereaved children , especially girls , reported significantly more sadness when thinking about their parents . The ability to report these grieving emotions correlated significantly with improved functioning . Children from families experiencing a drop in income after the death were more symptomatic . Disturbance among subject parents and children was highly correlated . Issues of developmental capacity to grieve and the impact of environmental mediators are discussed. J. Am . Acad. Child Adolesc. Psychiatry, 1990, 29, 4:513-520. Key Words: parental bereavement , preschoolers, acute, grief. Interest in the developmental and clinical effects of early loss of a parent is reflected in both the psychoanalytic and epidemiological literature . Evidence for an association between childhood parental bereavement and later psychopathology has been contradictory . Most studies have been retrospective. Childhood parental loss has been associated with later depression (e.g., Beck et al., 1963; Dennehy, 1966; Birtchnell, 1972; Brown et al., 1977) personality disorder (Barry and Lindemann, 1960; Felner et al., 1975; Birtchnell, 1978; Dietrich, 1979) and with cognitive and functional impairment (Markusen and Fulton, 1971; Lifshitz, 1976). An almost equal number of studies have failed to find increased risk (e.g., Granville-Grossman, 1966; Gregory, 1966; Hopkinson and Reed, 1966; Roy, 1979). Methodological disparities, including sample and control differences , the lack of consistent consideration of potentially important mediators such as sex of child and parent, age at time of loss , circumstances of death, preexisting relationships, and available supports, probably account for the inconsistent findings (Tenant et al., 1980; Krupnick, 1984). Two recent, retrospective studies present evidence for the importance of the environmental consequences of a parent's death. Harris et al. (1986) found that the quality of postloss childcare determined risk for depression in adulthood. Adults with a history of insufficient care following their bereavement were at risk, whereas those left in a stable, adequate parenting environment were at no greater risk than controls . Breier et al. (1988) concluded similarly that the quality of the home life after early parental loss was critical to the development of adult psychopathology. There have been surprisingly few acute or prospective
studies of bereaved children (Bendikson and Fulton , 1975; Shepard and Barraclough, 1976). Thus, it is not known whether bereaved children who show depressive or other psychiatric disorders as adults develop them after an interval of normality (' 'sleeper effect' ') or whether their disturbance is a continuous one . This question would be best addressed prospectively. Studies of acutely bereaved children have either used small samples or did not include interviews and observations of the children, relying instead on parent and caretaker reports (Kaffman and Elizur, 1979, 1983; Van Eerdewegh et al., 1982; Raphael , 1983). Conclusions drawn from case reports of children in treatment are not representative (Wolfenstein , 1969; Furman , 1974). A number of retrospecti ve studies that have examined age at loss concluded that bereavement before age 8 increases risk for later psychopathology (Barry and Lindemann, 1960; Greer, 1964; Haworth, 1964; Jacobson and Ryder, 1969; Lifshitz, 1976). Explanations for the particular vulnerability of the young child include cognitive and affective developmentallimitations and their effects on the child's capacity to grieve, increased susceptibility to disruption in the family environment, and greater need for emotional and practical sustenance (Krupnick , 1984). Despite the interest in younger children, in the few studies of acute bereavement, this age group has not been studied . Perhaps this is due to the lack of developmentally appropriate rating instruments and interviews . This study reports on the acute bereavement reactions of a cohort of preschool-aged children who experienced the death of either their mother or father ; The aims of the study were to describe the children's acute state, to examine developmental influences that might impact on their vulnerability, and to identify important outcome mediators. Bereaved children were compared with a nonbereaved, matched, control group. Criteria of major depressive disorder such as mood, concentration, and self-esteem were assessed in an age appropriate way . A direct interview with the children, designed for this study, obtained their affective self-reports. Other measures assessed children's behavioral disturbance and the impact of potential mediators on bereavement reactions.
Accepted October 3, 1989. From the Department of Psychiatry, Columbia University, College of Physicians and Surgeons , New York State Psychiatric Institute. Reprint requests to Dr. Kranzler, Division of Child Psychiatry , Columbia University, New York State Psychiatric Institute, 722 W. 168 si.. N .Y., N.Y. /0032 . 0890-8567/90/2904-0513$02 .00/0© 1990by the American Academy of Child and Adolescent Psychiatry.
513
KRANZLER ET AL.
Method
Subjects: Twenty-six 3- to 6 year-olds, whose mother or father had died within the previous 6 months were studied. Families were either self-referred, in response to media descriptions of the study (N = 15), or were referred by schools (N = 5) , health practitioners (N = 4), or police and fire departments (N = 2). In order to be included in the study, both the decedant and surviving parent had to have lived at home or to have had daily contact with the child before the death or before the precipitating illness. The 26 subjects (11 boys and 15 girls; 12 3- to 4-yearolds and 145- to 6-year-olds ; mean age 4.9 years old) came from 23 families. Sixty-six percent of bereaved families were Caucasian, 19% were black and 15% were Hispanic . The families were from predominantly professional and business social strata (Hollingshead socioeconomic status (SES) classification: 41% category V, 49% IV, 10% II or I). Seventeen children had experienced paternal deaths and nine had experienced maternal deaths. An equal proportion of children had lost an opposite (N = 14) and a same-sex parent (N = 12). Children and their surviving parent were seen for three to five assessment sessions within a 1 month period at the New York State Psychiatric Institute . All families who contacted the project, met study criteria, and agreed to come in, completed the assessment. Families were offered therapeutic intervention at the conclusion of the assessment. Controls , who were drawn from three preschool programs, were children from nonbereaved, intact families . Program administrators identified 3- to 6-year-old children from intact families and all were contacted by letter. Parents of 62% of eligible controls consented to participate. Thirtyseven control children were assessed (18 boys and 19 girls; 25 3- to 4-year-olds and 125- to 6-year-olds; mean age 4.2 years; 64% were Caucasian, 19% black, 16% Hispanic; SES categories-49% V, 44% IV, 7% II or I) . They were interviewed at their program sites, on two or three occasions, within a 2-week period. Measures . The psychiatric status of the child was measured with the parent completed Child Behavior Checklist (CBCL-P) (Achenbach and Edelbrock, 1983) and the revised Children's Manifest Anxiety Scale (CMAS) (Reynolds and Richmond, 1978). Teachers and childcare workers completed CBCL teacher form (CBCL-T) (Edelbrock and Achenbach , 1984). CBCL-P norms for 4-year-olds were used for 3-year-olds . On the CBCL-T, only total symptom scores for bereaved versus controls were compared. Surviving parents' mental status was assessed on the Beck Depression Inventory (BDI) (Beck et aI., 1961) and the Symptom Checklist-90 (SCL-90) (Derogatis et aI., 1974). A semistructured interview was designed to obtain information from the surviving parent about demographics , prior psychiatric history, events leading up to the death, and changes in financial and childcare arrangements after the death. Bereaved parents' current levels of emotional , childcare, and financial supports, as well as prior and current childcare involvement were assessed using questionnaires adapted from Hetherington et al. ' s (1985, personal communication) study of children of divorce. Scales included measures of how 514
frequently each caregiver does basic childcare tasks (e.g ., giving the child meals, measured in counts of childcare activities) and of emotional involvement (e.g., giving and receiving hugs). A direct evaluation schedule was devised for the children to assess analogs of important clinical features of depression, i.e. , mood , self-esteem, and concentration. Because of the age of this sample and the significant developmental advances made between 3 and 6 years, the children's cognitive and affective development are factors that might have been expected to influence outcome. A concept of death interview was therefore administered. Results from this interview will be described in a separate report . Self-esteem was assessed on the Pictorial Scale of Perceived Competence and Acceptance for Young Children (Harter and Pike, 1980). Using an age appropriate picture format , this measures four domains of self-esteem: physical and cognitive competence and maternal and peer acceptance. Concentration was assessed on the Preschool Embedded Figures Test (Coates, 1972). It is a timed, repetitive operation which, although influenced by visual-spatial capacity, is attention-demanding and measures persistence, impulsivity, and response accuracy . The Preschool Affect Interview (Kranzler et aI., 1987), a self-report measure developed for this study, assesses the child's present mood state as well as his emotions while thinking about the deceased parent. Psychometric data regarding this instrument will be presented in a separate report. Initially , affect recognition and labelling were tested , using sex and black/white matched facial drawings of a happy, sad, angry, scared, and neutral child. If the subject gave any incorrect labelling responses , he was trained and retested until all responses were correct. Next, children were asked to describe situations in which they felt each of these emotions, in order to confirm their understanding of emotion labelling and of the task. In the ensuing interview, children looked at the pictures while they were asked to describe their affective response to various situations. They chose the affect that best described their feelings. Items on the interview (Appendix) are divided into two scales: Scale 1: Everyday Affect Range (EAR)-how the child feels in 10 common, daily situations, subdivided into groups of positive or neutral situations (e.g . , while playing with best friend), and stressful or separation situations (e.g ., going to bed at night); and Scale 2: Thoughts about Parents (TAP)-four thoughts or memories about the deceased parent, or about the sex-matched parent in controls were elicited. The child was asked to identify his feeling while thinking about these experiences. Means for frequency of affects chosen on each of these scales are reported. Data Analysis. To identify differences between bereaved and control children , univariate analyses for differences (using z-tests or chi-square tests where appropriate) were applied (Snedecor and Cochran, 1967). Two-way analyses of variance (ANOVA) (age or sex by group) were conducted on factors that exhibited a significant univariate effect with age or sex to eliminate possible confounding by these two demographic variables. For the CBCL and affect interview, three-way (age x sex X group) analyses of variance were l .Am.Acad. Child Adolesc.Psychiatry, 29 :4, July 1990
EARLY CHILDHOOD BEREAVEMENT TABLE
1. Behavior Disturbance in Bereaved versus Control Children Boys
Totals
Girls
Bereaved X ± SD
Controls X ± SD
Bereaved X ± SD
A. CBCL total scores 1. CBCL-P (parents) 2. CBCL-T (teachers )
45.0 ± 22.2 38.8 ± 31.7
20.8 ± 12.6*** 9.0 ± 9.9**
26.5 ± 13.4 16.3 ± 18.3
B. CBCL-P factors 1. Internalizing 2. Externaliz ing
17.0 ± 8.5 21.6 ± 10.1
7.7 ± 9.7 ±
5 .6** 7.9**
15.3 ± 7.1 ±
7.9 5.2
9.3 ± 8.0 ±
7.1* 4.6
C. DSM III symptom clusters 1. Disruptive behavior 2. Depression 3. Anxiety
14.1 ± 10.3 ± 12.1 ±
7. 1 ± 3.4 ± 5 .0 ±
5.1 ** 2.8*** 3.7***
6.9 ± 6.5 ± 9.1 ±
5 .0 3.6 4 .6
6.3 ± 4. 3 ± 4.6 ±
3.2 2.9* 3.4 **
* P :
