Introduction
The death of a parent or sibling during adolescence is a tragic, irreversible loss, which leads to elevated levels of psychological distress [
1‐
6]. The prevalence of the loss of a parent or sibling varies between 1 and 5 % in previous studies [
3,
7]. The majority of bereaved adolescents exhibit acute grief reactions, sleep problems, anger, irritability, and behavioural problems [
6] and lower self-esteem [
8]. These grief reactions can give rise to serious concerns in parent(s) and teachers about the psychological adjustment of the adolescents, although the reactions can still be normal since 75–80 % of the children do not develop mental health problems after the death of a parent [
1,
9‐
12] or sibling [
1,
12]. Psychological adjustment after parental bereavement is most commonly characterized by depressive symptoms [
10]. Parentally bereaved adolescents are at risk for developing internalizing disorders [
8], including major depressive episodes [
14]. Furthermore, children who lose a parent or a sibling are at risk for the same mental health problems [
3,
12].
Adolescents who overcome bereavement without developing serious mental health problems may have certain protective factors in common [
13]. However, there is a lack of systematic attention to protective and risk factors and moderation of psychological adjustment after family bereavement [
10]. For professionals working within schools, hospitals and mental health care institutions, knowledge about protective and risk factors present before family bereavement may contribute to identifying children who are at risk for developing (more) mental health problems after bereavement. Early detection may prevent further aggravation of mental health problems or prevent unnecessary psychological treatment and psychiatric stigmatization.
Luecken [
11] proposed a comprehensive model of pathways linking early parental death to mental and physical health problems including risk factors. Risk factors for developing mental health problems can be divided in risk factors pre- and post-bereavement. Post-bereavement risk factors have already been identified, namely poorer quality of parenting, worse quality of the parent–child relationship, caregiver mental health problems, subsequent negative life events, low social economic status (SES) and low self-system beliefs, including self-esteem, self-efficacy and social relatedness [
10,
11]. However, risk factors may already be present before the loss occurs and may influence psychological adjustment after the loss. According to Dowdney [
10] mental health problems of the adolescent before bereavement may constitute an important risk factor because stress caused by the loss can aggravate pre-existing mental health problems. For instance, a depressive disorder is associated with a higher vulnerability to stress [
15]. Retrospective studies found that a history of depression [
14,
16], sexual abuse [
16] and any psychiatric disorder [
17] were correlated with depression after parental loss. Furthermore, the presence of mental health problems before bereavement can be associated with the death of a family member. An extensive review of parental cancer showed that a significant number of children developed psychosocial problems during the illness of their parent [
18].
In adolescents, gender is a risk factor for increased depressive symptoms in non-bereaved, with girls suffering twice as much as boys [
21‐
23]. Research on gender as a risk factor for depressive problems in family-bereaved adolescents is so far inconclusive [
14].
Family bereavement can cause financial hardship (e.g. decrease or loss of income), which may lead to negative life events (e.g. moving house, changing schools and loss of friends) and parenting difficulties [
10]. Low socio economic status is in it self associated with more negative life events [
9,
24] and parenting difficulties [
25] and is therefore associated with greater vulnerability to the effects of family bereavement.
Theoretical and clinical accounts suggest that family functioning, including family organization, cohesion, communication and role differentiation, pre- and post-bereavement is important for the effect of parental bereavement on mental health problems [
19]. Family functioning and parenting can be affected by family bereavement in a negative way, for example as a result of parental mental health problems, or in a positive way, when cohesion increases after the loss [
10,
19,
20].
Experiencing the death of a parent or sibling renders a child more vulnerable to developing mental health problems in the event of future losses [
13]. Experiencing a second family bereavement might have an even greater impact on mental health problems than a first bereavement.
The above-mentioned studies have several limitations. First, most studies in this area do not use a large and representative sample, or a comparison group [
26]. Second, research on pre-bereavement family functioning is limited to retrospective accounts of the parents or child about family functioning before bereavement took place, these accounts may be affected by their loss [
10]. Third, to our knowledge only one previous study focused on pre-bereavement measurements and prospective analyses of the development of mental health problems. In the current longitudinal study using a large sample (
n = 2230), the mental health of the adolescents that experienced the death of a parent (
n = 55) or sibling (
n = 15) was analysed prospectively.
The present study evaluates the nature and severity of changes in child mental health after bereavement in comparison with a non-bereaved peer population in a large representative sample, hereby taking into account pre-bereavement internalizing and externalizing problems and other potentially confounding variables. First, it is hypothesized that mental health problems, in particular internalizing problems, are more severe in adolescents approximately, 2 years after they experienced death within their family compared to non-bereaved adolescents. Differences in outcomes of family-versus sibling-bereavement will be analysed in an exploratory way. Second, it is hypothesized that more internalizing or externalizing problems before family bereavement are associated with more internalizing or externalizing problems after bereavement compared to the non-bereaved within the same period. Third, by the time adolescents reach the age of 19, those who experienced family bereavement are expected to exhibit more mental health problems (mainly internalizing problems), than their non-bereaved peers. Secondary analyses concern the following predictors in explaining internalizing or externalizing problems after bereavement: internalizing/externalizing problems before bereavement, low family functioning before bereavement, and multiple bereavement.
Results
Post (loss) mental health and type of bereavement
An independent t test of internalizing problems between the family-bereaved and non-bereaved subsample. Internalizing problems in family-bereaved (M = 0.08, SD = 0.27) increased significantly in comparison to non-bereaved (M = −0.04, SD = 0.22) from pre to post (loss) score over the same period t (1168) = −3.97, p < 0.001, showing a medium effect (Cohen’s d pooled 0.37; 95 % CI 0.13–0.62).
As a more rigorous measure, the clinical cut-off scores for the subscale internalizing problems were used to assess new clinical cases at post (loss) to establish clinically relevant changes. The increase in clinical cases was 22 versus 5.5 %, which is four times higher in family-bereaved than in non-bereaved over the same period. The difference in increase in clinical cases was tested with a Chi-square test and was found to be significant χ
2 (1) = 16.46, p < 0.001, a small effect (Cramers’V 0.10, p < 0.001).
Within-group analysis showed that internalizing problems increased significantly with a small effect when family bereavement occurred within the past 2 years (see Table
2). In the non-bereaved, a significant decrease with a small effect of internalizing problems was found for this period
, t (1213) = 6.2,
p < 0.01. The increase in internalizing problems after sibling bereavement was higher than after parental bereavement, but was not significant.
Table 2
Comparison of family-bereaved at T2, T3, T4 (n = 70), including sibling bereaved (n = 15) and parental bereaved (n = 55), and non-bereaved (n = 1213 internalizing and n = 1222 externalizing problems) on pre- and post-internalizing and externalizing problems
Parental bereavement | 0.34 | 0.23 | 0.39 | 0.28 | −1.72 | 0.19 | 0.31 | 0.20 | 0.35 | 0.24 | −1.04 | 0.18 | 19 | 9 |
Sibling bereavement | 0.37 | 0.28 | 0.52 | 0.41 | −1.61 | 0.41 | 0.26 | 0.20 | 0.32 | 0.19 | −0.92 | 0.31 | 22 | 8 |
Family bereavement | 0.34 | 0.24 | 0.42 | 0.31 | −2.35* | 0.28 | 0.30 | 0.20 | 0.34 | 0.23 | −1.35 | 0.19 | 22 | 9 |
Non-bereavement | 0.33 | 0.24 | 0.29 | 0.25 | 6.2** | 0.16 | 0.27 | 0.19 | 0.28 | 0.20 | −1.04 | 0.05 | 5.5 | 5.7 |
An independent
t test was conducted to test the changes in externalizing problems between both groups and this showed a significant increase in family-bereaved (
M = 0.04, SD = 0.25) compared to non-bereaved (
M = −0.01, SD = 0.19),
t (1180) = −1.99,
p < 0.05, with a small effect (Cohen’s
d pooled 0.12; 95 % CI −0.36 to 0.12). This difference in increase in clinical cases with externalizing problems between family-bereaved and non-bereaved was 2.3 %, which is very small, and not significant
χ
2 (1) = 2.17,
p > 0.05. Within both groups no differences were found in externalizing problems from pre to post (loss) (see Table
2).
Post (loss) mental health at age of 19
Two hierarchical multiple regression analyses were conducted separately for internalizing and externalizing problems at T4 to examine the effect of family bereavement during youth (0–19). In the first step, demographics (gender, SES) were added. In the second step, family-bereaved (
M = 3.03, SD = 0.81) versus non-bereaved (
M = 3.17, SD = 0.70) was added
(see Table
3).
Table 3
Mental health problems, internalizing and externalizing problems, in family-bereaved as well as non-bereaved adolescents
Step1 | 0.04 | | 0.005 | |
Gender | | −0.19** | | 0.03 |
SES T1 | | −0.07** | | −0.07** |
Step 2 | 0.003 | | 0.004 | |
Family-bereaved yes/no | | 0.05* | | 0.06** |
Total R
2
| 0.04 | | 0.009 | |
n
| 1580 | | 1581 | |
The results for internalizing problems showed that female gender (B = −0.19, SE = 0.01, p < 0.001) and low SES (B = −0.07, SE = 0.01, p < 0.01) significantly contributed to the variance, F (2, 1661) = 34.88, p < 0.001. Furthermore, family-bereaved versus non-bereaved explained an additional 0.3 % of the variance, F (3, 1660) = 25.02, p < 0.001, indicating that experiencing family bereavement is associated with more internalizing problems compared to non-bereaved adolescents. All variables explained four, 3 % of the variance of internalizing problems by the age of 19.
Results concerning post (loss) externalizing problems showed approximately the same results as were found for internalizing problems, except that gender was not significant. SES contributed significantly to the variance, F (2, 1661) = 4.32, p < 0.05. Family-bereaved versus non-bereaved, explained an additional 0.4 % of the variance F (3, 1626) = 5.11, p < 0.01, (B = 0.06, SE = 0.02, p < 0.01) indicating that experiencing family bereavement is associated with more externalizing problems than in non-bereaved at T4.
Control variables
Gender and SES
As presented in Table
4, the hierarchical multiple regression analyses of internalizing problems for family-bereaved showed that the first step, gender and SES, explained 21 % (versus 7 % in non-bereaved); a significant part of the variance. SES at T1 was centred and was lower in non-bereaved (
M = −0.04, SD = 0.80) than in bereaved (
M = −0.01, SD = 0.21). Low SES predicted internalizing problems in family-bereaved but not in non-bereaved. Being female predicted internalizing problems in both groups. In both groups Gender and SES did not predict externalizing problems.
Table 4
Predictors of change in internalizing and externalizing problems in non-bereaved and family-bereaved
Family-bereaved |
Step1 | 0.21 | | 0.01 | |
Gender | | −0.31* | | 0.10 |
SES T1 | | −0.35** | | 0.03 |
Step 2 | 0.18 | | 0.06 | |
Pre-loss internalizing or externalizing problems | | 0.47** | | 0.24 |
Step 3 | 0.02 | | 0.02 | |
Pre-loss Family Functioning | | 0.16 | | 0.14 |
Step 4 | 0.03 | | 0.08 | |
Multiple bereavement | | −0.18 | | −0.28* |
Total R
2
| 0.43 | | 0.16 | |
n
| 70 | | 70 | |
Non-bereaved |
Step 1 | 0.07 | | 0.01 | |
Gender | | −0.25** | | 0.05 |
SES T1 | | −0.05 | | −0.06 |
Step 2 | 0.30 | | 0.25 | |
Pre-loss internalizing or externalizing problems | | 0.56** | | 0.50** |
Step 3 | 0.01 | | 0.01 | |
Pre-loss Family Functioning | | 0.03 | | 0.08** |
Total R
2
| 0.37 | | 0.27 | |
n
| 1007 | | 1007 | |
Predictors
Pre (loss) mental health problems
Adding pre (loss) levels of internalizing problems in step 2 explained an additional 18 % of the variance in family-bereaved but much more in non-bereaved adolescents namely 30 %. The first and second steps together explained 38 % of the variance of internalizing problems in family-bereaved: adjusted R
2 is 0.35 and F (3, 52) = 10.68, p < 0.001, (B = 0.67, SE = 0.15, p < 0.001). In the non-bereaved, both steps explained in total 36 % of the variance, with an adjusted R
2 of 0.36 and F (3, 1000) = 144.25, p < 0.001 (B = 0.55, SE = 0.03, p < 0.001).
Pre (loss) externalizing problems in family-bereaved adolescents did not explain variance in externalizing problems after bereavement F (3, 52) = 1.26, p < 0.30, (B = 0.24, SE = 0.16, p > 0.05). In the non-bereaved, externalizing problems at pre-test explained an extra 25 % of the variance, F (3, 1005) = 113.06, p < 0.001, (B = 0.50, SE = 0.03, p < 0.001).
In sum: Pre (loss) scores on internalizing problems predicted post (loss) scores on internalizing problems in family-bereaved and in the non-bereaved adolescents. Pre (loss) scores on externalizing problems did not predict externalizing problems after bereavement. In the non-bereaved, however, pre (loss) scores on externalizing problems predicted post (loss) scores on externalizing problems.
Pre (loss) family functioning
An independent paired sample t test showed that family functioning within the family-bereaved did not significantly change after bereavement t (41) = 0.34, p > 0.05. In the non-bereaved, family functioning became significantly better over the same period t (1090) = 2.13, p < 0.05. This was a small effect (Cohen’s d pooled 0.13; 95 % CI 0.0102–0.25). The pre (loss) score on family functioning was significantly higher in the family-bereaved (M = 1.85, SD = 0.37) compared to the non-bereaved (M = 1.68, SD = 0.39), t (1327) = −3.22, p < 0.001).
An independent t test was conducted to test the difference in changes in family functioning between the family-bereaved and non-bereaved subsample. The difference score on family functioning, post (loss) score minus pre (loss) score was used. Change in family functioning in family-bereaved (M = −0.02, SD = 0.42) was not different compared to non-bereaved (M = −0.05, SD = 0.38) from pre- to post (loss) score over the same period t (1131) = −0.04, p > 0.05.
To examine whether family functioning before bereavement predicted mental health problems after bereavement, family functioning was added in the third step of the regression analysis. The pre (loss) score on family functioning did not predict internalizing problems after controlling for gender, SES and pre (loss) score on internalizing problems in family-bereaved F (4, 51) = 8.60, p < 0.001, (B = 0.16, SE = 0.10, p > 0.05), this was also true for non-bereaved adolescents, F (4, 1003) = 144.25, p < 0.001, (B = 0.03, SE = 0.02, p > 0.05).
Moreover, pre (loss) score on family functioning was not associated with post (loss) score on externalizing problems in the family-bereaved. In contrast, in the non-bereaved group the pre scores on family functioning predicted post (loss) scores on externalizing problems, indicating that dysfunctional family climate predicted externalizing problems. The additional variance explained was only 1 %
, F (4, 1003) = 10.68
, p < 0.001, (
B = 0.08, SE = 0.01
, p < 0.01) (see Table
4).
Multiple bereavement
Adding multiple bereavement in step 4 of the hierarchical multiple regression analyses (Table
4) showed that the experience of more than one family bereavement (
n = 24) did not predict internalizing problems after bereavement
F (5, 55) = 7.64
, p < 0.001, (
B = −0.18, SE = 0.05
, p > 0.05). However, it did predict fewer externalizing problems, while controlling for pre (loss) score externalizing problems:
F (5, 50) =
1.90, p < 0.05, (
B = −0.28, SE = 0.04
, p < 0.05).