Background
Death of a child or grandchild is devastating for parents and grandparents with effects on their physical and mental health and functioning. About 43,000 children ages 0–19 years die in the US annually [
1], most in intensive care units (ICUs) [
2]. The fast paced, high technology and unfamiliar ICU environment is stressful for parents who may watch their infant or child, scared and in pain, for days, weeks, or months before the death. Grandparents are stressed; they often cannot see their grandchild in the ICU because of visitation policies. Some do not live in the same state or country, also limiting their ability to see their critically ill grandchild before death.
Following a child’s death, parents have increased rates of physical and mental illnesses based on Denmark’s national data [
3‐
6]. Data on grandparents’ physical and mental health after grandchild death have been reported in only one cross-sectional study [
7]. However, it is not known if outcomes for mothers and grandmothers in the same family differ after the NICU/PICU death of the same child. This study’s aim was to compare grandmothers and mothers on physical health, mental health, and functioning from data collected at about the same time after the same child’s or grandchild’s NICU/PICU death.
In a national database of Danish parents 1–5 years after their child’s death, Li and colleagues [
3‐
6] found increased rates of parent cancer, heart disease, diabetes, mental disorders, and death. In a longitudinal study of relatively young US parents (176 mothers, 73 fathers) (76%, ages 18–40) during the first 13 months after an infant’s/child’s NICU/PICU death [
8], the total number of mothers’ chronic health conditions (
n = 183) more than doubled. Mothers reported 89 hospitalizations, 300 separate episodes of acute illnesses, and 76 medication changes to manage their chronic conditions; most (61%, 76%, and 67%, respectively) occurred in the first 6 months after the child’s death [
9]. The proportion of mothers with depression, PTSD, or both decreased from 61 to 71% at 1 month to 25–35% at 13 months. Youngblut et al. [
8] found that more Hispanic mothers had clinical depression at 6 months and clinical PTSD at all four time points (1, 3, 6, and 13 months post child death) than White mothers.
Few studies on grandparents’ stress-related health outcomes after a grandchild’s death have been reported. In a cross-sectional study of 99 grandmothers (43% Black, 31% White, 25% Hispanic) and 37 grandfathers (19% Hispanic, 24% Black, 57% White) at 1 to 6 months after their grandchild’s death, Youngblut et al. [
7] found that grandparents reported medication changes to manage their chronic health conditions (68%), a total of 59 illnesses (28%) and 7 hospitalizations (4.5%), and rated their health as ≤5 (16%) on a 1 “poor” to 10 “excellent” scale after the grandchild’s death. In addition, grandparents had clinical depression (31%), clinical PTSD (35%), or both (20%); 14% had neither. With statistical control for time since death, Black grandparents had more severe symptoms of PTSD than White grandparents [
7]. Of the 8 grandparents in therapy, half had clinical depression and/or PTSD. Results for grandmothers and grandfathers separately were not provided. The study’s cross-sectional design did not capture all illnesses, hospitalizations, medication changes, and mental health problems through 6 months post grandchild death because some grandparent interviews occurred earlier than 6 months, likely resulting in underestimation of grandparent morbidity in the first 6 months.
Parents [
10‐
13] and grandparents [
14‐
18] in separate studies have expressed pain, depression, helplessness, sorrow; shock, numbness, disbelief; bitterness, exhaustion, anger at God; and guilt that the child or grandchild died before them or that they did not do enough to protect or save the child or grandchild, blaming themselves for the child’s or grandchild’s death. Studies of predominantly White parents [
11,
19,
20] and White grandparents [
14,
18,
21] find that both experience flashbacks of the death, feelings of envy toward others with children or grandchildren, sleep disturbances, increased alcohol and drug use, and thoughts of suicide. However, when a child dies, friends and family focus primarily on the parents. Grandparents are often “forgotten grievers” [
16], and they experience greater pain when their loss is not acknowledged [
17,
22]. Some grandparents question the legitimacy of their grief [
23] or feel their grief is secondary to that of the parents [
17]. The grandparent’s role in the grieving family often is not clear, increasing their feelings of isolation.
In several qualitative studies [
17,
21‐
25], parents and grandparents characterized their relationship as strained or distant after the child’s/grandchild’s death. Ponzetti [
21] found that 56% of parents and 53% of grandparents reported a change in their feelings toward the other. In another study [
18], grandmothers and grandfathers did not differ in their feelings toward their adult child (grandchild’s parent) [
14]. Stroebe and colleagues [
26] found that Dutch parents felt the need to protect the grandparents by staying strong [
27], hiding their feelings and often withholding information [
25], increasing parents’ grief. Some studies find that parents’ grief decreases over time [
26,
28‐
30]. One study [
31] found a significant drop in mothers’ grief from 6 to 13 months post infant/child NICU/PICU death. However, others [
32] continued to find parent grief 3 or more years, and some more than 50 years [
33,
34], after a child’s death.
Grandparents’ grief includes the pain of thinking about and watching their grieving adult child (grandchild’s parent) [
22], fear of saying something that makes their adult child’s pain worse [
15], and unable to help or comfort their adult child [
15,
18,
24] and fulfill their role as parent to their adult child [
23]. In some studies, grandparents reported trying to “hold in,” suppress, and ignore their grief to protect their adult child and their surviving grandchildren [
15,
18,
25]. In studies of parent and grandparent grief, fathers and grandfathers tended to be “strong and silent;” mothers [
35,
36] and grandmothers [
14,
18,
21] preferred talking through their grief. Mothers and grandmothers also reported a greater need to talk about the deceased child/grandchild than fathers and grandfathers [
18,
21,
36]; Israeli grandparents had difficulty finding someone to listen to them [
23].
Parent and grandparent role functioning after child or grandchild death is often defined by employment. According to the Society for Human Resource Management [
37], employer policies generally provide paid bereavement leave for parents after their child’s death, but not for grandparents after a grandchild’s death. Employment can be a distracter, a source of support or a source of additional stress. In one study, 60% of families lost more than 10% of their annual income after a child’s death and 35% of parents quit their jobs [
11]. Grandparents reported that resuming their employment helped them to cope. Parents used work and other activities to distract themselves and to limit or interrupt their ruminating about the deceased child [
35]. Reilly-Smorawski et al. reported that mothers often delayed returning to work and were unproductive at work [
38,
39].
In summary, a child’s death is devastating for parents and grandparents. Studies document the effects of a child’s death on parents’ physical and mental health. However, research on grandparent physical and mental health and functioning after a grandchild’s death is very limited. The few reported studies found that grandparents had primarily negative mental health (depression, PTSD) and a few reported negative physical symptoms (pain, insomnia). Most studies of parents and grandparents post child death are qualitative, cross-sectional and limited by small, primarily White samples where time since death and the child’s or grandchild’s age at death vary widely within the same study. Gaps in knowledge include lack of research comparing mothers and grandmothers in the same family, especially with a sample that is racially/ethnically diverse with a narrow age range of the deceased children who all died in the NICU or PICU, and data collection in the first 6 months after the child’s death. This study adds to this knowledge base by comparing mothers and grandmothers in the same family on physical and mental health, grief, and functioning in the first 6 months after the same young child’s NICU/PICU death. The investigators hypothesized that mothers would report poorer physical and mental health, greater grief, and poorer functioning than grandmothers.
Discussion
Very few studies have compared mothers’ and grandmothers’ physical health, mental health, and functioning after the same child’s death. Comparing our findings with other studies’ findings is limited by the lack of quantitative data on grandmothers’ health and functioning and almost no research comparing quantitative data for mothers and grandmothers of the same deceased child. In this study, data were collected from mothers and grandmothers in the same family by the same interviewers at about the same time after the same child’s death. The limited reported studies also focus on White samples.
Both mothers and grandmothers experienced negative physical health effects after the child’s/grandchild’s death. Mothers developed more acute illnesses after the child’s/grandchild’s death than grandmothers. Although grandmothers had more chronic health conditions before the death than mothers, grandmothers and mothers developed about the same number of new chronic health conditions, on average, after the death. More grandmothers (66%) than mothers (44%) reported at least one chronic condition at interview after their grandchild’s/child’s death. Perhaps grandmothers’ acute illnesses after the death were attributed to or masked by their greater number of pre-existing chronic health conditions. With larger samples over the first 6 months post infant/child NICU/PICU death, researchers have reported 302 and 59 acute illnesses, 108 and 75 pre-existing chronic health conditions, 108 and 20 newly-diagnosed chronic conditions, 59 and 19 medication changes, and 59 and 7 hospitalizations for 176 mothers and 99 grandmothers, respectively [
7‐
9]. Mothers’ and grandmothers’ self-ratings of their health were about the same, with means toward the healthier end of the scale.
During the first 6 months after child/grandchild death, mothers experienced more severe depressive symptoms than grandmothers. Clinical depression rates were not statistically different between mothers (63%) and grandmothers (37%); however, they were much higher than for US adults of the same ages – 7.7% of adults age 18–39, 8.4% of adults age 40–59, and 8.0% of adults age 60 and older [
44].
Mothers had significantly more severe symptoms of the hyperarousal component of PTSD (excessive emotions, relationship problems, disruptions in sleep and concentration) than grandmothers. While more mothers (69%) than grandmothers (44%) had clinical PTSD scores, this difference was not statistically significant. Comparing our PTSD findings with other studies’ outcome variables was not possible due to lack of data from mothers and grandmothers of the same deceased child in the same time frame. As with clinical depression rates, mothers and grandmothers PTSD rates in this study were considerably higher than PTSD rates (3.6%) among US adults in any given year [
45].
Mothers had higher scores than grandmothers on 2 of the 6 grief (HGRC [
32]) subscales. Mothers experienced significantly more severe symptoms of despair (hopelessness, sadness, missing the child) and detachment (avoidance of tenderness, withdrawal from others) than grandmothers. Severity of grief symptoms regarding blame & anger (bitter, hostile, vengeful), panic (physiologic response), disorganization (difficulty concentrating, learning, remembering), and personal growth (spiritual, existential awareness) were similar for mothers and grandmothers. Detachment may be greater for mothers in the first 6 months as they distance themselves from their mothers (the deceased’s grandmother) [
23]. In another study, most parents whose child (0–48 years old) died up to 62 years earlier reported that this detachment was not long-lasting [
46]. The similar scores on the other 4 subscales suggest that grandmothers may have a level of grief close to that of mothers of the same deceased child in these areas.
Both grandparents and parents have reported feelings of bitterness, anger, and self-blame; pain, shock, and hearts pounding; and being unable to concentrate or focus and to remember things [
11‐
18,
21,
23]. Scores on personal growth were low (possible range 12–60) in this sample of mothers and grandmothers, perhaps because of the short time between the child’s/grandchild’s death and the time of interview. The first 6 months after a child’s/grandchild’s death is a period of many health challenges for both mothers and grandmothers [
7‐
9].
Employment is often described as a coping or escape mechanism after a child’s or grandchild’s death [
23]. Most grandmothers and about half of the mothers had returned to their jobs by the time of interview. In the larger sample [
8], 50% of mothers returned to work by 4 weeks post child NICU/PICU death. Grandmother-mother pairs did not differ on their ratings about their ability to work. However, the means for mothers and grandmothers on this employment item were low, around or below the midpoint (5) of the scale. These findings indicate that both mothers and grandmothers had difficulty managing their work with their grief.
Grandmothers and mothers had similar mean scores on their perceived social support. This is somewhat surprising given the results of qualitative studies of mothers and grandmothers (separate studies) [
17,
21‐
25,
36,
47‐
49]. When a child dies, the focus is on the parents’ grief, mental health, and functioning, and grandparents are often the “forgotten grievers” [
16]. It may be easier for parents to find social support because healthcare providers, clergy, and others have spent more time with the parents than the grandparents prior to the child’s/grandchild’s death and are more aware of the parents’ need for support. Parents, especially mothers, may attend support groups to help them cope [
50]. Grandmothers reported relying on their spouse, the grandchild’s mother, friends, and other relatives for support and preferred to talk through their grief [
14,
18]. Grandmothers may have to be more active in seeking the support they need.
O’Leary et al. [
25] suggested that parents feel a “double burden,” especially with pregnancy loss, because of the loss of their infant and also of disappointing or upsetting their parents (the infant’s grandparents). Others have hypothesized that grandparents experience “double pain” – pain for their deceased grandchild and pain for their grieving adult child (the deceased’s parent) [
23,
51]. The few significant differences between mothers and grandmothers in this study raise questions about the strength of the effects of parents’ double burden and grandparents’ double pain on their grief and morbidity. Perhaps the effects of double pain on grandparents and double burden on the parents are of similar magnitude. It is also possible that, when the two occur together, one masks the effect of the other. The present study’s findings may also reflect this sample’s racial/ethnic diversity versus the primarily White samples of other studies.
Thoughts about the appropriate timing for contacting parents after an infant’s/child’s death vary across clinicians, researchers, and others. Bereaved parents in a number of studies have noted the reticence of family, friends, and co-workers to talk with them after the death because they don’t know what to say to the parents or they don’t want to upset the parents [
36,
47‐
49]. Grandparents and parents in Australia, Canada, Israel, The Netherlands, and the US report suppressing or ignoring their grief to protect the other [
15,
23,
25,
26].
Limitations
The small number of women (n = 64, 32 mother-grandmother pairs) makes it more difficult to achieve statistical significance and limits the generalizability of the study’s findings. Since grandparents were identified through the parents, provision of the grandparent(s)’ name(s) and contact information may have been affected by the parents’ perception of the grandparent’s health and/or reaction to the grandchild’s death. If parents only provided names of grandparents they perceived as healthy and/or dealing well with the grandchild’s death, this study may underestimate grandparent morbidity. Parents who were estranged from the deceased child’s grandparents would be unable or unlikely to provide names and contact information for them. The possible effect of this factor on the study is not clear.
This study may under- or over-estimate the number of acute illnesses for mothers and grandmothers, since these data were collected as self-report. It may have been difficult for these women to accurately report their acute illnesses since the child’s death. Women may report an acute illness that has lasted for months (e.g. colds, headaches) as 1 episode, missing the fine distinctions between the end of one acute illness and the beginning of another. While this may under-represent the number of illnesses, obtaining these data from individual HCPs or urgent care centers was not feasible in this study. The illnesses recorded in a woman’s chart likely would yield a low count because adults often do not seek formal health care for illnesses like colds and headaches.
Women were categorized as having or not having depression and/or PTSD based on their self-reported severity of symptoms. Diagnosis from a mental health practitioner might be more definitive, although they often gauge the severity of symptoms based on the patient’s report of their symptoms. Women who reported high severity of symptoms, especially suicidality, were encouraged to seek help from a mental health practitioner. At a 6-month data collection visit, one woman was actively suicidal and appropriate steps were taken to ensure immediate assessment and treatment from a mental health practitioner.