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Section 12
Bereavement following Parental Death

Question 12 | Answer Booklet | Table of Contents

Psychological outcomes in children who have experienced the death of a parent are heterogeneous. One child in five is likely to develop psychiatric disorder. In the year following bereavement, children commonly display grief, distress, and dysphoria. Nonspecific emotional and behavioral difficulties among children are often reported by surviving parents and the bereaved children themselves. The highest rates of reported difficulties are found in boys. This review identifies the moderating and mediating variables that lead to some children being more vulnerable to disturbance than others following parental death. Limitations and gaps in the recent bereavement literature are identified. Theoretical and methodological advances that are necessary for a coherent account of childhood bereavement are outlined.

Introduction
In his consideration of the effects of attachment and loss upon early development, John Bowlby provided a theoretical basis for the proposition that even young children grieve and mourn following separation from, or the loss of, an attachment figure (Bowlby, 1963, 1973). Bowlby also hypothesized links between unresolved childhood grief and subsequent adult psychopathology, a position similar to that proposed earlier by Freud (1917). Subsequently, there has been increased theoretical and empirical interest in the effects of parental death upon children's later development. (Baker, Sedney, & Gross, 1992; Black, 1978; Worden, 1986).

Early studies of bereavement in childhood document "pathological mourning'' following the death of a parent (Furman, 1974); depressed mood; phobic disorders; and school refusal (Arthur & Kemme, 1964; Black, 1974; Caplan & Douglas, 1969). However, early studies are often descriptive and based on psychoanalytic case studies (see Miller, 1971, for review), or consider children referred for psychiatric help (Black, 1978). A higher incidence of parental bereavement has been reported in child psychiatric clinic attendees compared to controls (Rutter, 1966).

In a previous review of the literature in this journal, Black (1978) concludes ``bereaved children are more likely than children from intact homes to develop psychiatric disorders both in childhood and in adult life, although the differences are small'' (p. 291). The putative association between parental loss, childhood disturbance, and later psychiatric disorder continues to receive support (Black, 1994, 1998), although the strongest evidence comes from retrospective studies of adults with mental health problems. These appear to establish a link between parental death in childhood and subsequent depression in adulthood (e.g., Birtchnell, 1972; Brown, Harris, & Copeland, 1977). But the validity of that link has been challenged. First, because a number of other studies have not found significant associations between childhood parental death and adult psychopathology. Second, because of serious methodological inadequacies, including a reliance on hospital samples, inadequate control groups and a failure to control for independent or mediating variables likely to be associated with outcome (Crook & Eliot, 1980). Tennant, Bebbington, and Hurry (1980) argue that child bereavement alone is unlikely to be related to adult psychopathology, while Brown proposes that it is not bereavement per se that leads to adult depression (T. Harris, Brown,&Bifulco, 1986). Rather, it is the factors associated with bereavement, such as the quality of parental care and the presence of other adverse social and economic sequelae following the bereavement, that influence adult outcome. Nonetheless, debate continues as to whether serious adverse sequelae do or do not follow childhood bereavement (Black, 1996; Harrington, 1996).

Child Outcome Following Parental Death
From the extensive literature on childhood bereavement, a limited number of studies has been chosen for review, with three criteria guiding this choice. First, a satisfactory methodology that allows confidence in presented findings for example, studies including a control group and employing standardized measures (e.g., Dowdney et al., 1999;Hutton&Bradley, 1994;Kranzler, Shaffer, Wasserman, & Davies, 1990). Second, where studies have both strengths (such as the use of standardized assessment), and certain methodological limitations (for example, poorly specified control group entry criteria), but present findings compatible with studies meeting the first criteria (e.g., Van Eederwegh, Bieri, Parrilla, & Clayton, 1982; Van Eerdewegh, Clayton, & Van Eerdewegh, 1985). Finally, studies that are frequently cited in the clinical literature, and where findings have influenced practitioner opinion, clinical training and, therefore, by implication, clinical practice (see, e.g., Black's 1994 review in Rutter, Taylor, &Hersov). In each case, the strengths, limitations and implications of the presented findings are discussed. The review focuses almost entirely on the impact of parental death, because of the major methodological limitations inherent in the majority of studies relating to sibling death. The few rigorous studies on sibling death that are available (e.g., Freeman, Shaffer, & Smith, 1996; Hutton & Bradley, 1994; Pfeffer et al., 1997) are cited when relevant.

What Are the Psychological Effects upon Children of Parental Death?
Although this is a simple question to pose, finding an adequate answer is not an easy task. The difficulties encountered in ascertaining samples of recently bereaved children, and then gaining a grieving parent's consent to research, have imposed severe restrictions upon researchers.

The issue is further complicated as investigators have different aims and objectives. Some document the nonspecific disturbance and grief that bereaved children display, whereas others focus primarily on pathological outcomes as reflected in psychiatric diagnoses, or document the social and educational adjustment of these children. The evidence on child outcome in each of these areas is reviewed, followed by consideration of the duration of reported effects.
- Dowdney, L. (2000). Annotation: Childhood Bereavement Following Parental Death. Journal of Child Psychology and Psychiatry, 41(7), 819-830. doi:10.1111/1469-7610.00670

Update
Parental Death: A Systematic Review
of Support Experiences and Needs
of Children and Parent Survivors

- Wray, A., Pickwell-Smith, B., Greenley, S., Pask, S., Bamidele, O., Wright, B., Murtagh, F., & Boland, J. W. (2022). Parental death: a systematic review of support experiences and needs of children and parent survivors. BMJ supportive & palliative care, bmjspcare-2022-003793.

Peer-Reviewed Journal Article References:
Howard Sharp, K. M., Russell, C., Keim, M., Barrera, M., Gilmer, M. J., Foster Akard, T., Compas, B. E., Fairclough, D. L., Davies, B., Hogan, N., Young-Saleme, T., Vannatta, K., & Gerhardt, C. A. (2018). Grief and growth in bereaved siblings: Interactions between different sources of social support. School Psychology Quarterly, 33(3), 363–371.

Murray, K. J., Sullivan, K. M., Lent, M. C., Chaplo, S. D., & Tunno, A. M. (2019). Promoting trauma-informed parenting of children in out-of-home care: An effectiveness study of the resource parent curriculum. Psychological Services, 16(1), 162–169.

Salinas, C. L. (2021). Playing to heal: The impact of bereavement camp for children with grief. International Journal of Play Therapy, 30(1), 40–49.

QUESTION 12
What factors associated with bereavement lead to adult depression? Record the letter of the correct answer the Answer Booklet.

Answer Booklet
Section 13
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