Psychological disturbance and service provision in parentally bereaved children: prospective case-control study

British Medical Journal, August 7, 1999 by Linda Dowdney, Richard Wilson, B Maughan, M Allerton, P Schofield, D Skuse

Abstract

Objectives To identify whether psychiatric disturbance in parentally bereaved children and surviving parents is related to service provision.

Design Prospective case-control study.

Setting Two adjacent outer London health authorities.

Participants 45 bereaved families with children aged 2 to 16 years.

Main outcome measures Psychological disturbance in parentally bereaved children and surviving parents, and statistical associations between sample characteristics and service provision.

Results Parentally bereaved children and surviving parents showed higher than expected levels of psychiatric difficulties. Boys were more affected than girls, and bereaved mothers had more mental health difficulties than bereaved fathers. Levels of psychiatric disturbance in children were higher when parents showed probable psychiatric disorder. Service provision related to the age of the children and the manner of parental death. Children under 5 years of age were less likely to be offered services than older children even though their parents desired it. Children were significantly more likely to be offered services when the parent had committed suicide or when the death was expected. Children least likely to receive service support were those who were not in touch with services before parental death.

Conclusions Service provision was not significantly related to parental wishes or to level of psychiatric disturbance in parents or children. There is a role for general practitioners and primary care workers in identifying psychologically distressed surviving parents whose children may be psychiatrically disturbed, and referring them to appropriate services.

Introduction

The few empirical studies of parentally bereaved children report increased psychological disturbance, with a wide range of symptoms including anxiety, depression, withdrawal, sleep disturbance, and aggression.[1-10] The risk of psychiatric disorders in children is greater when surviving parents have mental health difficulties.[4] When impaired parenting results, bereaved children are at risk of psychiatric disturbance in adult life.[11]

Despite this risk, bereaved children are not routinely offered support services. Mental health professionals disagree about service provision. Although counselling after parental death could be an important preventive mental health measure,[12] limited resources, coupled with a lack of specificity in identifying children at greatest risk, militate against service provision in the absence of overt disorder.[13] Yet surviving parents, who may themselves be experiencing mental health difficulties, may want support for their children.

Methodological shortcomings in previous research include a lack of standardised measures or control groups[1 6 8]; the use of referred samples[1 4] or community samples identified through obituaries or undertakers,[2 5 7 10] a method that fails to identify up to 30% of bereaved families.[3] Our study is novel for two reasons: it is the first British study of childhood bereavement using a representative community sample, and it is the first study to ascertain whether surviving parents wanted service support for their children and whether service provision is related to parental or child mental health. We obtained ethical approval for our study from the ethics committees of the health authorities in which the study families lived.

Participants and methods

Sample

We identified deceased adults aged 18-55 years from the death records of public health offices for two adjacent health authorities over an 18 month period. General practitioners were asked to provide the age and sex of the deceased's children. Cooperation of general practitioners was exceptionally high. Of the 542 recorded deaths, 476 were registered with general practitioners. Only four general practitioners refused access to families. Of the remaining 472 (99%) patients, 94 had children aged 2-18 years. We included all children (81 families) whose parent had died 3-12 months previously and who lived with both parents when the death occurred. We excluded children (two families) not living with the surviving parent, and two families where one parent had murdered the other. Of the remaining 77 families, 73 were still living in the health authorities concerned. We traced and contacted 71 families (97%): 45 families (63%) agreed to be interviewed, and 40 (56%) completed all standardised questionnaires. The final sample consisted of 32 surviving mothers and 13 surviving fathers. We chose one child at random from each family for our study, giving 16 boys and 29 girls. Eight children were aged 2-5 years, 15 were aged 5-11 years, and 22 were aged 12-16 years. The median length of time since parental death was 7 months. The 45 participating families did not differ from non-participants in manner of death (expected or unexpected), sex of surviving parent, sex of index child, age of child, or family size (one or more children).

Measures

We conducted a semistructured interview in each family's home, gathering information on the death, familial grieving activities, and adjustment of the child and family after the death. We also obtained information on whether parents had desired, sought, or been offered bereavement support from public or voluntary services for themselves or their children, and their uptake of bereavement services.