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

Parental mental health measures

Parental mental health was assessed with the general health questionnaire. This was scored using the conventional method to identify adults with probable psychiatric disorder.[14]

Child mental health measures

Child emotional and behavioural disturbances were measured with standardised checklists completed by the parents (child behaviour checklist),[15, 16] and, for school aged children, by teachers (teachers' report form).[17] These instruments measure a broad range of symptoms including behaviour that is withdrawn, anxious, and depressed (internalising scale), and behaviours that are disruptive, aggressive, or delinquent (externalising scale). To reflect appropriate expressions of child disturbance for age, separate checklists were used for 2-3 year olds[16] and 4-18 year olds.[15] All subscales are summed to give a total problem score. For each scale the normative sample mean T (standardised) score is 50. For both parent and teacher checklists, T scores of 67 and above on the internalising and externalising scales and 60 or more on the total problem scale are expected to be obtained by only 5% of the general population, and indicate problems of probable clinical severity.

Each teacher also completed a checklist on a randomly chosen classroom control matched with the bereaved child for age and sex. Teacher checklists on cases and controls were available for 28 of the 32 school age children.

Statistics

Not all measurement scales were distributed continuously or according to an interval scale. Therefore we used non-parametric statistics. Significance values were two tailed, and [Chi square] significance values were corrected for continuity. When expected cell values were less than 5, we used the Fisher exact probability test. We used the Wilcoxon matched pairs signed rank test for analyses of matched pairs and the logistic regression and the Pearson product moment correlation when appropriate. Confidence intervals were calculated for median values with confidence interval analysis.[18, 19]

Results

Parental mental health

Parental mental health scores ranged from 0 (6 cases) to 21 (2 cases), the median being 8 (interquartile range 3-14). Twenty nine (64%) parents scored 5 or more, a level indicating probable psychiatric disorder.[14] Twenty one mothers (78%) showed probable psychiatric disturbance compared with only four fathers (31%) (P = 0.05). Parents with more than one child living at home had significantly higher scores (P = 0.03). No significant associations were found between parental mental health scores and time since death, age of the surviving parent, age or sex of the child, or whether the death was expected or unexpected.

Children's emotional and behavioural problems: parental report

Problem scores reported by parents showed a wide range (table 1). Median scores were above the population mean for 25 (63%) children on the internalising scale, 23 (58%) children on the externalising scale, and 24 (60%) children on total problem scores. Eleven children (28%) had total problem scores above the 95th centile. Bereaved boys had significantly higher externalising and total problem scores than bereaved girls (table 2). Total problem scores were not significantly influenced by age, ordinal position, sex of the deceased parent, whether the death was expected or unexpected, length of time since the death, or the number of children living at home. Parental mental health scores were significantly correlated with parents' reports of emotional and behavioural distress in their children on the internalising scale (r = 0.55, P = 0.001) and total problem scores (r = 0.53, P = 0.001) but not on the externalising scale.