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Adolescents' bereavement experiences. Prevalence, association with depressive symptoms, and use of services
Journal of Adolescence 2001, 24, 159–169 doi:10.1006/jado.2001.0379, available online at http://www.idealibrary.com on
Adolescents’ bereavement experiences. Prevalence, association with depressive symptoms, and use of services LUCY HARRISON AND RICHARD HARRINGTON
The present study set out to estimate the prevalence of bereavement experiences in adolescents, the association between these experiences and depressive symptoms and the attitudes of bereaved young people to professional interventions. The study was based on 1746 adolescents aged between 11 and 16 years from two secondary schools in Northern England. Questionnaire measures of bereavement experiences and depressive symptoms were completed by the adolescents in the classroom. One thousand three hundred and fifty-five (77?6%) reported that at least one of their firstor second-degree relatives or close friends had died. These losses were associated with increased levels of depressive symptoms in comparison with the loss of other relatives or pets. The impact of the loss of someone close depended to an important extent on the young person’s perception of how the loss had changed their lives. Most adolescents did not feel the need for professional services. Those who did use these services had higher levels of depressive symptoms, suggesting that service use was likely to have been appropriate. # 2001 The Association for Professionals in Services for Adolescents
Introduction Early bereavement and loss have been prominent themes in many models of psychopathology (Freud, 1917; Bowlby, 1969) and may be vulnerability factors for mental disorder in both childhood and adult life (Black, 1998). As a result, a variety of services exist for bereaved young people (Kaplan, 1992). In planning such services, information is needed on several issues. The first is the prevalence of bereavement among adolescents. Mortality rates among the young and middle aged have continued to fall in the U.K. (Office of Population Census and Surveys, 1990), raising the question as to how often adolescents will experience the death of someone close to them. The second question is the extent to which bereavement is associated with psychological distress and depressive symptoms. It could be that many bereaved young people remain symptom free and might not therefore require psychological help. The third issue is whether bereaved youngsters feel the need for professional counselling. It could be that many of them prefer to rely on other sources of comfort and support. There has been surprisingly little research on bereaved young people (Garmezy and Masten, 1994). Most of the extant studies have been based on selected samples who have lost a parent (Weller et al., 1991; Silverman and Worden, 1992) or friend (Brent et al., 1992). So far as we know there have been no community-based studies that have assessed the whole Reprint requests and correspondence should be addressed to: Richard Harrington, Department of Child Psychiatry, Royal Manchester Children’s Hospital, Pendlebury, Manchester M27 4HA, U.K. (E-mail [email protected]). 0140-1971/01/020159+11 $3500/0
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range of bereavements that adolescents might be exposed to, and measured their attitudes towards seeking help. This study set out to estimate the prevalence of bereavement experiences in adolescents, the association between these experiences and depressive symptoms and the attitudes of bereaved young people to professional interventions.
Method Subjects The study was based on a convenience sample of two large secondary schools in North England. Demographic data for the schools were similar to the population norms for the area. At the time of the study there were 2027 pupils on the school roles of whom 1746 (86%) completed bereavement questionnaires [210 (10%) were absent on the day of questionnaire administration and 71 (4%) refused to take part]. The average age of those who participated was 13?3 years (S.D. = 1?5, range 11 through 16 years). Eight hundred and ninety nine (51?5%) were male. Most (1586, 90?8%) were white, 114 (6?5%) Asian, with the remainder coming from other ethnic groups.
Measures Two questionnaire measures were completed by the adolescents in the classroom. The first was a questionnaire measure of bereavement experiences that was devised for this study (included in the appendix). Adolescents were asked whether relatives or friends had died, when they had died, the impact it had had on them (e.g. how much it had changed their lives, how much effect they felt it had), whether they felt the need for professional help, and whom they had talked to about it. Test–retest reliability of the adolescents’ recollections of deaths was examined in a random sample of 29 cases who repeated the questionnaires 16 weeks later. The average kappa coefficient for the recollection of deaths was 0?81. Most adolescents (questionnaires were spoiled in 22 instances) also completed the Mood and Feelings Questionnaire [MFQ (Angold et al., 1987)], which is measure of depressive symptoms of known reliability and validity (Wood et al., 1995).
Results Deaths of significant others Table 1 shows the prevalence of deaths known to adolescents ‘ever’ and within the last 5 years. Only 7?6% (n=132) of the sample reported that they knew of no first-degree relative (FDR), second-degree relative (SDR), other significant relative, friend, or treasured pet who had ever died. The maximum number of human losses was 10 per subject (median 2). Four percent (4?1%) had lost a parent, a rate similar to the U.S.A. (Garmezy and Masten, 1994). Since the sample varied in age, the actual period of observation was not the same for all young people. Therefore the probability that a child would experience a particular type of death by the age of 16 years was calculated using survival methods. As the table shows, the risk of parental death was about 6 per cent and of the risk of death of a sibling about 5 per cent (this figure includes stillbirths).
Bereavement in adolescence
Table 1
161
Deaths reported by adolescents Deaths ever*
Parent/s Sibling/s Grandparent/s Uncle or aunt/s Close friend/s Treasured pet/s Other significant relative/s
n
(%)
71 89 1153 407 189 831 338
(4?1) (5?1) (66?0) (23?3) (10?8) (47?6) (19?4)
Deaths in last 5 years Risk
+
0?06 0?05 0?77 0?32 0?16 0?56 0?27
n
(%)
33 18 542 236 135 587 205
(1?9) (1?0) (31?0) (13?5) (7?7) (33?6) (11?7)
n=1746. *Before or after the subject’s birth. { Cumulative risk up to 16 years calculated in survival analysis.
Association of deaths and current depressive symptoms Table 2 shows the bivariate associations between these deaths and self-reported depressive symptoms. Deaths of parents, siblings, grandparents, aunts/uncles and close friends were all associated with increased levels of current depressive symptoms. It will be appreciated that there was much overlap between these deaths, and in some this was more than would be expected by chance. For example, adolescents who had lost a parent through death were more likely to report the loss of an uncle or aunt through death (24/71 or 33?8%) than adolescents who had not lost a parent (383/1675 or 22?9%), a significant difference (w2 = 4?6, p50?05). Therefore the association of deaths and depressive symptoms was examined simultaneously within a multiple regression, with age, gender and school also added to the equation. In this multivariate analysis, all the deaths that had been associated with depressive symptoms in the univariate analyses (Table 2) continued to be significantly associated (t43?5 and p50?001) with these symptoms, except death of a parent where the association was still significant but a little weaker (beta = 0?06, t=2?5, p=0?01). Death of other relatives was not significantly associated with depressive symptoms and death of a pet was only just significant (p=0?03). R2 for the model was just 0?10, suggesting that many other factors influenced variation in MFQ scores. Depressive symptoms in young people can be conceptualized as a category as well as a symptoms dimension (Harrington et al., 1996). Therefore, in line with previous research with the MFQ (Wood et al., 1995), a cut-point of 24 was used to define a group of adolescents with a depression category. This category was also associated with losses. For instance, young people who had lost a first-degree relative, grandparent, uncle/aunt or friend, had a higher risk of the depression category than those who had not (297/1338 or 22?2% vs. 51/386 or 13?2%, respectively; odds ratio 1?9, 95% confidence interval 1?4–2?6).
Features of bereavements that predicted depressive symptoms It seemed, then, that loss of FDRs or SDRs or friends was associated with depressive symptoms. The association between depressive symptoms and loss of other relatives or of treasured pets was less strong. To explore further the issue of which kinds of bereavements were associated with depressive symptoms, the sample was divided into four groups: no losses (n=130), other relatives or pets only (n=256), FDRs, SDRs or friends only (n=592), or both
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Table 2 Bivariate associations between deaths and self-reports of depressive symptoms on the Mood and Feelings Questionnaire* Death n
Mean (S.D.)
No death n
Parent/s 70 19?7 (13?3) 1654 Sibling/s 87 21?9 (12?8) 1637 Grandparent/s 1137 15?8 (12?1) 587 Uncle or aunt/s 404 17?2 (12?4) 1320 Close friend/s 186 21?4 (13?9) 1538 Treasured pet/s 823 15?5 (12?1) 901 Other significant 337 16?1 (12?1) 1387 relative/s
Mean difference
Mean (S.D.) (95% confidence interval) 14?9 14?8 13?8 14?5 14?4 14?7 14?9
(11?9) (11?9) (11?7) (11?8) (11?6) (12?0) (12?0)
4?8 7?1 2?0 2?8 7?1 0?8 1?2
(1?9–7?7) (4?6–9?7) (0?8–3?2) (1?4–4?1) (5?3–8?9) (70?4–1?9) (70?2–2?7)
t
p
3?3 5?4 3?3 4?1 7?7 1?4 1?7
0?001 0?000 0?001 0?000 0?000 0?2 0?09
*MFQ data were missing on 22 cases.
types of loss (n=746). The MFQ scores for these groups were 10?4 (S.D. 10?1), 12?8 (S.D. 11?2), 15?4 (S.D. 12?0) and 16?5 (S.D. 12?4) respectively. In a one-way analysis of variance with post-hoc Tukey tests, the differences between the last two groups and the no-loss group were significant (p50?000), but that between the no-loss group and the other relative/pets group was not (mean difference 2?4, 95% confidence interval, 5?7–0?9). The greater the number of losses the higher the MFQ score (Pearson r=0?23, p=0?000). For example, the MFQ score for two losses was 15?0 (n=682, S.D. 11?3) and for four losses 24?4 (n=52, S.D. 13?3). Adolescents who experienced four losses or more had a much higher risk of the depression category (22/52 or 42?3%) than adolescents who had never experienced a loss (13/130 or 10?0%), with an odds ratio of 6?6 (95% confidence interval 3?0–14?6). Deaths that had occurred more than 5 years before were just as likely to be associated with depressive symptoms as deaths that had occurred more recently. For instance, the mean MFQ score of adolescents who had lost a sibling through death in the past five years (mean=20?2, S.D.=10?2) did not differ significantly from those who had lost a sibling more than five years before (mean 22?3, S.D.=13?3), t = 0?6, df 85, p = 0?6. Adolescents were asked how much deaths had changed their lives on a four-point scale, ranging from ‘‘enormously’’ to ‘‘it didn’t change my life much’’. Within the sample who had experienced the death of a near relative or friend (parent, sib, aunt/uncle, grandparent or friend), this scale was a strong predictor of MFQ scores (Table 3). As might be expected, however, the mediating role of the change of life brought about by a bereavement depended crucially on the type of loss. Thus, when change of life was added to the regression equation described in the previous section, the effects of loss of parent, grandparents, and aunts/uncles all became non-significant. The implication is that the effects of this kind of loss depend to an important extent on the changes they bring about in the child’s life. By contrast, the effects of loss of siblings or friends were not materially altered by adding life changes to the regression equation, suggesting that their effects were not mediated by these changes.
Help seeking It seemed, then, many adolescents had experienced the death of near relatives or friends and that exposure to such deaths was associated with increased levels of depressive symptoms.
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Table 3 Adolescents’ views about how much the death of a relative (parent, sib. aunt/uncle, grandparent) or friend* had changed their lives and depressive symptoms Mood and feelings questionnaire score n
Mean
(S.D.)
407 523 286 86
10?7 16?0 20?2 27?5
(9?5) (10?8) (13?1) (14?4)
Extent of change to life Not much A little A lot Enormously
*Within this group data were missing on 17 MFQs and 38 responses to the question about change of life. ANOVA, df 3, F=72?5, p50?001. In post-hoc tests correcting for multiple comparisons, the differences between each group and all the others was significant at p50?001.
Table 4
Who adolescents talked with about death/s Amount of talking
Talked with Parents, n (%) Other adults in the family, n (%) Siblings, n (%) Friends, n (%) School counselor, n (%) Primary care professional*, n (%) Bereavement counselor{, n (%) Child mental health professional, n (%)
Never 267 513 596 529 1298 1214 1265 1262
(20?4) (39?2) (46?3) (40?4) (96?8) (92?6) (95?9) (96?5)
Rarely
Sometimes
Often
A lot
407 (31?1) 419 (32) 177 (13?5) 39 (3?0) 417 (31?9) 287 (21?9) 76 (5?8) 15 (1?1) 344 (26?7) 230 (17?9) 92 (7?1) 25 (1?9) 374 (28?6) 299 (22?9) 82 (6?3) 24 (1?8) 28 (2?1) 10 (0?8) 2 (0?2) 2 (0?2) 63 (4?8) 21 (1?6) 7 (0?5) 2 (0?2) 36 (2?7) 12 (0?9) 5 (0?4) 1 (0?1) 30 (2?3) 11 (0?8) 3 (0?2) 2 (0?2)
*General practitioner, practice nurse, practice counsellor, health visitor. { E.g. Macmillan nurse.
The next question was whether adolescents felt the need for some kind of help to deal with their feelings about these deaths. Adolescents’ attitudes towards help were examined within the sample who had experienced the death of someone close (n=1355; see Table 4), as this group had elevated MFQ scores and might therefore be expected to be interested in seeking help. There were several findings. First, most adolescents (n=1143/1318 or 87%; data were missing on 37 cases) said that they had never, rarely or only sometimes talked about the deaths of relatives or friends. Second, talking about deaths was associated with higher levels of depressive symptoms. Thus, adolescents who said they had ‘‘often’’ or ‘‘always’’ talked about death had much higher MFQ scores (n=160, mean=23?9, S.D.=13?6) than adolescents who never/ rarely/only sometimes talked about deaths (n=1143, mean=14?8, S.D.=11?5), t=9?2, df 1301, p = 0?000. This relationship held even when age, gender, school, person who died, and the amount the death had changed life, were controlled in a multiple regression. Third, most adolescents stated that they never or only rarely needed professional help for the way they were feeling after the deaths they had experienced (1164/1315 or 88?5%). Table 4 shows the adolescents’ reports of whom they had talked to about their bereavements. As the table indicates, most adolescents had not talked with health professionals about their bereavement experiences. Of those that did talk to others about
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these experiences, the most common people chosen to talk to were parents, other adults within the family, and friends. On all of the scales shown in Table 4, more frequent talking was associated with greater levels of depression. For instance, adolescents who had had any kind of professional counseling for bereavement had higher MFQ scores (n=141, mean=23?4, S.D.=13?1) than adolescents who had not (n=1151, mean=15?1, S.D. =11?7), t=7?8, df=1290, p=0?000.
Discussion Prevalence of deaths of significant others So far as we know, this is the first study to survey bereavement experiences in a large U.K. community sample of adolescents. The findings were striking in showing that loss of a relative or friend through death was a common experience. Indeed, young people who did not experience the death of a significant other were in a minority.
Association of deaths of significant others and depressive symptoms In line with non-community studies (Van Eerdewegh et al., 1982; Weller et al., 1991; Brent et al., 1992), we found that loss of a parent or close friend was associated with depressive symptoms. Our results extend previous research in suggesting that depressive symptoms are also associated with other more common deaths, such as of grandparents. This finding is important because if it reflects a causal mechanism, then it suggests that bereavement accounts for more depressive symptoms in this age group than has previously been thought (Harrington and Clark, 1998). It will be appreciated, however, that in a cross-sectional study we cannot be certain that this association is causal. Indeed, one of our findings was not consistent with a causal relationship between bereavement and depressive symptoms. Longitudinal research on bereaved children suggests that depressive symptoms usually decrease over time (Silverman and Worden, 1992), so it would be expected that recent losses would have a stronger association with depressive symptoms than more distant ones. We found no relationship between timing of a loss and depressive symptoms. It could be, then, that the association between the deaths of significant others and depressive symptoms is partly induced by the association of both with some third variable that was not measured in our study, such as family dysfunction. On the other hand, the finding of a ‘‘dose–response’’ relationship between the numbers of losses and the severity of depression suggests that there may be an aetiological link between the two. Longitudinal research with better measures of the consequences of bereavement and of other risk factors for depression would help to resolve this issue. Such research should also measure other kinds of psychological symptoms, such as anxiety, as these might also be increased after bereavement.
Services for bereaved young people Our findings also have implications for the planning of services for bereaved young people. Most of the adolescents who had lost significant others did not feel the need for professional help. Those that did want to talk about their bereavement experiences were often able to do so with relatives or friends. There is little support, then, among adolescent themselves for the widespread development of specialized bereavement counselling services. However, in a small number of cases young people did feel the need for professional help and some of them got it.
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Since this group had high levels of depressive symptoms it would seem that these referrals were appropriate. Our research suggests that the impact of bereavement may be mediated in some instances by the changes it brings about in the child’s life. Interventions to target these changes, such as family work, may therefore be required. Indeed, one of the programmes that seems to be effective for bereaved young people includes a family intervention (Sandler et al., 1992). In other cases, particularly those with multiple bereavements, there may be high levels of depressive symptoms that require treatment. Bereavement services for adolescents therefore need to be able to call upon a range of different interventions.
References Angold, A., Costello, E. J., Pickles, A. and Winder, F. (1987). The Development of a Questionnaire for use in Epidemiological Studies of Depression in Children and Adolescents. Institute of Psychiatry, London (unpublished). Black, D. (1998). Bereavement in childhood. British Medical Journal, 316, 931–933. Bowlby, J. (1969). Attachment and Loss: I. Attachment. London: Hogarth Press. Brent, D. A., Perper, J., Moritz, G., Allman, C., Friend, A., Schweers, J., Roth, C., Balach, L. and Harrington, K. (1992). Psychiatric effects of exposure to suicide among the friends and acquaintances of adolescent suicide victims. Journal of the American Academy of Child Psychiatry, 31, 629–640. Freud, S. (1917). Mourning and Melancholia. London: Hogarth Press. Garmezy, N. and Masten, A. S. (1994). Chronic adversities. In Child and Adolescent Psychiatry: Modern Approaches, 3rd Edn. Rutter, M., Taylor, E. and Hersov, L.(Eds). Oxford: Blackwell Scientific. pp. 191–208. Harrington, R. C. and Clark, A. (1998). Prevention and early intervention for depression in adolescence and early adult life. European Archives of Psychiatry and Clinical Neuroscience, 248, 32–45. Harrington, R., Rutter, M. and Fombonne, E. (1996). Developmental pathways in depression: multiple meanings, antecedents and endpoints. Development and Psychopathology, 8, 601–616. Kaplan, C. (Ed.) (1992). Bereaved Children. Occasional Papers No. 7. London: Association of Child Psychology and Psychiatry. Office of Population Census and Surveys (1990). 1990 Mortality Statistics. Cause: England and Wales. (Vol. Series DH 2, No. 17). London: HMSO. Sandler, I. N., West, S. G., Baca, L., Pillow, D. R., Gersten, J. C., Rogosch, F., Virdin, L., Beals, J., Reynolds, K. D., Kallgren, C., Tein, J. Y., Kriege, G., Cole, E. and Ramirez, R. (1992). Linking empirically based theory and evaluation: the family bereavement program. American Journal of Community Psychology, 20, 491–521. Silverman, P. R. and Worden, J. W. (1992). Children’s reactions in the early months after the death of a parent. American Journal of Orthopsychiatry, 62, 93–104. Van Eerdewegh, M. M., Bieri, M. D., Parrilla, R. H. and Clayton, P. (1982). The bereaved child. British Journal of Psychiatry, 140, 23–29. Weller, R. A., Weller, E. B., Fristad, M. A. and Bowes, J. M. (1991). Depression in recently bereaved prepubertal children. American Journal of Psychiatry, 148, 1536–1540. Wood, A., Kroll, L., Moore, A. and Harrington, R. C. (1995). Properties of the Mood and Feelings Questionnaire in adolescent psychiatric outpatients: a research note. Journal of Child Psychology and Psychiatry, 36, 327–334.
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Appendix BEREAVEMENT QUESTIONNAIRE FOR YOUNG PEOPLE
Date.............
Id. Number............. PLEASE CIRCLE THE APPROPRIATE ANSWER
1. I am: male
female
2. My age is: 11
12
13
14
15
16
years old.
3. My ethnic origin is: Caucasian (White) Asian Afro-Caribean Oriental Mixed race Other The next question asks whether you have ever had losses by death and asks for details about each of them. Please answer it as in the following example: Id. Number............. PLEASE TICK ALL THOSE WHICH APPLY
EXAMPLE Q. I HAVE LOST THROUGH DEATH: DECEASED LOVED ONES GRANDMOTHER
YES
IF YES YEAR OF DEATH 1994
6
FATHER TREASURED PET
NO
6 6
DOG-1995
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167
Id. Number............. 4. I HAVE LOST THROUGH DEATH : DECEASED LOVED ONES
YES
NO
IF YES GIVE YEAR OF DEATH
MOTHER FATHER STEP-MOTHER STEP-FATHER BROTHER
SISTER
GRANDMOTHER (MUM’S) GRANDMOTHER (DAD’S) GRANDFATHER (MUM’S) GRANDFATHER (DAD’S) AUNT
UNCLE
CLOSE FRIEND
TREASURED PET
OTHER LOVED ONE
Please specify if ‘‘other’’....................................... The rest of the questionnaire is designed for those people who ticked ‘‘yes’’ in any of the boxes in question 4.
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L. Harrison and R. Harrington
Id. Number............. IN THE SECTION THAT FOLLOWS WE WOULD LIKE YOU TO PUT A LINE THROUGH THE BEST ANSWER: Example. Q. Since the death(s) I have talked about the loss(es): Always Often Sometimes Rarely
Never
The person in the example had rarely talked about the loss(es). 1. Since the death(s) I have talked about the loss(es): Always Often Sometimes Rarely 2. The loss(es) changed my life Enormously A lot 3. I got over the loss(es) Straight away Quickly
A little
Slowly
4. I felt I needed more professional help Always Often Sometimes
Never
It didn’t change my life much
I never got over it
Rarely
Never
Sometimes
Rarely
Never
b) ‘other adult(s) in my family Always Often Sometimes
Rarely
Never
c) my brother(s) or sister(s) Always Often Sometimes
Rarely
Never
d) my friend(s) Always Often
Sometimes
Rarely
Never
e) a School Counsellor Always Often
Sometimes
Rarely
Never
5. Since the death(s) I have talked about it with: a) my parent(s) Always Often
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169
Id. Number............. f ) my GP/Family Doctor or Health Visitor Always Often Sometimes
Rarely
Never
g) A Special Bereavement Counsellor/Macmillan Nurse Always Often Sometimes Rarely
Never
h) a Child Psychiatrist/Child Psychologist Always Often Sometimes
Never
Rarely
Thankyou very much for your help. Please ensure your I.D. Number is on each page.
Adolescents’ bereavement experiences. Prevalence, association with depressive symptoms, and use of services LUCY HARRISON AND RICHARD HARRINGTON
The present study set out to estimate the prevalence of bereavement experiences in adolescents, the association between these experiences and depressive symptoms and the attitudes of bereaved young people to professional interventions. The study was based on 1746 adolescents aged between 11 and 16 years from two secondary schools in Northern England. Questionnaire measures of bereavement experiences and depressive symptoms were completed by the adolescents in the classroom. One thousand three hundred and fifty-five (77?6%) reported that at least one of their firstor second-degree relatives or close friends had died. These losses were associated with increased levels of depressive symptoms in comparison with the loss of other relatives or pets. The impact of the loss of someone close depended to an important extent on the young person’s perception of how the loss had changed their lives. Most adolescents did not feel the need for professional services. Those who did use these services had higher levels of depressive symptoms, suggesting that service use was likely to have been appropriate. # 2001 The Association for Professionals in Services for Adolescents
Introduction Early bereavement and loss have been prominent themes in many models of psychopathology (Freud, 1917; Bowlby, 1969) and may be vulnerability factors for mental disorder in both childhood and adult life (Black, 1998). As a result, a variety of services exist for bereaved young people (Kaplan, 1992). In planning such services, information is needed on several issues. The first is the prevalence of bereavement among adolescents. Mortality rates among the young and middle aged have continued to fall in the U.K. (Office of Population Census and Surveys, 1990), raising the question as to how often adolescents will experience the death of someone close to them. The second question is the extent to which bereavement is associated with psychological distress and depressive symptoms. It could be that many bereaved young people remain symptom free and might not therefore require psychological help. The third issue is whether bereaved youngsters feel the need for professional counselling. It could be that many of them prefer to rely on other sources of comfort and support. There has been surprisingly little research on bereaved young people (Garmezy and Masten, 1994). Most of the extant studies have been based on selected samples who have lost a parent (Weller et al., 1991; Silverman and Worden, 1992) or friend (Brent et al., 1992). So far as we know there have been no community-based studies that have assessed the whole Reprint requests and correspondence should be addressed to: Richard Harrington, Department of Child Psychiatry, Royal Manchester Children’s Hospital, Pendlebury, Manchester M27 4HA, U.K. (E-mail [email protected]). 0140-1971/01/020159+11 $3500/0
# 2001 The Association for Professionals in Services for Adolescents
160
L. Harrison and R. Harrington
range of bereavements that adolescents might be exposed to, and measured their attitudes towards seeking help. This study set out to estimate the prevalence of bereavement experiences in adolescents, the association between these experiences and depressive symptoms and the attitudes of bereaved young people to professional interventions.
Method Subjects The study was based on a convenience sample of two large secondary schools in North England. Demographic data for the schools were similar to the population norms for the area. At the time of the study there were 2027 pupils on the school roles of whom 1746 (86%) completed bereavement questionnaires [210 (10%) were absent on the day of questionnaire administration and 71 (4%) refused to take part]. The average age of those who participated was 13?3 years (S.D. = 1?5, range 11 through 16 years). Eight hundred and ninety nine (51?5%) were male. Most (1586, 90?8%) were white, 114 (6?5%) Asian, with the remainder coming from other ethnic groups.
Measures Two questionnaire measures were completed by the adolescents in the classroom. The first was a questionnaire measure of bereavement experiences that was devised for this study (included in the appendix). Adolescents were asked whether relatives or friends had died, when they had died, the impact it had had on them (e.g. how much it had changed their lives, how much effect they felt it had), whether they felt the need for professional help, and whom they had talked to about it. Test–retest reliability of the adolescents’ recollections of deaths was examined in a random sample of 29 cases who repeated the questionnaires 16 weeks later. The average kappa coefficient for the recollection of deaths was 0?81. Most adolescents (questionnaires were spoiled in 22 instances) also completed the Mood and Feelings Questionnaire [MFQ (Angold et al., 1987)], which is measure of depressive symptoms of known reliability and validity (Wood et al., 1995).
Results Deaths of significant others Table 1 shows the prevalence of deaths known to adolescents ‘ever’ and within the last 5 years. Only 7?6% (n=132) of the sample reported that they knew of no first-degree relative (FDR), second-degree relative (SDR), other significant relative, friend, or treasured pet who had ever died. The maximum number of human losses was 10 per subject (median 2). Four percent (4?1%) had lost a parent, a rate similar to the U.S.A. (Garmezy and Masten, 1994). Since the sample varied in age, the actual period of observation was not the same for all young people. Therefore the probability that a child would experience a particular type of death by the age of 16 years was calculated using survival methods. As the table shows, the risk of parental death was about 6 per cent and of the risk of death of a sibling about 5 per cent (this figure includes stillbirths).
Bereavement in adolescence
Table 1
161
Deaths reported by adolescents Deaths ever*
Parent/s Sibling/s Grandparent/s Uncle or aunt/s Close friend/s Treasured pet/s Other significant relative/s
n
(%)
71 89 1153 407 189 831 338
(4?1) (5?1) (66?0) (23?3) (10?8) (47?6) (19?4)
Deaths in last 5 years Risk
+
0?06 0?05 0?77 0?32 0?16 0?56 0?27
n
(%)
33 18 542 236 135 587 205
(1?9) (1?0) (31?0) (13?5) (7?7) (33?6) (11?7)
n=1746. *Before or after the subject’s birth. { Cumulative risk up to 16 years calculated in survival analysis.
Association of deaths and current depressive symptoms Table 2 shows the bivariate associations between these deaths and self-reported depressive symptoms. Deaths of parents, siblings, grandparents, aunts/uncles and close friends were all associated with increased levels of current depressive symptoms. It will be appreciated that there was much overlap between these deaths, and in some this was more than would be expected by chance. For example, adolescents who had lost a parent through death were more likely to report the loss of an uncle or aunt through death (24/71 or 33?8%) than adolescents who had not lost a parent (383/1675 or 22?9%), a significant difference (w2 = 4?6, p50?05). Therefore the association of deaths and depressive symptoms was examined simultaneously within a multiple regression, with age, gender and school also added to the equation. In this multivariate analysis, all the deaths that had been associated with depressive symptoms in the univariate analyses (Table 2) continued to be significantly associated (t43?5 and p50?001) with these symptoms, except death of a parent where the association was still significant but a little weaker (beta = 0?06, t=2?5, p=0?01). Death of other relatives was not significantly associated with depressive symptoms and death of a pet was only just significant (p=0?03). R2 for the model was just 0?10, suggesting that many other factors influenced variation in MFQ scores. Depressive symptoms in young people can be conceptualized as a category as well as a symptoms dimension (Harrington et al., 1996). Therefore, in line with previous research with the MFQ (Wood et al., 1995), a cut-point of 24 was used to define a group of adolescents with a depression category. This category was also associated with losses. For instance, young people who had lost a first-degree relative, grandparent, uncle/aunt or friend, had a higher risk of the depression category than those who had not (297/1338 or 22?2% vs. 51/386 or 13?2%, respectively; odds ratio 1?9, 95% confidence interval 1?4–2?6).
Features of bereavements that predicted depressive symptoms It seemed, then, that loss of FDRs or SDRs or friends was associated with depressive symptoms. The association between depressive symptoms and loss of other relatives or of treasured pets was less strong. To explore further the issue of which kinds of bereavements were associated with depressive symptoms, the sample was divided into four groups: no losses (n=130), other relatives or pets only (n=256), FDRs, SDRs or friends only (n=592), or both
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Table 2 Bivariate associations between deaths and self-reports of depressive symptoms on the Mood and Feelings Questionnaire* Death n
Mean (S.D.)
No death n
Parent/s 70 19?7 (13?3) 1654 Sibling/s 87 21?9 (12?8) 1637 Grandparent/s 1137 15?8 (12?1) 587 Uncle or aunt/s 404 17?2 (12?4) 1320 Close friend/s 186 21?4 (13?9) 1538 Treasured pet/s 823 15?5 (12?1) 901 Other significant 337 16?1 (12?1) 1387 relative/s
Mean difference
Mean (S.D.) (95% confidence interval) 14?9 14?8 13?8 14?5 14?4 14?7 14?9
(11?9) (11?9) (11?7) (11?8) (11?6) (12?0) (12?0)
4?8 7?1 2?0 2?8 7?1 0?8 1?2
(1?9–7?7) (4?6–9?7) (0?8–3?2) (1?4–4?1) (5?3–8?9) (70?4–1?9) (70?2–2?7)
t
p
3?3 5?4 3?3 4?1 7?7 1?4 1?7
0?001 0?000 0?001 0?000 0?000 0?2 0?09
*MFQ data were missing on 22 cases.
types of loss (n=746). The MFQ scores for these groups were 10?4 (S.D. 10?1), 12?8 (S.D. 11?2), 15?4 (S.D. 12?0) and 16?5 (S.D. 12?4) respectively. In a one-way analysis of variance with post-hoc Tukey tests, the differences between the last two groups and the no-loss group were significant (p50?000), but that between the no-loss group and the other relative/pets group was not (mean difference 2?4, 95% confidence interval, 5?7–0?9). The greater the number of losses the higher the MFQ score (Pearson r=0?23, p=0?000). For example, the MFQ score for two losses was 15?0 (n=682, S.D. 11?3) and for four losses 24?4 (n=52, S.D. 13?3). Adolescents who experienced four losses or more had a much higher risk of the depression category (22/52 or 42?3%) than adolescents who had never experienced a loss (13/130 or 10?0%), with an odds ratio of 6?6 (95% confidence interval 3?0–14?6). Deaths that had occurred more than 5 years before were just as likely to be associated with depressive symptoms as deaths that had occurred more recently. For instance, the mean MFQ score of adolescents who had lost a sibling through death in the past five years (mean=20?2, S.D.=10?2) did not differ significantly from those who had lost a sibling more than five years before (mean 22?3, S.D.=13?3), t = 0?6, df 85, p = 0?6. Adolescents were asked how much deaths had changed their lives on a four-point scale, ranging from ‘‘enormously’’ to ‘‘it didn’t change my life much’’. Within the sample who had experienced the death of a near relative or friend (parent, sib, aunt/uncle, grandparent or friend), this scale was a strong predictor of MFQ scores (Table 3). As might be expected, however, the mediating role of the change of life brought about by a bereavement depended crucially on the type of loss. Thus, when change of life was added to the regression equation described in the previous section, the effects of loss of parent, grandparents, and aunts/uncles all became non-significant. The implication is that the effects of this kind of loss depend to an important extent on the changes they bring about in the child’s life. By contrast, the effects of loss of siblings or friends were not materially altered by adding life changes to the regression equation, suggesting that their effects were not mediated by these changes.
Help seeking It seemed, then, many adolescents had experienced the death of near relatives or friends and that exposure to such deaths was associated with increased levels of depressive symptoms.
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Table 3 Adolescents’ views about how much the death of a relative (parent, sib. aunt/uncle, grandparent) or friend* had changed their lives and depressive symptoms Mood and feelings questionnaire score n
Mean
(S.D.)
407 523 286 86
10?7 16?0 20?2 27?5
(9?5) (10?8) (13?1) (14?4)
Extent of change to life Not much A little A lot Enormously
*Within this group data were missing on 17 MFQs and 38 responses to the question about change of life. ANOVA, df 3, F=72?5, p50?001. In post-hoc tests correcting for multiple comparisons, the differences between each group and all the others was significant at p50?001.
Table 4
Who adolescents talked with about death/s Amount of talking
Talked with Parents, n (%) Other adults in the family, n (%) Siblings, n (%) Friends, n (%) School counselor, n (%) Primary care professional*, n (%) Bereavement counselor{, n (%) Child mental health professional, n (%)
Never 267 513 596 529 1298 1214 1265 1262
(20?4) (39?2) (46?3) (40?4) (96?8) (92?6) (95?9) (96?5)
Rarely
Sometimes
Often
A lot
407 (31?1) 419 (32) 177 (13?5) 39 (3?0) 417 (31?9) 287 (21?9) 76 (5?8) 15 (1?1) 344 (26?7) 230 (17?9) 92 (7?1) 25 (1?9) 374 (28?6) 299 (22?9) 82 (6?3) 24 (1?8) 28 (2?1) 10 (0?8) 2 (0?2) 2 (0?2) 63 (4?8) 21 (1?6) 7 (0?5) 2 (0?2) 36 (2?7) 12 (0?9) 5 (0?4) 1 (0?1) 30 (2?3) 11 (0?8) 3 (0?2) 2 (0?2)
*General practitioner, practice nurse, practice counsellor, health visitor. { E.g. Macmillan nurse.
The next question was whether adolescents felt the need for some kind of help to deal with their feelings about these deaths. Adolescents’ attitudes towards help were examined within the sample who had experienced the death of someone close (n=1355; see Table 4), as this group had elevated MFQ scores and might therefore be expected to be interested in seeking help. There were several findings. First, most adolescents (n=1143/1318 or 87%; data were missing on 37 cases) said that they had never, rarely or only sometimes talked about the deaths of relatives or friends. Second, talking about deaths was associated with higher levels of depressive symptoms. Thus, adolescents who said they had ‘‘often’’ or ‘‘always’’ talked about death had much higher MFQ scores (n=160, mean=23?9, S.D.=13?6) than adolescents who never/ rarely/only sometimes talked about deaths (n=1143, mean=14?8, S.D.=11?5), t=9?2, df 1301, p = 0?000. This relationship held even when age, gender, school, person who died, and the amount the death had changed life, were controlled in a multiple regression. Third, most adolescents stated that they never or only rarely needed professional help for the way they were feeling after the deaths they had experienced (1164/1315 or 88?5%). Table 4 shows the adolescents’ reports of whom they had talked to about their bereavements. As the table indicates, most adolescents had not talked with health professionals about their bereavement experiences. Of those that did talk to others about
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these experiences, the most common people chosen to talk to were parents, other adults within the family, and friends. On all of the scales shown in Table 4, more frequent talking was associated with greater levels of depression. For instance, adolescents who had had any kind of professional counseling for bereavement had higher MFQ scores (n=141, mean=23?4, S.D.=13?1) than adolescents who had not (n=1151, mean=15?1, S.D. =11?7), t=7?8, df=1290, p=0?000.
Discussion Prevalence of deaths of significant others So far as we know, this is the first study to survey bereavement experiences in a large U.K. community sample of adolescents. The findings were striking in showing that loss of a relative or friend through death was a common experience. Indeed, young people who did not experience the death of a significant other were in a minority.
Association of deaths of significant others and depressive symptoms In line with non-community studies (Van Eerdewegh et al., 1982; Weller et al., 1991; Brent et al., 1992), we found that loss of a parent or close friend was associated with depressive symptoms. Our results extend previous research in suggesting that depressive symptoms are also associated with other more common deaths, such as of grandparents. This finding is important because if it reflects a causal mechanism, then it suggests that bereavement accounts for more depressive symptoms in this age group than has previously been thought (Harrington and Clark, 1998). It will be appreciated, however, that in a cross-sectional study we cannot be certain that this association is causal. Indeed, one of our findings was not consistent with a causal relationship between bereavement and depressive symptoms. Longitudinal research on bereaved children suggests that depressive symptoms usually decrease over time (Silverman and Worden, 1992), so it would be expected that recent losses would have a stronger association with depressive symptoms than more distant ones. We found no relationship between timing of a loss and depressive symptoms. It could be, then, that the association between the deaths of significant others and depressive symptoms is partly induced by the association of both with some third variable that was not measured in our study, such as family dysfunction. On the other hand, the finding of a ‘‘dose–response’’ relationship between the numbers of losses and the severity of depression suggests that there may be an aetiological link between the two. Longitudinal research with better measures of the consequences of bereavement and of other risk factors for depression would help to resolve this issue. Such research should also measure other kinds of psychological symptoms, such as anxiety, as these might also be increased after bereavement.
Services for bereaved young people Our findings also have implications for the planning of services for bereaved young people. Most of the adolescents who had lost significant others did not feel the need for professional help. Those that did want to talk about their bereavement experiences were often able to do so with relatives or friends. There is little support, then, among adolescent themselves for the widespread development of specialized bereavement counselling services. However, in a small number of cases young people did feel the need for professional help and some of them got it.
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Since this group had high levels of depressive symptoms it would seem that these referrals were appropriate. Our research suggests that the impact of bereavement may be mediated in some instances by the changes it brings about in the child’s life. Interventions to target these changes, such as family work, may therefore be required. Indeed, one of the programmes that seems to be effective for bereaved young people includes a family intervention (Sandler et al., 1992). In other cases, particularly those with multiple bereavements, there may be high levels of depressive symptoms that require treatment. Bereavement services for adolescents therefore need to be able to call upon a range of different interventions.
References Angold, A., Costello, E. J., Pickles, A. and Winder, F. (1987). The Development of a Questionnaire for use in Epidemiological Studies of Depression in Children and Adolescents. Institute of Psychiatry, London (unpublished). Black, D. (1998). Bereavement in childhood. British Medical Journal, 316, 931–933. Bowlby, J. (1969). Attachment and Loss: I. Attachment. London: Hogarth Press. Brent, D. A., Perper, J., Moritz, G., Allman, C., Friend, A., Schweers, J., Roth, C., Balach, L. and Harrington, K. (1992). Psychiatric effects of exposure to suicide among the friends and acquaintances of adolescent suicide victims. Journal of the American Academy of Child Psychiatry, 31, 629–640. Freud, S. (1917). Mourning and Melancholia. London: Hogarth Press. Garmezy, N. and Masten, A. S. (1994). Chronic adversities. In Child and Adolescent Psychiatry: Modern Approaches, 3rd Edn. Rutter, M., Taylor, E. and Hersov, L.(Eds). Oxford: Blackwell Scientific. pp. 191–208. Harrington, R. C. and Clark, A. (1998). Prevention and early intervention for depression in adolescence and early adult life. European Archives of Psychiatry and Clinical Neuroscience, 248, 32–45. Harrington, R., Rutter, M. and Fombonne, E. (1996). Developmental pathways in depression: multiple meanings, antecedents and endpoints. Development and Psychopathology, 8, 601–616. Kaplan, C. (Ed.) (1992). Bereaved Children. Occasional Papers No. 7. London: Association of Child Psychology and Psychiatry. Office of Population Census and Surveys (1990). 1990 Mortality Statistics. Cause: England and Wales. (Vol. Series DH 2, No. 17). London: HMSO. Sandler, I. N., West, S. G., Baca, L., Pillow, D. R., Gersten, J. C., Rogosch, F., Virdin, L., Beals, J., Reynolds, K. D., Kallgren, C., Tein, J. Y., Kriege, G., Cole, E. and Ramirez, R. (1992). Linking empirically based theory and evaluation: the family bereavement program. American Journal of Community Psychology, 20, 491–521. Silverman, P. R. and Worden, J. W. (1992). Children’s reactions in the early months after the death of a parent. American Journal of Orthopsychiatry, 62, 93–104. Van Eerdewegh, M. M., Bieri, M. D., Parrilla, R. H. and Clayton, P. (1982). The bereaved child. British Journal of Psychiatry, 140, 23–29. Weller, R. A., Weller, E. B., Fristad, M. A. and Bowes, J. M. (1991). Depression in recently bereaved prepubertal children. American Journal of Psychiatry, 148, 1536–1540. Wood, A., Kroll, L., Moore, A. and Harrington, R. C. (1995). Properties of the Mood and Feelings Questionnaire in adolescent psychiatric outpatients: a research note. Journal of Child Psychology and Psychiatry, 36, 327–334.
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Appendix BEREAVEMENT QUESTIONNAIRE FOR YOUNG PEOPLE
Date.............
Id. Number............. PLEASE CIRCLE THE APPROPRIATE ANSWER
1. I am: male
female
2. My age is: 11
12
13
14
15
16
years old.
3. My ethnic origin is: Caucasian (White) Asian Afro-Caribean Oriental Mixed race Other The next question asks whether you have ever had losses by death and asks for details about each of them. Please answer it as in the following example: Id. Number............. PLEASE TICK ALL THOSE WHICH APPLY
EXAMPLE Q. I HAVE LOST THROUGH DEATH: DECEASED LOVED ONES GRANDMOTHER
YES
IF YES YEAR OF DEATH 1994
6
FATHER TREASURED PET
NO
6 6
DOG-1995
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Id. Number............. 4. I HAVE LOST THROUGH DEATH : DECEASED LOVED ONES
YES
NO
IF YES GIVE YEAR OF DEATH
MOTHER FATHER STEP-MOTHER STEP-FATHER BROTHER
SISTER
GRANDMOTHER (MUM’S) GRANDMOTHER (DAD’S) GRANDFATHER (MUM’S) GRANDFATHER (DAD’S) AUNT
UNCLE
CLOSE FRIEND
TREASURED PET
OTHER LOVED ONE
Please specify if ‘‘other’’....................................... The rest of the questionnaire is designed for those people who ticked ‘‘yes’’ in any of the boxes in question 4.
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Id. Number............. IN THE SECTION THAT FOLLOWS WE WOULD LIKE YOU TO PUT A LINE THROUGH THE BEST ANSWER: Example. Q. Since the death(s) I have talked about the loss(es): Always Often Sometimes Rarely
Never
The person in the example had rarely talked about the loss(es). 1. Since the death(s) I have talked about the loss(es): Always Often Sometimes Rarely 2. The loss(es) changed my life Enormously A lot 3. I got over the loss(es) Straight away Quickly
A little
Slowly
4. I felt I needed more professional help Always Often Sometimes
Never
It didn’t change my life much
I never got over it
Rarely
Never
Sometimes
Rarely
Never
b) ‘other adult(s) in my family Always Often Sometimes
Rarely
Never
c) my brother(s) or sister(s) Always Often Sometimes
Rarely
Never
d) my friend(s) Always Often
Sometimes
Rarely
Never
e) a School Counsellor Always Often
Sometimes
Rarely
Never
5. Since the death(s) I have talked about it with: a) my parent(s) Always Often
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Id. Number............. f ) my GP/Family Doctor or Health Visitor Always Often Sometimes
Rarely
Never
g) A Special Bereavement Counsellor/Macmillan Nurse Always Often Sometimes Rarely
Never
h) a Child Psychiatrist/Child Psychologist Always Often Sometimes
Never
Rarely
Thankyou very much for your help. Please ensure your I.D. Number is on each page.