Introduction

Top Abstract Introduction Participants and methods Results Discussion Conclusion References

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

Top Abstract Introduction Participants and methods Results Discussion Conclusion References

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.

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 olds¹⁶ 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.

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 ² 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

Top Abstract Introduction Participants and methods Results Discussion Conclusion References

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.

Children's emotional and behavioural problems: teachers' report
Bereaved children had significantly higher internalising and total problem scores than controls (table 3). Teachers considered them to be significantly more withdrawn, anxious, depressed, aggressive, and delinquent and to show more attention and thinking difficulties. Ten bereaved children had total problem scores above the 95th centile compared with none of the controls (P=0.002).

Parent and teacher agreement
Parents and teachers agreed whether a child was above or below the 95th centile on their total problem scores in 79% of the paired sample (=0.51, P=0.003).

Service support for bereaved children
Most parents (27/45, 60%) wanted service support for their children. The only significant influence on this desire was the mental state of the child, specifically externalising behaviour (above or below the median: P=0.03) and total problem scores (above or below the median: P=0.05). Of those parents whose children were probably psychiatrically disturbed, 82% (9 of 11) would have liked support compared with 53% (18 of 34) of parents whose children were not psychiatrically disturbed (P=0.07). Similarly, 90% (9 of 10) of parents whose children were rated by teachers as probably psychiatrically disturbed desired support compared with only 55%¹¹ of those not so rated (P=0.06). The manner of parental death did not influence whether surviving parents wanted support for their children (P=0.7), neither did parental mental health scores when forced into a logistic regression before child total problem scores (P=0.1).

	Discussion

Top Abstract Introduction Participants and methods Results Discussion Conclusion References

We found high levels of psychological morbidity in a representative sample of parentally bereaved children and the surviving parents 3 to 12 months after the death. Mothers were more disturbed than fathers. Boys were more symptomatic than girls, particularly in acting out or aggressive behaviour. Parents with high levels of psychiatric disturbance reported more symptoms in their child. Independent teacher ratings indicated that bereaved children were significantly more likely than matched controls to show widespread psychological difficulties. Teacher and parental ratings of probable child psychiatric disturbance showed good agreement.

Service provision for bereaved children was unrelated to probable psychiatric disturbance in children or parents or to parental desire for support. Given resource limitations, service provision should be targeted at psychologically disturbed children or psychiatrically disturbed parents wanting parenting support, or both. It was only the child's level of disturbance that significantly influenced parental desire for service support. Yet those most likely to be offered service provision were families in touch with services before the death, particularly services such as hospices with existing child provision. We found no association between the children's age and outcome. None the less, preschool children were less likely than older children to be offered services even though their parents were no less likely to want them. These findings indicate a serious mismatch between service need and provision.

The literature offers little guidance on the duration of childhood grieving. Our clinical experience suggests that where childhood disturbance persists beyond 3 months after death and results in family disturbance or affects performance or relationships at school, primary care practitioners should consider referral to specialist services. Practitioners should also be aware that child disturbance may reflect undetected psychological distress in the surviving parent.

Limitations
Bereaved children are neither easily identifiable nor accessible. We overcame the first difficulty by searching death records. Researchers followed ethical guidelines²⁰ and did not unduly pressurise general practitioners or bereaved patients who declined to participate. Our response rate of 63% was lower than we wanted but better than in other community studies (26%-54%). ^{6 9}

	Conclusion

Top Abstract Introduction Participants and methods Results Discussion Conclusion References

Our findings indicate a gap in support for bereaved families at the primary care level. The supportive role of paediatricians and their function as gatekeepers for the referral of bereaved children to specialised services are well specified.²³ We agree with Black²⁴ that general practitioners and primary care workers are ideally placed to identify families in need of help, particularly when levels of parental distress are high and when parents report persistent child disturbance at home or at school.

	Acknowledgments

We thank the families who participated at a very difficult time in their lives. We hope their efforts and the information they provided will result in an improvement in the match between service provision and need. We also thank the general practitioners who cooperated with this study and gave us access to their patients. Their understanding and desire to help was important for the project.

Contributors: LD and RW initiated the research and with BM and DS designed the study and generated primary study hypotheses. LD, RW, BM, MA, and PS developed interview measures. LD supervised data collection, took the primary role in data analysis and interpretation, and took responsibility for writing the paper. RW and BM discussed core ideas and interpretation of findings and, with DS, contributed to the paper. MA and PS conducted piloting of instruments, sensitively interviewed the families, participated in discussion of core ideas, and undertook preliminary analyses. LD will act as guarantor for the paper.

	Footnotes

Funding: South Thames Regional Health Authority (PGA 105/D).

Competing interests: None declared.

	References

Top Abstract Introduction Participants and methods Results Discussion Conclusion References

1.	Cheifetz PN, Stavrakakis G, Lester EP. Studies of the affective state in bereaved children. Can J Psychiatry 1989; 34: 688-692[Medline].
2.	Fristad MA, Jedel R, Weller RA, Weller EB. Psychosocial functioning in children after the death of a parent. Am J Psychiatry 1993; 150: 511-513[Abstract/Free Full Text].
3.	Gersten JC, Beals J, Kallgren CA. Epidemiology and preventive interventions: parental death in childhood as a case example. Am J Community Psychol 1991; 19: 481-500[Medline].
4.	Kranzler EM, Shaffer D, Wasserman G, Davies MA. Early childhood bereavement. J Am Acad Child Adolesc Psychiatry 1990; 29: 513-519[Medline].
5.	Sanchez L, Fristad M, Weller R, Weller EB, Moye J. Anxiety in acutely bereaved prepubertal children. Ann Clin Psychiatry 1994; 6: 39-43[Medline].
6.	Silverman PR, Worden JW. Children's reactions in the early months after the death of a parent. Am J Orthopsychiatry 1992; 62: 93-104[Medline].
7.	Sood B, Weller EB, Weller RA, Fristad MA, Bowe JM. Somatic complaints in grieving children. Compr Ment Health Care 1992; 2: 17-25.
8.	Van Eerdewegh MM, Bieri MD, Parrilla RH, Clayton PJ. The bereaved child. Br J Psychiatry 1982; 140: 23-29[Abstract/Free Full Text].
9.	Weller RA, Weller EB, Fristad MA, Bowes JM. Depression in recently bereaved prepubertal children. Am J Psychiatry 1991; 148: 1536-1540[Abstract/Free Full Text].
10.	Worden JW, Silverman PR. Parental death and the adjustment of school-age children. Omega J Death Dying 1996; 33: 91-102.
11.	Harris T, Brown GW, Bifulco A. Loss of parent in childhood and adult psychiatric disorder: the role of lack of adequate parental care. Psychol Med 1986; 16: 641-659[Medline].
12.	Black D. Childhood bereavement: distress and long term sequelae can be lessened by early intervention. BMJ 1996; 312: 1496[Free Full Text].
13.	Harrington R. Childhood bereavement: bereavement is painful but does not necessarily make children ill. BMJ 1996; 313: 822[Free Full Text].
14.	Goldberg D, Williams P. A user's guide to the general health questionnaire. Windsor: NFER-Nelson , 1988.
15.	Achenbach TM. Manual for the child behavior checklist/4-18 and 1991 profile. Burlington, VT: University of Vermont , 1991.
16.	Achenbach TM. Manual for the child behavior checklist/2-3 and 1992 profile. Burlington, VT: University of Vermont , 1992.
17.	Achenbach TM. Manual for the teachers' report form and 1991 profile. Burlington, VT: University of Vermont , 1991.
18.	Gardner MJ, Altman DG. Statistics with confidenceconfidence intervals and statistical guidelines. London: BMJ , 1989.
19.	Gardner MJ, Gardner SB, Winter PD. Confidence interval analysis (CIA) microcomputer program manual. Version 1.1. London: BMJ , 1991.
20.	Parkes CM. Guidelines for conducting ethical bereavement research. Special issue: ethics and bereavement research. Death Studies 1995; 19: 171-181[Medline].
21.	Worden JW, Silverman PS. Grief and depression in newly widowed parents with school-age children. Omega J Death Dying 1993; 27: 251-261.
22.	Black D, Harris-Hendriks KT. Father kills mother: post-traumatic disorder in the children. Psychother Psychosom 1992; 57: 152-157[Medline].
23.	Committee on Psychosocial Aspects of Child and Family Health. The pediatrician and childhood bereavement. Pediatrics 1992; 89: 516-518[Abstract/Free Full Text].
24.	Black D. Coping with loss: bereavement in childhood. BMJ 1998; 316: 931-933[Free Full Text].

(Accepted 28 April 1999)