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The Relief of Grief: The Impact of Sudden Parent Loss on

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The Relief of Grief: The Impact of Sudden Parent Loss on Children David A. Brent, M.D. 21st Annual STAR-Center Conference May 3, 2007 Pittsburgh, PA – PowerPoint PPT presentation

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Title: The Relief of Grief: The Impact of Sudden Parent Loss on


1
The Relief of Grief The Impact of Sudden Parent
Loss on Children
  • David A. Brent, M.D.
  • 21st Annual STAR-Center Conference
  • May 3, 2007
  • Pittsburgh, PA
  • Supported by MH65368 No financial relationship
    with industry.

2
Impact of Sudden Parental Death on Children
Personnel
  • Nadine Melhem, PhD Co-Investigator
  • Monica Walker, MA Project Coordinator
  • Grace Moritz, LSW
  • David Rizzo, LSW
  • Bertille Donohoe, MA
  • Yuan Brustoloni, MAMS
  • Grant MH65368

3
Objectives
  • Review what is known about impact of parent loss
    on children
  • Outline gaps in the field
  • Describe IMPACT Study
  • What are 1-2 year effects of bereavement?
  • Is suicide bereavement different?
  • Pathways and predictors of outcome
  • Phenomenology of grief What is pathological?

4
Extent of Problem
  • 4 of children will lose one parent by age 18
  • Subjectively, rated one of the most stressful
    life events
  • No long-term prospective, controlled studies of
    parent loss

5
Retrospective Studies
  • Adults with mental disorders have higher rates of
    parent loss
  • Kendler 12 year impact of parent loss on risk
    for depression
  • Bias of retrospective studies depressed people
    more likely to recall negative events

Kendler et al., 2002
6
Record Linkage Studies
  • Large standard population-based data sets
  • Breadth rather than depth
  • Suicide particularly deleterious, but also impact
    from maternal loss due to any source
  • Outcome suicide, psychiatric hospitalization

7
Prospective Studies
  • Sandler 244 children, 53 internalizing, 45
    externalizing
  • Weller, 1991 increased risk of depression
  • Risky sexual behavior (Rotheram-Borus)

Sandler et al., 2003 Weller et al., 1991
8
Longer Term Impact of Bereavement
  • Rutter 5yr. Study- worse functional outcomes
  • Kendler the increased rate of depression
    12 years later
  • Reinherz (1999) 13-fold increased risk in
    females for depression if lost parent lt 9 years
    of age

Rutter et al., 1983 Kendler et al., 2006 Reinherz
et al., 1999
9
Broader Range of Outcomes
  • Developmental competency
  • Health - retrospective studies tie family
    adversity to range of health outcomes
  • Stress response - HPA and BP reactivity
  • Mediated by family environment and threat
    appraisal

10
Theoretical Model of Impact of Parent Loss on
Child Outcome
Mediating Variables
Pre-Death Variables Child Prior
Psychopathology Trauma History Age
Gender Family Proband and Caregiver
Psychopathology SES Proband Relationship
to Child Stress Genes
Outcomes Mental Health Depression, PTSD,
Int/Ext Complicated Grief (CG) Developmental
Competence Health-Related Stress Response (HPA,
BP) BP, BMI, Health Risk Behaviors
Child Resources Coping, Threat
Assessment Self-Esteem Locus of Control
Parental Death
Family Resources Caregiver Function and Mental
Health Parenting School Connection Social
Support Life Events
Mediation
Circumstances and Type of Death
Moderation
11
Predictors of Outcome
  • Not loss, what happens afterwards
  • Pre-death parent and child psychiatric disorder
  • Mediators
  • Child coping, self-esteem, locus of control,
    threat appraisal, open expression
  • Family caregiver function, positive parenting,
    social support, life events
  • Gender Moderates outcome?

12
Effect, Cause and Manner of Death
  • Sudden vs. anticipated very little evidence
    that there is a difference One study
    showed slower recovery
  • Suicide vs. other very little data. One small
    study (N24) found no differential impact
  • Pfeffer suicide vs. cancer bereavement
    Increased depression in suicide grief

Pfeffer et al., 2000
13
Impact of Parent Loss Due to Suicide vs. Other
Causes of Death
  • Cerel (1999) compared 26 children who lost a
    parent to suicide vs. 322 parentally bereaved
    children
  • Suicide group less acceptance, more shame, anger
    and impairment
  • But not more depression, PTSD, suicidal behavior
  • Cerel (2000) suicide group had more impaired
    family functioning than others before the death,
    but after the death were similar (therefore,
    family function in suicide survivors improved).

14
Suicide Bereavement Could Be Different Because
  • Family loading for disorder and suicidal behavior
  • Stigma
  • Pre-death family adversity
  • Traumatic exposure

15
Complicated Grief (CG)
  • Impairment associated with grief experience
    Rumination, yearning, sense of loss of purpose,
    anger/bitterness
  • Is it a separate condition?
  • Yes Predicts functional outcome (ideation,
    health) after controlling for depression and
    PTSD. CG specific treatment gt IPT for
    depressed individuals with CG
  • No High correlations with PTSD and depression

16
CG in Children
  • Brown Goodman traumatic grief grief is
    intrusive and interferes with development of
    positive memories (but based upon children who
    lost parents in uniformed services in 9/11)
  • Sandler Intrusive grief, continued affective
    reactions, social detachment related to
    functional impairment (the latter with peers)

Brown Goodman, 2005 Sandler et al., 2003
17
Gaps In The Field
  • No controlled, long-term population-based
    prospective studies
  • Role of suicide, other pre-death factors,
    exposure
  • Complicated grief
  • Mediators and moderators (pathways)
  • Impact on health and development

18
Impact of Sudden Death on Children
  • Describe course of children bereaved by parental
    suicide, accident, sudden natural death
  • Compare to non-bereaved neighborhood controls
  • Role of cause and circumstances of death
  • Predictors and pathways
  • Complicated grief

19
Design (1)
  • Probands suicide, accident, sudden natural
    death
  • Definite verdict/no ambiguous cases
  • No multiple death/injuries/no suicides in non
    suicide families
  • Death within 24 hours
  • Children 8-18, biological parent, living at home

20
Design (2)
  • Obtained for coroners records and advertisement
  • 71 acceptance
  • Appears representative of suicides and accidents
    in Allegheny County

21
Design (3)
  • Neighborhood controls Random Digital Dialing or
    advertisement, no bereavement in last 2 years,
    both parents alive, demographically matched to
    deceased families

22
Demographic Characteristics of Probands
  • S A N C p
  • N (Probands) 44 36 60 99
  • Age 43ab 41a 47 44 lt.01
  • Sex ( male) 77 72 82 76 ns
  • Race ( white) 93 78 82 86 ns
  • Income (x 10,000) 6a 6ab 6a 7b lt.01

S Suicide A Accident N Natural C
Controls Superscripts that are different indicate
significant pairwise difference.
23
Demographic Characteristics of Adult Caregivers
  • S A N C p
  • N (Adult Caregivers) 43 36 60 101
  • Age (years) 42a 45a,b 46b 42a lt.01
  • Sex ( female) 84 81 92 74 ns
  • Race ( white) 93 78 85 87 ns
  • Relation to proband
  • ( married) 56a 50a 68a,b 77b lt.01

S Suicide A Accident N Natural C
Controls Superscripts that are different indicate
significant pairwise difference.
24
Demographic Characteristics of Children
  • S A N C
    p
  • N (Children) 66 51 94
    183
  • Age (years) 14 13
    13 13 ns
  • Sex ( male) 52 47 56
    50 ns
  • Race ( white) 92a 82a,b 73b
    85a lt.05
  • Lived with both parents
  • before death 35a 45a
    65b 81c lt.001
  • Biological Parent
  • of child () 88a 88a
    85a 100b lt.001
  • Time since death
  • (months) 9 9 9
    - ns

25
Pre-Death Psychiatric History and Family
Adversity Probands
  • S A N C p  
  • N (Probands) 44 36 60 99
  • Any disorder () 98a 78ab 65b 75b lt.001
  • Depression () 56 44 37
    33 ns
  • Bipolar disorder () 23a 8ab 7ab
    2b lt.001
  • Anxiety () 26 25 19 28
    ns
  • Substance/alcohol () 84a 72a 42b
    42b lt.001
  • Cluster B personality
  • disorders () 43a 19ab
    15bc 4c lt.001

26
Pre-Death Psychiatric History and the Caregiving
Adults
  • S A N C p
  • N (Caregivers) 43 36 60 101
  • Past psychiatric
  • disorders (any) () 86 a 69a, b 64b 56b
    lt.01
  • Past depression () 63 a 42a, b 40b 31b
    lt.01
  • Past anxiety () 35 a 33a 35a 14b lt.01

27
Pre-death Psychiatric History and Family
Adversity
  • S A N C p
  • N (reChildren) 66 51 94 183
  • Sexual Abuse () 3a,b 8a 4a,b 1b
    lt.05
  • Physical Abuse () 5a,b 4a,b 0a,b 1b
    lt.05
  • Past disorder
  • Any disorder() 46a 33a,b 32a,b 23b lt.01
  • Behavioral disorder () 14a 12a 11a
    4b lt.05
  • Mood disorder () 17 20 12 8 ns
  • Anxiety disorder () 12 8 6 8
    ns

28
Bereavement Sequelae in Children at 9-months
after Parental Death
  • S A N C
    p
  • N (Children) 66 51 94
    183
  • New-onset disorder () 39a 32a,b
    49a 24b .001
  • New-onset MDD () 23a 20a
    21a 6b lt.001
  • New-onset PTSD () 11a 2a,b
    11a 0b lt.001
  • Depression .37a .21a .13a
    -.23b lt.001
  • PTSD 7.3a 3.5b 5.7a
    1.1b lt.001
  • SIQ (suicide ideation) 25.2a 21.9a
    21.3a 19.8b lt.02
  • CGAS (functioning) 76a 78a,b
    76a 82b lt.001
  • ICG (complicated grief 59.2 53.6
    52.8 --- ns

S Suicide A Accident N Natural C
Controls Superscripts that are different
indicate significant pairwise difference.
Standardized scores.
29
Bereavement Sequelae in Caregiving Adults
  • S A N C p
  • N (Caregivers) 43 36 60 101
  • New-onset depression () 28 36 35
    11 lt.001
  • New-onset PTSD () 26 31 23
    1 lt.001
  • BDI (depression) 12.5 13.4 11.9 4.9
    lt.001
  • BAI (anxiety) 10.7 10 8.5 4.2
    lt.001
  • PTSD 12.4 10 8.8 1.8 lt.001
  • SIQ (suicide ideation) 26.7 28.5 26.2
    19.3 lt.001
  • GAS (functioning) 72 75
    75 82 lt.001
  • ICG ( complicated grief) 32 25 31
    na ns

S Suicide A Accident N Natural C
Controls Superscripts that are different
indicate significant pairwise difference.
Above clinical cutpoint of 25.
30
Risk of New Onset Depression in Children by
Type of Parental Death
Kaplan Meier for New-Onset Depression by Type of
Death
0.50
0.40
0.30
0.20
1-Survival Probability
0.10
0.00
0
10
20
30
Time to Onset Since Death (months)
Suicide
Accident
Natural
Control
31
Predictor of MDD within First Year
  • Adjusted risk (IR) 2.6 (95 CI 1.2-6.9)
  • within bereaved
  • Higher care giving function protective (OR
    .93, 95 CI .88-.99)
  • Last conversation was confiding (OR4.8, 95 CI
    1.4 - 17.1)

32
Impact of Parental Death on Children Over 1st Two
Years ()
  • Bereaved Controls P IR
  • New-onset depression 27 11.5 lt.001
    2.6
  • New-onset, recurrent
  • ongoing (depression) 16 8.4
    .04
  • Substance abuse 4.5 0
    lt.02

33
Predictors of PTSD in Children (Within Bereaved
Only)
  • OR 95CI
  • Past history of psychiatric
    10.7 1.2-97.7
  • disorder
  • Family history of PTSD 12 1.9-78
  • Being at the scene of death 12.4 1.2-130
  • Confiding conversation .08
    (.006-.99)

34
Predictors of New-Onset Depression through Year 2
  • HR 95CI
  • Bereavement 3.8 27.3
  • Child history of
  • depression 2.6 1.5-4.6
  • Caregiver function (higher) .97 .95-.98
  • Not living with natural mother 1.9
    1.5-2.4
  • Child negative coping 1.3
    1.0-1.6

35
Pathways from Parental Loss to Child New-Onset
Depression
36
Global Health
Bereaved Controls P Baseline
1.4(.55) 1.3(.57) .26 Year 1 1.6
(.71) 1.4(.58) .00 Year 2 1.6 (.63) 1.4 (.58)
lt.03
37
Complicated Grief (1)
  • Inventory of complicated grief Revised (ICG-R)
    ? .94
  • 3 Factors
  • Yearning/Preoccupational/Anger
  • Numbness/lack of safety and control/startle
  • Avoidance, detactment
  • Similar to Sandlers intrusive grief,
    affective reaction, and social attachment

Sandler et al., 2003 Melhem et al., in press
38
Complicated Grief (2)
  • All factors show high internal consistency
  • (? .79-.93) and correlation with total
  • (r.78-.95)
  • ICG-R Correlates with depression (r.47), PTSD
    (r.62), anxiety (r.45), CGAS (r.38)
  • Relationship to impairment persisted after
    controlling for PTSD and depression
  • Melhem et al., in press

39
Prevention Study (Sandler et al., 2003)
  • Bereaved youth, 6-30 months after parent loss
  • Groups for parents and for children (random
    assignment)
  • Targeted childrens active coping, efficacy,
    threat appraisal, open expression, positive
    parenting
  • Improvement in int/ext symptoms up to 3 years
    after death, mainly in girls

40
Conclusions (1)
  • Parent loss increases risk for depression, PTSD,
    substance abuse, behavioral disorders, global
    health
  • Circumstances of death relevant for depression,
    PTSD
  • Effect is above and beyond pre-death risk factors

41
Conclusions (2)
  • Mediated by caregiver function, life events,
    positive parenting, child coping, and threat
    appraisal
  • CG appears to be real
  • Unclear if suicide bereavement is worse

42
Limitations
  • Hard to prove it is a representative sample
  • Not diverse
  • Did not study homicide

43
Future Plans
  • Longer-term follow-up
  • Broader assessment of outcomes
  • More definitive tests of model
  • Develop interventions based on findings
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