grief and trauma in children after the death of a sibling

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71 Journal of Child & Adolescent Trauma, 2:71–80, 2009 Copyright © Taylor & Francis Group, LLC ISSN: 1936-1521 print / 1936-153X online DOI: 10.1080/19361520902861913 WCAT 1936-1521 1936-153X Journal of Child & Adolescent Trauma, Vol. 2, No. 2, April 2009: pp. 1–19 Journal of Child & Adolescent Trauma Research on Trauma and Loss Grief and Trauma in Children After the Death of a Sibling Grief and Trauma M. M. Paris et al. MEGAN M. PARIS, 1,2 BRIAN L. CARTER, 2 SUSAN X. DAY, 1 AND MARY W. ARMSWORTH 1 1 University of Houston 2 University of Texas M. D. Anderson Cancer Center Parent loss is understood as a fundamental loss to a child, but less is known about the consequences of a sibling’s death. The present study explored self-reported grief and trauma among 26 sibling-bereaved children to help inform effective support interven- tions. Grief and trauma scores were highly correlated in our sample, and there were no definitive differences based upon type of loss. The main limitation was a small sample, but our results provide ecologically valid information rather than data from children recruited for research purposes. Implications for continued data collection and publication from naturalistic settings and meta-analytic recommendations are discussed. Keywords sibling bereavement, childhood grief, trauma Introduction The death of a loved one is considered one of life’s most stressful events (Holmes & Rahe, 1967). In 2006 alone, approximately 2.4 million people died in the United States (Heron, Hoyert, Xu, Scott, & Tejada-Vera, 2008), with millions more left behind to cope with the loss. An examination of the personal process of coping with the loss of a loved one is important to help understand the components of healing, to minimize complications, and to maximize effective support. Childhood Grief Experience Distinguishing childhood grief from adults’ will help counselors recognize the unique features of childhood grief. Children will not necessarily interpret a loss as an adult would and may not benefit from the same kind of support. For example, social rituals (e.g., funerals Received September 3, 2008; revised November 17, 2008; revised February 19, 2009; accepted February 22, 2009. Address correspondence to Megan M. Paris, Department of Behavioral Science, Unit 1330, University of Texas M. D. Anderson Cancer Center, PO Box 301439, Houston, TX 77230–1439. E-mail: [email protected]

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Page 1: Grief and Trauma in Children After the Death of a Sibling

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Journal of Child & Adolescent Trauma, 2:71–80, 2009Copyright © Taylor & Francis Group, LLCISSN: 1936-1521 print / 1936-153X onlineDOI: 10.1080/19361520902861913

WCAT1936-15211936-153XJournal of Child & Adolescent Trauma, Vol. 2, No. 2, April 2009: pp. 1–19Journal of Child & Adolescent Trauma

Research on Trauma and Loss

Grief and Trauma in Children After the Death of a Sibling

Grief and TraumaM. M. Paris et al. MEGAN M. PARIS,1,2 BRIAN L. CARTER,2 SUSAN X. DAY,1

AND MARY W. ARMSWORTH1

1University of Houston2University of Texas M. D. Anderson Cancer Center

Parent loss is understood as a fundamental loss to a child, but less is known about theconsequences of a sibling’s death. The present study explored self-reported grief andtrauma among 26 sibling-bereaved children to help inform effective support interven-tions. Grief and trauma scores were highly correlated in our sample, and there wereno definitive differences based upon type of loss. The main limitation was a smallsample, but our results provide ecologically valid information rather than data fromchildren recruited for research purposes. Implications for continued data collectionand publication from naturalistic settings and meta-analytic recommendations arediscussed.

Keywords sibling bereavement, childhood grief, trauma

Introduction

The death of a loved one is considered one of life’s most stressful events (Holmes & Rahe,1967). In 2006 alone, approximately 2.4 million people died in the United States (Heron,Hoyert, Xu, Scott, & Tejada-Vera, 2008), with millions more left behind to cope with theloss. An examination of the personal process of coping with the loss of a loved one isimportant to help understand the components of healing, to minimize complications, andto maximize effective support.

Childhood Grief Experience

Distinguishing childhood grief from adults’ will help counselors recognize the uniquefeatures of childhood grief. Children will not necessarily interpret a loss as an adult wouldand may not benefit from the same kind of support. For example, social rituals (e.g., funerals

Received September 3, 2008; revised November 17, 2008; revised February 19, 2009; acceptedFebruary 22, 2009.

Address correspondence to Megan M. Paris, Department of Behavioral Science, Unit 1330,University of Texas M. D. Anderson Cancer Center, PO Box 301439, Houston, TX 77230–1439.E-mail: [email protected]

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and memorial services) draw grieving individuals together to relieve the pain of loss andfinal separation from loved ones, but these rituals may lack relevance for naïve and devel-oping children (McCown & Davies, 1995). Children may react to grief with feelings similarto adults’, such as denial, anger, guilt, sadness, and longing, but childhood grief reactionsdiffer in manifestation and duration and cannot be conceptualized from an adult perspec-tive (Osterweis, Solomon, & Green, 1984; Webb, 2002).

The type of loss in childhood receiving the most attention in contemporary literature is theloss of a parent, which is widely understood as a fundamental loss to a child (Berlinsky &Biller, 1982; Dowdney, 2000; Worden, 1996; Worden, Davies, & McCown, 1999). Incontrast, much less is known about the consequences of the death of a sibling. For survivingchildren, the “death of a sibling marks an end to what is expected to be one of the longestand sometimes most intimate relationships of a lifetime” (Robinson & Mahon, 1997, p. 477).

Normal Grief

Uncomplicated bereavement is used in the Diagnostic and Statistical Manual of MentalDisorders (DSM-IV-TR; American Psychiatric Association [APA], 2000) to describe thetypical grieving process in which individuals adjust to the death of a loved one, character-ized by symptoms similar to depression, including intense sadness, sleep and appetiteproblems, lack of interest in regular activities, and difficulty concentrating. Researchershave long sought to identify and describe common features of individuals’ grief experi-ences, and stage models for the normal grieving process have maintained popularity inpsychological literature (Kübler-Ross, 1969; Parkes, 1986; Worden, 1996), perhaps becausethey provide a clear beginning, middle, and end to an experience that often feels intermi-nable (Gilbert, 2008).

Normal grief is expected in response to the death of a loved one, especially when thedeath is anticipated or occurs as a peaceful or timely encounter. Other deaths, such ashomicides, suicides, sudden illnesses, or accidents, are shocking and traumatic by theirvery nature and may interfere with the normal grieving process (Raphael & Martinek,1997).

Traumatic Grief

In contrast to normal grief, some argue that circumstances of the loss and/or survivors’characteristics may result in trauma. The DSM-IV-TR (APA, 2000) describes traumasymptoms of posttraumatic stress disorder (PTSD) resulting from exposure to an eventinvolving actual or threatened death that include reexperiencing, avoidance, and increasedarousal. Beginning with Lindemann’s (1944) classic description of the symptomatologyand management of grief from his work with survivors of the Cocoanut Grove nightclubfire in Boston, differences between grief and trauma have long been acknowledged. How-ever, there are differing opinions within the psychological community regarding theirprecise roles in bereavement. Some researchers separate normal grief from pathological ortraumatic grief as distinct categories of experience appropriate for diagnosis as a psycho-logical disorder (Horowitz et al., 1997; Jacobs, Mazure, & Prigerson, 2000; Prigerson et al.,1999). Trauma symptoms may complicate children’s bereavement response and preventthem from successfully negotiating normal grief (Cohen & Mannarino, 2004). Othersargue this distinction may not be warranted (Hogan, Worden, & Schmidt, 2003–2004),and grief and trauma instead function together as a combined reaction to certain types oflosses (Brom & Kleber, 2000; Nader, 1997).

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Poor understanding of trauma and grief in childhood bereavement and the tendency toimpose adult models of grieving onto children have resulted in confusion (McCown &Davies, 1995). Loss in childhood should be understood in terms of a child’s cognitive,emotional, and social development. Mahon (1993) found that developmental level and agewere significant predictors of children’s accurate concept of death, which may affect achild’s grief and trauma responses. The childhood grieving process is complex in partbecause children’s immature cognitive development can interfere with their understandingof the concepts of the irreversibility, universality, and inevitability of death (Webb, 2002). Inaddition, since childhood development is ongoing, grief and feelings of loss are often repeat-edly processed as children become more capable of understanding their loss (Oltjenbruns,2001). This reprocessing can cause children’s grief reactions to occur for a much longerperiod of time than adults’ grief reactions. Therefore, we thought it important to studychildren’s reactions to expected and unexpected sibling losses.

Sibling Loss

Previous studies have shown children who have lost siblings are at an overall higher risk thannon-bereaved peers for behavior problems (McCown & Pratt, 1985). Although siblings’reported experiences vary widely, even within the same family (Mahon & Page, 1995),behavior problems are a common manifestation of grief in children (McCown & Pratt,1985), especially young children (McCown & Davies, 1995), and may include aggressivesymptoms like frequent arguing and demands for attention. This connection between griefand behavior problems confirms a need to understand children’s experience of siblingdeath.

Previous findings indicate gender may be an important variable in a child’s responseto loss. Worden et al. (1999) suggested gender differences in children’s grief experiencesmay depend on the type of loss (parent or sibling) and characteristics of the deceased.Worden (1996) found that reactions to parent loss were largely related to the gender of thedeceased and to some extent the gender of the child. Previous studies have reported girlswho experienced a sibling loss scored an average of one half year lower on standardizedGeneral Certificate of Secondary Education exams than parent-loss children (Abdelnoor& Hollins, 2004). Male and female siblings with deceased brothers have demonstratedmore behavior problems than other bereaved siblings (McCown & Pratt, 1985).

Rationale for Present Study

The purpose of the present study was to investigate the impact of type of sibling loss ontrauma and grief reactions using children’s self report. Findings on childhood siblingbereavement have most commonly been obtained by parent report. One may argue thatparents know their children best and are therefore the most reliable source for an accuratedescription of their behavior and experiences. However, Hogan and Balk (1990) foundthat bereaved mothers held a much more favorable view of their bereaved children’s self-concept than fathers, and mothers considered their children’s grief reactions more enduringthan did fathers or the children themselves. Broadening the scope of inquiry to include thechild’s direct perspective is necessary for a more accurate picture of childhood grief.

The present study also sought to gain an ecologically valid perspective of what childrenmay be experiencing when they seek community support. Support groups, commoncommunity-based interventions for grieving families, have been shown to be effectivetools to facilitate healing after the loss of a loved one. Children can learn to share their

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feelings, discover that they are not alone, and move through the grief process (Healy-Romanello, 1993). Are the circumstances of sibling death, foreseen or unexpected, adetermining factor of children’s reactions to sibling loss? If so, this variable may haveimportant implications for the way in which bereaved siblings are offered support. Forexample, in the present study, the community organization in which children enrolledoffers an 8-week program with a specialized curriculum for children coping withtraumatic losses. Children who experienced a sudden loss are encouraged to attend thisprogram before enrolling in ongoing grief support groups. However, Brown, Sandler,Tein, Liu, and Haine (2007) found similarities in adjustment outcomes for different typesof parental death and argued similar support interventions are likely to be helpful forchildren coping with all causes of death. Findings from the present study may justify orquestion such classification of children for intervention purposes. Increased knowledge ofsibling-bereaved children’s experience of grief and trauma will help distinguish the fea-tures of these reactions and guide appropriate community interventions.

We hypothesized that siblings who experienced a sudden death (e.g., homicide, suicide,accident, or sudden illness) would report higher levels of trauma compared to siblings whoexperienced an anticipated death (e.g., long-term or chronic illness). Conversely, siblingswho experienced an anticipated death would report higher levels of grief than childrenwho experienced a sudden death. In addition, the present study sought to explore otherpossible factors that may influence children’s reactions to sibling death (e.g., age, genderof the bereaved, gender of the deceased, and the match between siblings’ genders). Resultsmay help clarify previous inconsistencies regarding characteristics of bereaved siblingsand their influences on grief and trauma reactions.

Method

Participants

Participants were 26 children, ages 9–18, who experienced the death of a sibling. Theywere drawn from 22 families that sought support services from a non-profit organizationin a large metropolitan area that offers free specialized trauma programs and ongoing griefsupport groups to bereaved children and their families. All children who lost a sibling andattended a program orientation session during a 15-month period were included in thestudy (see Table 1 for a description of the sample). These data were collected when familiesattended an orientation meeting after enrollment at the community organization. Thenature of the study and details of participation were explained, and measures were adminis-tered by support group facilitators trained in consent and assessment procedures. Participantswere later sorted into two groups, according to whether their siblings’ death was sudden oranticipated.

An earlier study using data from children who lost parents (see Meagher, 2007) and thestudy reported here were both designed in conjunction with the grief support organizationand were approved by the researchers’ institutional review board.

Measures

Basic demographic information was obtained from a brief questionnaire created for thepresent study, and any missing information was collected from the organization’s records.Grief symptoms were assessed using the child (ages 9–12) and adolescent (ages 13–18)forms of the Hogan Inventory of Bereavement (HIB, formerly called Hogan Sibling

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Inventory of Bereavement; Hogan, 1988; Hogan & DeSantis, 1996). The HIB consists of46 items to which children are asked to respond on a 5-point scale ranging from 1 (Does notdescribe me at all) to 5 (Describes me very well). A sample item from the scale is “I don’tthink I will ever be happy again.” Factor analytic studies using the HIB have identifiedtwo factors: Grief (Cronbach’s alpha = 0.90–0.95, 24 items) and Personal Growth (alpha =0.88–0.92, 22 items; Neimeyer & Hogan, 2001). Only the Grief factor was analyzed in thestudy reported here (Cronbach’s alpha = .92).

Trauma symptoms were assessed with the Impact of Events-8 (IES-8). The originalIES, developed by Horowitz, Wilner, and Alvarez (1979), is widely used as a measure ofposttraumatic stress symptoms in adults. An 8-item version has been developed for usewith children and adolescents (Dyregrov & Yule, 1995). The IES-8 measures traumaticstress symptoms of intrusion and avoidance and consists of eight statements on a 4-pointscale. For example, children are asked to respond to items such as “I thought about it whenI didn’t mean to” by circling a response ranging from “not at all” to “often.” The IES-8demonstrated a total Cronbach’s alpha of 0.75 when used with 9–14 year-olds (Smith,Perrin, Dyregrov, & Yule, 2003) and efficiently discriminated children with and without adiagnosis of PTSD (Stallard, Velleman, & Baldwin, 1999). In our study, Cronbach’s alphaon the IES-8 was 0.82.

Table 1Demographic information

Participants(n = 26)

Deceased siblings(n = 22)

Average Age 13.46 (SD = 3.10) 15.14 (SD = 6.41)

GenderBoys 13 17Girls 13 5

Type of Death

Sudden 17Accident 8 (4 M, 4 F)Homicide 4 (4 M)Suicide 1 (1 M)Sudden Illness 4 (3 M, 1 F)

Anticipated 5Cancer 2 (2 M)Heart Disease 2 (2 M)Chronic Illness 1 (1 M)

Race/EthnicityWhite 17Hispanic 5Biracial 3African American 1

Average Months Since Death to Program Orientation

4.41 (SD = 3.99)

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Results

We hypothesized that siblings who experienced a sudden death would report higher levelsof trauma compared to siblings who experienced an anticipated death, and siblings whoexperienced an anticipated death would report higher levels of grief than children whoexperienced a sudden death. Preliminary analysis revealed that grief scores on the HIBand the total stress score on the IES-8 were highly correlated, r(26) = 0.70, p < 0.001. Inother words, grief and trauma were difficult to distinguish in this group. Though means inTable 2 appear smaller in all cases for anticipated deaths, differences are not wide enoughfor us to draw conclusions due to gross inequality in cell size. Because of small samplesize and some interdependence of responses (the 26 children came from 22 families), datawere not appropriate for statistical comparison testing. Instead, we present relevant meanscores for boys and girls in Table 2. In this sample, boys and girls did not differ apprecia-bly, except for girls’ grief scores, which are notably higher and more variable than boys’.

We sought to explore characteristics that may influence children’s reactions to siblingdeath (e.g., age, gender of the bereaved, gender of the deceased, and the match betweensiblings’ genders). A meaningful representation of the association of deceased siblings’gender with the gender of participants was not possible because 17 of the deceased wereboys, 5 of the deceased were girls, and only 1 girl lost a sister. There was no correlationbetween age and grief or trauma, suggesting that the developmental differences between9 and 18 in this sample did not affect the severity of reported grief and trauma.

Discussion

Confusion remains regarding the precise experiences of trauma and grief in childhoodbereavement, and more empirical evidence is needed to clarify their interaction and meaningto children. The research reported here holds the advantage of studying children in a natu-ralistic setting rather than children recruited for research purposes. These children alsowere the source of the data, rather than their parents or teachers. However, the use of thissetting made for a small sample size, which precluded statistical conclusions from thestudy. The informative descriptive data are ecologically valid for children whose familiesseek help after the loss of a sibling. Though small, our sample was ethnically diverse andreflected national mortality statistics on gender and cause of death. According to Centers

Table 2Mean grief and trauma scores

Boys Girls

M SD n M SD n

Grief-Overall 52.69 9.67 13 69.69 22.16 13Grief-Sudden Deaths 53.83 9.14 12 72.50 25.85 8Grief-Anticipated Deaths 39.00 — 1 65.20 16.21 5Trauma-Overall 4.56 2.36 13 5.78 2.44 13Trauma-Sudden Deaths 4.67 2.43 12 6.53 2.08 8Trauma-Anticipated Deaths 3.25 — 1 4.60 2.73 5

Note. Grief scores range from 24–120 and trauma scores range from 0–10, with higher scoresindicating more severe reactions.

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for Disease Control and Prevention (2007), boys have higher mortality rates than girls,and accidents are the leading cause of death among children and adolescents; bothnational averages held true in our sample.

Our results failed to definitively support two hypotheses drawn from the literature:that sudden and anticipated loss would be different experiences and that trauma and griefwould be different experiences. Children demonstrated varying levels of grief and trauma,regardless of the type of loss they experienced, which may tentatively suggest that themanner in which a sibling dies neither inhibits nor enhances the surviving child’s emotionalresponse. Adults may benefit from the opportunity to anticipate and prepare for a loved one’sdeath. In fact, anticipatory bereavement is largely considered a psychologically therapeuticexperience for adults (Rando, 2000). However, unlike adults, children’s developmentallevel influences their concept of death (Mahon, 1993). An inaccurate concept of the finalityof death may interfere with a child’s ability to prepare for the reality of the loss. It is pos-sible that children may not be capable of preparing psychologically for anticipated death,so that even an anticipated death feels sudden or traumatic.

In this small sample, trauma and grief scores were highly correlated; thus, a cleardistinction between grief and trauma in children may be a dubious proposition. Traumaand grief may overlap to create a more complex response to bereavement, as reflected inBrom and Kleber’s (2000) integrated grief and trauma model, which may be functioningin participants in the present study and worthwhile for future investigation with a moresubstantial sample.

Integration of trauma and grief has been supported by other researchers studyingvarious populations. Sigman and Wilson (1998) surveyed women whose mothers diedthrough a variety of causes and found significant correlations between PTSD scales ofavoidance, intrusion, and hyperarousal on the Impact of Events Scale-Revised and 10 ofthe 12 subscales of the Grief Experience Inventory. Applebaum and Burns (1991) foundsymptoms of PTSD among adolescents an average of 35 months after their sibling’ssuicide. Although Applebaum and Burn’s (1991) study lacked a measure of grief, theseenduring trauma symptoms suggest that trauma may be a lasting component of grief,rather than a short-term obstacle to overcome.

Grief and trauma may, in fact, exist simultaneously as an interrelated set of processesthat are difficult to distinguish. Hogan et al. (2003–2004) examined the correlation of theproposed criteria of Complicated Grief Disorder, separation distress and traumaticdistress, and the factors of the Hogan Grief Reaction Checklist, a measure of normal adultgrief, and found that both instruments measured similar phenomena among bereavedadults. Further analysis revealed no evidence for complicated grief being conceptuallydifferent from normal grief.

The hypothesis that gender may influence children’s reactions to sibling death didfind partial support in this sample. In this study, boys and girls appeared generally equal interms of trauma, but female siblings reported greater grief after the loss than males. Thesefindings may influence how we conceptualize childhood experiences of grief and traumaand how we ask children about them. Girls are socialized to be nurturers and caregiversand may be more devastated by a sibling’s death than boys, who are often socialized to beindependent and strong. The present study lacked an assessment of behavioral responses,and perhaps its measures are better structured to assess emotional reactions more charac-teristic of girls and prohibited a complete picture of boys’ experiences. Girls may haveresponded to the emotional and psychological questions of the HIB more openly thanboys, while all siblings responded similarly to the IES-8, which asks about cognitive andphysiological reactions. Clarification is needed to determine whether girls in fact have

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more severe grief reactions or whether findings reflect gender-socialized responding.Future studies that incorporate a more comprehensive evaluation of both behavioral andpsychological assessments can compare boys and girls on both types of reactions for a bet-ter representation of responses to a sibling’s death.

A highly salient point from this study is that collecting these important data from anaturalistic setting (a grief support organization) is extremely difficult. Fewer sibling-bereaved children present for support compared to parent-bereaved children because deathin childhood is less prevalent than death in adulthood. Other factors such as turnoveramong organizational personnel, varying levels of interest and commitment to collectingdata for outside researchers, and attrition among program attendees combined to result insmall numbers of complete, usable data. We hope future studies find the data presentedhere informative for recruitment and organizational outreach purposes. To solve the smallsample problem, we encourage collaboration among researchers to promote collectionprocedures across several settings for a more substantial sample. Researchers may alsointegrate findings from small studies like ours using meta-analytic methods, thus achievingsamples large enough for statistical inference.

Research on childhood sibling loss is gaining attention, but the number of publishedstudies remains relatively small, perhaps in part due to the challenges of collecting suffi-cient data. Researchers should continue to collect and publish small sample size data fromreal-world settings for future researchers to agglomerate and present meaningful patterns.If we want ecologically valid information and not laboratory data, we need to continueconducting small studies that can be considered in aggregate. Continued efforts are impor-tant to better understand the relationship between trauma and grief and better anticipatepossible gender differences in children’s grief reactions. This increased knowledge willinform appropriate intervention strategies that effectively support bereaved siblings.

Note

An earlier version of this paper was presented at the 116th annual meeting of the American Psycho-logical Association held August 14–17, 2008 in Boston, MA.

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