Parental Loss in Children Tied to Long-term Functional Impairment

Megan Brooks

July 03, 2018

Children who suffer the death of a parent, particularly before age 12, are at increased risk of developing a psychiatric disorder, especially depression and posttraumatic stress disorder (PTSD), new research show.

"It is important to routinely assess youth after the loss of a parent, due to the initial high rates of disorder after death and because detection and treatment of these disorders can reduce the risk of long-term functional impairment," David Brent, MD, from University of Pittsburgh Medical Center in Pennsylvania, told Medscape Medical News.

"Support of the surviving parent is also critical in protecting youth from the burden of bereavement," he noted.

The study was published online June 20 in the American Journal of Psychiatry.

Early and Enduring Impact

To gauge the long-term impact of losing a parent, the researchers followed for up to 7 years 216 children (mean age, 12 years; 104 girls) who had lost a parent to suicide, accident, or sudden natural death, as well as 172 nonbereaved youths (mean age, 12 years, 84 girls).

Compared with nonbereaved youth, the incidence of depression was increased in bereaved youth during the first 2 years after the loss (incidence rate ratio [IRR], 3.13; 95% confidence interval [CI], 1.89 - 5.40), but not thereafter (IRR, 1.24; 95% CI, 0.70 to 2.20). Bereavement increased the incidence of depression, even after adjusting for predeath risk factors (adjusted hazard ratio [aHR], 2.67; 95% CI, 1.58 - 4.51).

Age was a factor in depression onset after the death of a parent, with the risk higher in children who lost a parent at age 12 or younger (aHR, 4.92; 95% CI, 2.04 - 11.87) but not in those who lost a parent during adolescence (aHR, 1.15; 95% CI, 0.69 - 1.90).

"The loss of a parent conveyed an early and enduring negative impact on the functioning of offspring that was in part mediated by the onset of depression beginning early in the course of bereavement," the researchers note in their article.

For children who lost a parent, there was also an increase in the incidence of PTSD in the first 2 years after the loss (IRR, 10.41; 95% CI, 2.57 - 91.10) but not thereafter. Bereavement increased the incidence of PTSD, even after adjusting for predeath risk variables (aHR, 5.66; 95% CI, 1.95 - 16.40).

There were no significant effects of bereavement on the incidence of anxiety, alcohol or drug abuse, bipolar disorder, or behavioral disorders (conduct disorder, oppositional defiant disorder).

Suicidal Thoughts

The researchers also found increased rates of clinically significant suicidal ideation at nearly all time points in bereaved children compared with their nonbereaved peers, consistent with other studies, although this seems to be related to risk factors present before the loss of a parent.

Nonetheless, "clinicians should be aware that parentally bereaved youths are at increased risk for clinically significant suicidal ideation," write Brent and colleagues.

It's also important to note that lifetime rates of several psychiatric disorders, including bipolar disorder, substance use disorder, and personality disorder, were higher among the deceased parents in the study compared with living counterparts. These findings "serve as a reminder that parents with a psychiatric disorder are at increased risk for premature death," the authors note.

"Since psychiatrically ill parents are at increased risk to die prematurely, collaboration between psychiatrists and primary care physicians is essential to reduce the risk of premature death in this vulnerable population, which then would reduce the incidence of parental bereavement," Brent told Medscape Medical News.

Death of a parent is perceived by many surviving children as a traumatic loss. Dr Sherry Cormier

Commenting on the findings for Medscape Medical News, Sherry Cormier, PhD, psychologist from Edgewater, Maryland, who specializes in grief and bereavement, said it's "wonderful to have a study that assesses the parameters of bereavement over the period of a number of years following a traumatic loss rather than soon after the loss event itself. We have too few longitudinal studies of bereavement. We know that grief shifts over time and does not change in the ways we used to believe it did, eg, according to linear 'stages.' "

One noteworthy finding, said Cormier, is that children aged 12 years and younger are more likely to experience depression in the first 2 years following the parental loss compared to adolescents aged 13 to 17 in the study.

"This is probably because adolescents are more connected to and dependent on their peers for emotional support than younger children, who are more connected to and dependent on their parents for emotional support," she noted.

"The younger child is more likely to feel the absence of the deceased parent and the resulting changes in the family system than the teenager. Monitoring and treating depression in these younger kids, as well as providing parent training with the surviving parent and family therapy, would be especially important treatment targets in working with bereaved children 12 and under," said Cormier.

"Moreover, making sure that treatment interventions occur earlier rather than later in the bereavement process is especially important, since the incidence of depression was found to impact later functioning in an adverse way, and since suicidal ideation also was heightened for the bereaved youth, even as long as 7 years following the parental death," she added.

The PTSD finding, said Cormier, "suggests that death of a parent is perceived by many surviving children as a traumatic loss. For these youth, treatment interventions will also need to focus on and address this event as a trauma in addition to a loss. Interventions will be needed that not only support the youth through the processes of grieving the lost parent but also help the youth process the traumatic loss emotionally and cognitively," said Cormier.

The study was supported in part by grants from the National Institute of Mental Health. Dr Brent receives royalties from Guilford Press and from the electronic self-rated version of the Columbia–Suicide Severity Rating Scale from eResearch Technology, is on the editorial board of UpToDate, is a reviewer for Healthwise, and is a consultant for McKesson. Dr Cormier is the author of Sweet Sorrow: A Psychologist's Surprising Discoveries About Life After Loss.

Am J Psychiatry. Published online June 20, 2018. Abstract

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