Journal of Adolescence 2001, 24, 159–169doi: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 inadolescents, the association between these experiences and depressive symptoms andthe attitudes of bereaved young people to professional interventions. The study wasbased on 1746 adolescents aged between 11 and 16 years from two secondary schoolsin Northern England. Questionnaire measures of bereavement experiences anddepressive symptoms were completed by the adolescents in the classroom. Onethousand three hundred and fifty-five (77?6%) reported that at least one of their first-or second-degree relatives or close friends had died. These losses were associated withincreased levels of depressive symptoms in comparison with the loss of other relativesor pets. The impact of the loss of someone close depended to an important extent onthe young person’s perception of how the loss had changed their lives. Mostadolescents did not feel the need for professional services. Those who did use theseservices had higher levels of depressive symptoms, suggesting that service use was likelyto 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 bothchildhood and adult life (Black, 1998). As a result, a variety of services exist for bereavedyoung people (Kaplan, 1992).

In planning such services, information is needed on several issues. The first is theprevalence of bereavement among adolescents. Mortality rates among the young and middleaged 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 closeto them. The second question is the extent to which bereavement is associated withpsychological distress and depressive symptoms. It could be that many bereaved young peopleremain symptom free and might not therefore require psychological help. The third issue iswhether bereaved youngsters feel the need for professional counselling. It could be that manyof them prefer to rely on other sources of comfort and support.

There has been surprisingly little research on bereaved young people (Garmezy andMasten, 1994). Most of the extant studies have been based on selected samples who havelost 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 ChildPsychiatry, Royal Manchester Children’s Hospital, Pendlebury, Manchester M27 4HA, U.K. (E-mail r.c.harring-ton@man.ac.uk).

0140-1971/01/020159+11 $35�00/0 # 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 attitudestowards 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 ofbereaved young people to professional interventions.

Method

SubjectsThe study was based on a convenience sample of two large secondary schools in NorthEngland. 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 questionnaireadministration and 71 (4%) refused to take part]. The average age of those who participatedwas 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 remaindercoming from other ethnic groups.

MeasuresTwo questionnaire measures were completed by the adolescents in the classroom. The firstwas 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 theirlives, how much effect they felt it had), whether they felt the need for professional help, andwhom they had talked to about it. Test–retest reliability of the adolescents’ recollections ofdeaths was examined in a random sample of 29 cases who repeated the questionnaires16 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 Moodand Feelings Questionnaire [MFQ (Angold et al., 1987)], which is measure of depressivesymptoms of known reliability and validity (Wood et al., 1995).

Results

Deaths of significant othersTable 1 shows the prevalence of deaths known to adolescents ‘ever’ and within the last 5years. 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 whohad ever died. The maximum number of human losses was 10 per subject (median 2). Fourpercent (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 allyoung people. Therefore the probability that a child would experience a particular type ofdeath 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 about5 per cent (this figure includes stillbirths).

Table 1 Deaths reported by adolescents

Deaths ever* Deaths in last 5 years

n (%) Risk+ n (%)

Parent/s 71 (4?1) 0?06 33 (1?9)Sibling/s 89 (5?1) 0?05 18 (1?0)Grandparent/s 1153 (66?0) 0?77 542 (31?0)Uncle or aunt/s 407 (23?3) 0?32 236 (13?5)Close friend/s 189 (10?8) 0?16 135 (7?7)Treasured pet/s 831 (47?6) 0?56 587 (33?6)Other significant 338 (19?4) 0?27 205 (11?7)relative/s

n=1746.*Before or after the subject’s birth.{Cumulative risk up to 16 years calculated in survival analysis.

Bereavement in adolescence 161

Association of deaths and current depressive symptomsTable 2 shows the bivariate associations between these deaths and self-reported depressivesymptoms. Deaths of parents, siblings, grandparents, aunts/uncles and close friends were allassociated with increased levels of current depressive symptoms.

It will be appreciated that there was much overlap between these deaths, and in some thiswas more than would be expected by chance. For example, adolescents who had lost a parentthrough death were more likely to report the loss of an uncle or aunt through death (24/71 or33?8%) than adolescents who had not lost a parent (383/1675 or 22?9%), a significantdifference (w2 = 4?6, p50?05). Therefore the association of deaths and depressive symptomswas examined simultaneously within a multiple regression, with age, gender and school alsoadded to the equation. In this multivariate analysis, all the deaths that had been associatedwith depressive symptoms in the univariate analyses (Table 2) continued to be significantlyassociated (t43?5 and p50?001) with these symptoms, except death of a parent where theassociation was still significant but a little weaker (beta = 0?06, t=2?5, p=0?01). Death ofother relatives was not significantly associated with depressive symptoms and death of a petwas only just significant (p=0?03). R2 for the model was just 0?10, suggesting that manyother factors influenced variation in MFQ scores.

Depressive symptoms in young people can be conceptualized as a category as well as asymptoms dimension (Harrington et al., 1996). Therefore, in line with previous research withthe MFQ (Wood et al., 1995), a cut-point of 24 was used to define a group of adolescentswith a depression category. This category was also associated with losses. For instance, youngpeople who had lost a first-degree relative, grandparent, uncle/aunt or friend, had a higherrisk of the depression category than those who had not (297/1338 or 22?2% vs. 51/386 or13?2%, respectively; odds ratio 1?9, 95% confidence interval 1?4–2?6).

Features of bereavements that predicted depressive symptomsIt seemed, then, that loss of FDRs or SDRs or friends was associated with depressivesymptoms. The association between depressive symptoms and loss of other relatives or oftreasured pets was less strong. To explore further the issue of which kinds of bereavementswere 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

Table 2 Bivariate associations between deaths and self-reports of depressive symptoms on theMood and Feelings Questionnaire*

Death No death Mean difference

n Mean (S.D.) n Mean (S.D.) (95% confidenceinterval)

t p

Parent/s 70 19?7 (13?3) 1654 14?9 (11?9) 4?8 (1?9–7?7) 3?3 0?001Sibling/s 87 21?9 (12?8) 1637 14?8 (11?9) 7?1 (4?6–9?7) 5?4 0?000Grandparent/s 1137 15?8 (12?1) 587 13?8 (11?7) 2?0 (0?8–3?2) 3?3 0?001Uncle or aunt/s 404 17?2 (12?4) 1320 14?5 (11?8) 2?8 (1?4–4?1) 4?1 0?000Close friend/s 186 21?4 (13?9) 1538 14?4 (11?6) 7?1 (5?3–8?9) 7?7 0?000Treasured pet/s 823 15?5 (12?1) 901 14?7 (12?0) 0?8 (70?4–1?9) 1?4 0?2Other significant 337 16?1 (12?1) 1387 14?9 (12?0) 1?2 (70?2–2?7) 1?7 0?09

relative/s

*MFQ data were missing on 22 cases.

162 L. Harrison and R. Harrington

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 variancewith post-hoc Tukey tests, the differences between the last two groups and the no-loss groupwere significant (p50?000), but that between the no-loss group and the other relative/petsgroup 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 losses24?4 (n=52, S.D. 13?3). Adolescents who experienced four losses or more had a much higherrisk of the depression category (22/52 or 42?3%) than adolescents who had neverexperienced a loss (13/130 or 10?0%), with an odds ratio of 6?6 (95% confidence interval3?0–14?6).

Deaths that had occurred more than 5 years before were just as likely to be associated withdepressive symptoms as deaths that had occurred more recently. For instance, the meanMFQ 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 morethan 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 hadexperienced the death of a near relative or friend (parent, sib, aunt/uncle, grandparent orfriend), 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 dependedcrucially on the type of loss. Thus, when change of life was added to the regression equationdescribed in the previous section, the effects of loss of parent, grandparents, and aunts/unclesall became non-significant. The implication is that the effects of this kind of loss depend toan important extent on the changes they bring about in the child’s life. By contrast, theeffects of loss of siblings or friends were not materially altered by adding life changes to theregression equation, suggesting that their effects were not mediated by these changes.

Help seekingIt seemed, then, many adolescents had experienced the death of near relatives or friends andthat exposure to such deaths was associated with increased levels of depressive symptoms.

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

Extent of change to life n Mean (S.D.)

Not much 407 10?7 (9?5)A little 523 16?0 (10?8)A lot 286 20?2 (13?1)Enormously 86 27?5 (14?4)

*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 betweeneach group and all the others was significant at p50?001.

Table 4 Who adolescents talked with about death/s

Amount of talking

Talked with Never Rarely Sometimes Often A lot

Parents, n (%) 267 (20?4) 407 (31?1) 419 (32) 177 (13?5) 39 (3?0)Other adults in the family, n (%) 513 (39?2) 417 (31?9) 287 (21?9) 76 (5?8) 15 (1?1)Siblings, n (%) 596 (46?3) 344 (26?7) 230 (17?9) 92 (7?1) 25 (1?9)Friends, n (%) 529 (40?4) 374 (28?6) 299 (22?9) 82 (6?3) 24 (1?8)School counselor, n (%) 1298 (96?8) 28 (2?1) 10 (0?8) 2 (0?2) 2 (0?2)Primary care professional*, n (%) 1214 (92?6) 63 (4?8) 21 (1?6) 7 (0?5) 2 (0?2)Bereavement counselor{, n (%) 1265 (95?9) 36 (2?7) 12 (0?9) 5 (0?4) 1 (0?1)Child mental health professional, n (%) 1262 (96?5) 30 (2?3) 11 (0?8) 3 (0?2) 2 (0?2)

*General practitioner, practice nurse, practice counsellor, health visitor.{E.g. Macmillan nurse.

Bereavement in adolescence 163

The next question was whether adolescents felt the need for some kind of help to deal withtheir feelings about these deaths.

Adolescents’ attitudes towards help were examined within the sample who hadexperienced the death of someone close (n=1355; see Table 4), as this group had elevatedMFQ scores and might therefore be expected to be interested in seeking help. There wereseveral findings. First, most adolescents (n=1143/1318 or 87%; data were missing on 37cases) said that they had never, rarely or only sometimes talked about the deaths of relativesor friends. Second, talking about deaths was associated with higher levels of depressivesymptoms. Thus, adolescents who said they had ‘‘often’’ or ‘‘always’’ talked about death hadmuch 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, df1301, p = 0?000. This relationship held even when age, gender, school, person who died, andthe amount the death had changed life, were controlled in a multiple regression. Third, mostadolescents stated that they never or only rarely needed professional help for the way theywere 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 theirbereavements. As the table indicates, most adolescents had not talked with healthprofessionals about their bereavement experiences. Of those that did talk to others about

164 L. Harrison and R. Harrington

these experiences, the most common people chosen to talk to were parents, other adultswithin the family, and friends. On all of the scales shown in Table 4, more frequent talkingwas associated with greater levels of depression. For instance, adolescents who had had anykind 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 othersSo 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 arelative or friend through death was a common experience. Indeed, young people who didnot experience the death of a significant other were in a minority.

Association of deaths of significant others and depressive symptomsIn line with non-community studies (Van Eerdewegh et al., 1982; Weller et al., 1991; Brentet al., 1992), we found that loss of a parent or close friend was associated with depressivesymptoms. Our results extend previous research in suggesting that depressive symptoms arealso associated with other more common deaths, such as of grandparents. This finding isimportant because if it reflects a causal mechanism, then it suggests that bereavementaccounts 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 thatthis association is causal. Indeed, one of our findings was not consistent with a causalrelationship between bereavement and depressive symptoms. Longitudinal research onbereaved children suggests that depressive symptoms usually decrease over time (Silvermanand Worden, 1992), so it would be expected that recent losses would have a strongerassociation with depressive symptoms than more distant ones. We found no relationshipbetween timing of a loss and depressive symptoms.

It could be, then, that the association between the deaths of significant others anddepressive symptoms is partly induced by the association of both with some third variablethat was not measured in our study, such as family dysfunction. On the other hand, thefinding of a ‘‘dose–response’’ relationship between the numbers of losses and the severity ofdepression suggests that there may be an aetiological link between the two. Longitudinalresearch with better measures of the consequences of bereavement and of other risk factorsfor depression would help to resolve this issue. Such research should also measure otherkinds of psychological symptoms, such as anxiety, as these might also be increased afterbereavement.

Services for bereaved young peopleOur 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 professionalhelp. Those that did want to talk about their bereavement experiences were often able to doso with relatives or friends. There is little support, then, among adolescent themselves for thewidespread development of specialized bereavement counselling services. However, in a smallnumber of cases young people did feel the need for professional help and some of them got it.

Bereavement in adolescence 165

Since this group had high levels of depressive symptoms it would seem that these referralswere appropriate.

Our research suggests that the impact of bereavement may be mediated in someinstances by the changes it brings about in the child’s life. Interventions to target thesechanges, such as family work, may therefore be required. Indeed, one of the programmesthat 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. Bereavementservices for adolescents therefore need to be able to call upon a range of differentinterventions.

References

Angold, A., Costello, E. J., Pickles, A. and Winder, F. (1987). The Development of a Questionnaire for usein 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 andacquaintances 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 inadolescence 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: multiplemeanings, antecedents and endpoints. Development and Psychopathology, 8, 601–616.

Kaplan, C. (Ed.) (1992). Bereaved Children. Occasional Papers No. 7. London: Association of ChildPsychology 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). Linkingempirically based theory and evaluation: the family bereavement program. American Journal ofCommunity Psychology, 20, 491–521.

Silverman, P. R. and Worden, J. W. (1992). Children’s reactions in the early months after the death of aparent. American Journal of Orthopsychiatry, 62, 93–104.

Van Eerdewegh, M. M., Bieri, M. D., Parrilla, R. H. and Clayton, P. (1982). The bereaved child. BritishJournal of Psychiatry, 140, 23–29.

Weller, R. A., Weller, E. B., Fristad, M. A. and Bowes, J. M. (1991). Depression in recently bereavedprepubertal children. American Journal of Psychiatry, 148, 1536–1540.

Wood, A., Kroll, L., Moore, A. and Harrington, R. C. (1995). Properties of the Mood and FeelingsQuestionnaire in adolescent psychiatric outpatients: a research note. Journal of Child Psychologyand Psychiatry, 36, 327–334.

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Appendix

BEREAVEMENT QUESTIONNAIREFOR 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 asksfor 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 YES NO IF YES YEAR OF DEATH

GRANDMOTHER 6 1994

FATHER 6

TREASURED PET 6 DOG-1995

Bereavement in adolescence 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 boxesin question 4.

168 L. Harrison and R. Harrington

Id. Number.............

IN THE SECTION THAT FOLLOWS WE WOULD LIKE YOU TO PUT A LINETHROUGH 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 Never

2. The loss(es) changed my lifeEnormously A lot A little It didn’t change my life much

3. I got over the loss(es)Straight away Quickly Slowly I never got over it

4. I felt I needed more professional helpAlways Often Sometimes Rarely Never

5. Since the death(s) I have talked about it with:

a) my parent(s)Always Often Sometimes Rarely Never

b) ‘other adult(s) in my familyAlways 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 CounsellorAlways Often Sometimes Rarely Never

Bereavement in adolescence 169

Id. Number.............

f ) my GP/Family Doctor or Health VisitorAlways Often Sometimes Rarely Never

g) A Special Bereavement Counsellor/Macmillan NurseAlways Often Sometimes Rarely Never

h) a Child Psychiatrist/Child PsychologistAlways Often Sometimes Rarely Never

Thankyou very much for your help. Please ensure your I.D. Number is on each page.