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Patterns of grief in young childrenfollowing the death of a siblingDarlene E. McCown a c & Betty Davies ba Department of Nursing , St. John Fisher College ,Rochester, New York, USAb School of Nursing, University of British Columbia, andBritish Columbia's Children's Hospital , Vancouver, BritishColumbia, Canadac Department of Nursing , St. John Fisher College , 3690 EastAvenue, Rochester, NY, 14618Published online: 14 Aug 2007.

To cite this article: Darlene E. McCown & Betty Davies (1995) Patterns of grief inyoung children following the death of a sibling, Death Studies, 19:1, 41-53, DOI:10.1080/07481189508252712

To link to this article: http://dx.doi.org/10.1080/07481189508252712

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w m m m m m w m m w m w ~ m m m m m w w w m m m m m m m m m m ~ m m m w m m ~ m ~ m m m m m m m m ~

PATTERNS OF GRIEF IN YOUNG CHILDREN FOLLOWING THE DEATH OF A SIBLING

m w m m m m m m m m m ~ ~ w w m m m m m m m w w m m m m m m m m m m m m ~ w m m m m m m m m m m m ~

DARLENE E. McCOWN Department of Nursing, St. John Fisher College, Rochester, New York, USA

BE’ITY DAVIES

School of Nursing, University of British Columbia, and British Columbia’s Children’s Hospital, Vancouver, British Columbia, Canada

Spectfi grief behaviors observed in children ages 4-16 years in the 2 years aft.. the death of a sibling are reported. Using the Child Behavior Checklist (CBCL), the parents of 90 boys and girls rated the occurreme o f behavior problems in their children. Behavior problems identafied in 50% or more o f the children are reported both for the total sample and @ age and sex groups. The behaviors c o m m l y observed in the bereaved children predominant4 fell into the Ag<qession subscale of the standardized CBCL. It is suggested that bereaved children use aggressive behaviors instrmmntally to gain parental attention, rather than as an instinctual expression of hostility and angel:

The pictures of adult grief are painfully clear. The scenes are familiar-weeping, crying, somber clothing, sad countenances, and subdued voices. The images of childhood grief reflect strik- ing contrast and are unfocused-talking, playing, watching, and questioning. Early documentations of manifestations of adults’ responses to another’s death (Engle, 1964) and to anticipation of their own death (Kiibler-Ross, 1969) provided a classical model of grief that includes shock and denial, anger, depression, accep- tance, and restitution. Since that time, other descriptions of grief have evolved as the basis for interventions with the bereaved

Address correspondence to Darlene E. McCown, Department of Nursing, St. John Fisher College, 3690 East Avenue, Rochester, NY 14618.

Death Studies, 19:41-53, 1995 Copyright 0 1995 Taylor & Francis

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42 D. E. McCozcm and B. DavGs

(Johnson, 1987; Oaks & Ezell, 1993; Raphael, 1983; Worden, 1982). The authors of these descriptions indicate that social rit- uals such as wakes, funerals, burials, and memorials draw mour- ners together in an effort to relieve the adult’s pain of loss and final separation. However, death rituals may lack relevance for the naive, active, alert, and developing child (McCown, 1984; Siegel, 1985; Silverman & Worden, 1992).

Early research on children’s grief behavior was primarily nar- rative and anecdotal and identified serious problems that may interfere with the ongoing life of surviving children. The prob- lems described as frequently experienced by bereaved children include one or more of the following: school difficulties, somatic complaints, stomach and headaches, health fears, enuresis, sleep disturbances, jealousy and guilt, depression, and antisocial be- havior (Binger et al., 1969; Black & Urbanowicz, 1987; Cain, Fast, 8c Erickson, 1964; Fischhoff & O’Brien, 1976; Geiger, 1973; Go- gan, Koocher, Foster, & O’Malley, 1977; Lascari & Stehbens, 1973; Martinson, 1980; Martinson et al., 1978; Spinetta & Deasy- Spinetta, 1981 ; Tietz, McSherry, & Britt, 1977; Van Eerdewegh, Bieri, Parrilla, & Clayton, 1982).

i he sample sizes in these initial studies ranged 8 to 65 chil- dren. Most of the studies were retrospective, and the researchers failed to use comparison groups or standardized tools to measure specific behaviors. More recently, investigators have used stand- ardized tools to identify the extent of behavior problems com- pared to norms and to control for salient variables such as family environment, time since death, before-death behavior, age, and sex (Birenbaum, Robinson, Phillips, Stewart, & McCown, 1990; Davies, 1988; McCown, 1987). These studies have shown that bereaved siblings have significantly more behavior problems than does the normal population. Although these studies identified a general increase in behavior problems experienced by surviving siblings, they were not intended to describe systematically the specific behaviors observed in the bereaved siblings. Thus our purpose in the present study was to identify the specific behaviors parents reported observing in their children after a sibling’s death. We believe a systematic description of childhood grief be- haviors will enable parents and those who work with children to recognize common grief behaviors and ensure that bereaved chil-

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Grief in Children af& the Death of a Sibling 43

dren may be offered the understanding and support they need during times of bereavement.

Sample

The data of two studies of children’s behavior after the death of a sibling were combined (Davies, 1983, 1988; McCown, 1982, 1987). The subjects included 42 boys and 48 girls ages 4-16 years (M = 9.9 years, SD = 4 years) whose siblings had died 2-24 months earlier. The sample was drawn from Arizona; Washing- ton; Oregon; and Alberta, Canada. They represented 61 families.

The deceased children died from a variety of conditions, with cancer the most frequent cause of death. (4 [6.5%] of the deaths had been caused by accidents, 4 [6.5%] by murder or suicide, 5 [8%] by cardiac disease, 4 [6.5%] by infections, 29 [47.5%] by cancer, 3 [5%] by metabolic disorder, and 1 [1.6%] by aplastic anemia). The deceased children had all been living at home at the time of death and had ranged in age from 2 months to 20 years. The majority of the deceased children had been male. Most of the families expressed a religious preference for the Protestant faith. Ninety percent of the children were white and 10% were Hispanic, Native Americans, Asian, or black.

Methodology

The Child Behavior Checklist (CBCL) (Achenbach 8c Edelbrock, 1983) was used to identify the behaviors observed in the bereaved children. The CBCL is a commonly used tool that measures 118 behavior problems observed in children. The list of problems includes the behaviors often associated anecdotally with grief in children. Behavioral problems included in the tool encompass both internalizing and externalizing problem behaviors.

Examples of CBCL internalizing behaviors frequently asso- ciated with grief include crying, sleep disturbances, fears, self- consciousness, nightmares, sadness, guilt, tiredness, and somatic complaints. Examples of externalizing behaviors are hyperactiv-

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44 D. E. il.lcCou~n and B. Dazvis

ity, demands for attention, disobedience, impulsiveness, poor school performance, and inability to concentrate.

Achenbach (1991) recently updated the CBCL profile subscales. The revision is applicable to all the previous checklist versions and allows one to compare children of all ages and sexes on the same eight subscales. Previous subscales varied somewhat across age and sex, making direct comparison across groups difficult. The new version also extends the age range from 4-16 to 4-18 years.

The behaviors on the CBCL are grouped into eight syndrome subscales. These subscales were derived from principal components analysis and have recently undergone extensive development and revision (Achenbach, 1991). T h e tool is standardized by sex for ages 4-18 years. Detailed psychometrics have been reported elsewhere, and test-retest reliability varies by age and sex group, ranging from 0.82 for older boys to 0.9 for older girls, with younger age groups falling between that range (Achenbach, 1991; Achenbach & Edelbrock, 1983). The standardized mean for the CBCL is 50, with a standard deviation of 10. The tool provides a total behavior problem score as well as scores on the subscales and the two main Internalizing and Externalizing dimensions.

The parents of surviving siblings ages 4-16 years were interviewed about their children’s behavior using the CBCL. Because mothers’ and fathers’ scores are highly correlated on the CBCI,, ratings by either parent are acceptable (Achenbach, 1979). Mothers most frequently completed the checklist, and, in all but one instance, mothers’ ratings were used for final analysis. The CBCL asks parents to indicate on a scale of 0 to 2 whether a particular behavior relates to their child, with 0 representing not true; 1, somewhat m sometimes true; and 2 , very true OT oft.. true.

For the purposes of the present study, a behavior was scored as observed if the parents responded with either a 1 or a 2. Thus, behavior problems in this study were categorized as either observed or not observed in order to identify the behavior problems most frequently demonstrated by bereaved siblings. To identify specific behavior problems commonly observed in bereaved siblings, we tabulated the frequency of occurrence for each behavior for each subject. Those behaviors reported as

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Grief in Chilclren af?m the Death of a Sibling 45

TABLE 1 the Total Sample of Bereaved Siblings

Child Behavior Checklist Behaviors Observed in 50% or More of

4-5 6-1 1 12-16 Total years years years Sample (n=16) (n=41) (n=33) (n=90)

Behavior n % n % n % n %

Aggression subscale 3. Argues a lot 13 81.2 29 70.1 17 51.5 59 65.5

19. Demandsa lot of 13 81.2 23 56.1 12 36.4 48 53.3

22. Disobedient at 11 68.8 20 48.8 15 45.5 46 51.0

86. Stubborn, sullen, or 7 43.7 22 53.6 17 51.5 45 50.0

attention

home

irritable

Depression subscale 7 1 . Self-conscious or 7 43.7 25 61.0 13 39.4 45 50.0

easily embarrassed

present in more than 50% of the bereaved children were identified as common grief behaviors in response to sibling loss. Commonly occurring grief behaviors were grouped for the entire sample and were also broken down by sex and age. This procedure for calculating the percentage of bereaved children for whom a particular problem was reported follows the method Achenbach used to report each problem item score (Achenbach, 1991).

Results

As a whole, the sample of children demonstrated primarily exter- nalizing behaviors that fell into the Aggression subscale of the CBCL. The specific behaviors observed in more than 50% of the total sample are shown in Table 1 and are also discussed more specifically in relation to sex and age.

Sex and Age

Analysis of the data based on sex revealed that all but one of the five behaviors observed in half or more of the girls fell within the

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46 D. E . M c C m and B. Dauies

TABLE 2 the Total Sample of Bereaved Female Siblings

Child Behavior Checklist Behaviors Observed in 50% or More of

Behavior

Total 4-5 6-1 1 12-16 Female

years years years Sample ( n = 7 ) (n=20) (n=21) (n=48)

n % n ’ % n % n %

Aggression subscale 3. Argues a lot 5 71.4 12 60 11 52.4 28 58.3

19. Demands a lot of 4 57.1 13 65 8 38.1 25 52.0

27. Easily jealous 2 28.6 12 60 11 52.4 25 52.0 86. Stubborn, sullen, or 6 85.7 10 50 11 52.4 27 56.2

attention

irritable

Depression subscale 7 1. Self-conscious or 4 57.1 14 70 11 52.4 29 60.4

easily embarrassed

externalizing Aggression subscale. The one remaining common female grief behavior, “Self-conscious or easily embarrassed,” fell within the internalizing Depression subscale. Boys also showed almost exclusively aggressive behaviors. The one exception to aggression in bereaved boys as Item 74, “Can’t concentrate,” which falls within the Attention Problem subscale. Specific behav- iors most frequently identified in both girls and boys were “Ar- gues a lot” and “Demands a lot of attention.” Other behaviors noted in more than 50% of the boys included “Disobedient at home” and “Showing off, clowning.” The additional behaviors seen most frequently in girls were “Easily jealous,” “Stubborn, sullen, or irritable,” and “Self-conscious or easily embarrassed.” Tables 2 and 3 show a breakdown of behaviors by sex and age.

In evaluating the data according to age, we found that the highest incidence of behavioral problems occurred in preschool and school-age children. The youngest children, those ages 4-5, almost uniformly showed the behaviors “Argues a lot,” “Stubborn, sullen, or irritable,” “Demands a lot of attention,” and “Disobedi- ent at home.” Behaviors that occurred more frequently in school-

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Grief in Children after the Death ofa Sibling 47

TABLE 3 Child Behavior Checklist Behaviors Observed in 50% or More of the Total Sample of Bereaved Male Siblings

Total 4-5 6-1 1 12-16 Male years years years Sample (n = 9) (n=21) (n=12) (n=42)

Behavior n % n % n % n %

Aggression subscale 3. Argues a lot 8 88.9 17 80.9 6 50.0 31 73.8

19. Demands a lot of 9 100.0 10 47.6 4 33.3 23 54.8

22. Disobedient at 8 88.9 12 57.1 6 50.0 26 69.0

74. Showing off, 6 55.5 14 66.7 5 41.7 24 57.1

attention

home

clowning

Hyperactive subscale 8. Can’tconcentrate 5 55.5 12 57.1 5 41.7 24 57.1

age children than in other age groups were “Stubborn, sullen, or irritable” and “Self-conscious or easily embarrassed.” The major- ity of behaviors appeared to decline with age, with adolescents showing the lowest incidence of behavioral problems. Few behav- iors occurred in more than 50% of the 12- to 16-year-olds. The behaviors that occurred in more than 50% of adolescents were most frequently observed in girls and included “Secretiveness” and “Preference for being alone,’’ in addition to those listed in Table 2.

The single most frequent behavior observed in bereaved chil- dren-“Demands a lot of attention”-occurred in 100% of the 4- to 5-year-old boys. The youngest boys also received the highest score, with 88.9% observed to argue a lot and to be disobedient at home. The most common behavior among the girls-“Stub- born, sullen or irritable”-occurred in 85.7% of 4- to 5-year-old girls. The three behaviors that were found to be consistently fre- quent (occurring in more than 50% of the sample) across all age groups were “Argues a lot,” “Stubborn, sullen, or irritable,” and “Self-conscious or easily embarrassed.”

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TABLE 4 Somatic Problems Observed in 20% or More of Bereaved Siblings

4-.5 6-1 1 12-16 Total ,ears ?ears years Sample

(n = 16) ( n = 4 1) (n = 33) (n = 90)

Problems I1 % 11 % n 7c n %

Allerg, 3 18.1 12 29 5 15 20 22.0 Doesn’t eat well 6 37.5 12 29 7 21 25 27.7 Nightniai es 6 37.5 12 29 9 27 27 30.0 Overtired 1 6 12 29 8 24 21 23.0 Aches and 1 6 12 29 6 18 19 21.0

pains Headac he 1 12.5 10 24 7 21 19 21.0 Stomach.iches. 3 18.8 10 24 5 15 18 20.0

cramps

Somatic Probhis

Somatic problems are often mentioned as manifestations of grief in children as well as adults. The CBCL includes 22 behaviors representing somatic problems. In our sample of bereaved sib- lings, the frequency of somatic problems was not excessive. Phys- ical problems ranged from 5.5% for “Overeats” and “Eye prob- lems” to a maximum 30% for “Nightmares.” Only two somatic problems were identified in more than 25% of the children, and they were “Doesn’t eat well” and “Nightmares.” These behaviors are also commonly described as adult grief responses. Night- mares were most common (37.5%) in the younger children. It is noteworthy that other slee p-rela ted problems (over tiredness, sleeping more, sleeping less, and trouble sleeping) were not fre- quently observed. “Doesn’t eat well” was the second most com- mon (27.7%) somatic behavior observed in the bereaved children. Table 4 records the somatic problems observed in 20% or more of the surviving siblings.

Behuuim Problems Not Obserued

Some behaviors were not observed in any of the children and are conspicuous for their absence among the responses to the loss of it sibling. None of the children in the present sample were re-

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Grief in Children afkr the Death ofa Sibling 49

ported to have run away from home, smeared or played with bowel movements, vandalized or wet themselves during the day.

Discussion

The relationship between grief and aggression in adults can be linked to the classic response of anger observed in grieving adults (Kiibler-Ross, 1969; Lindemann, 1965; Rando, 1986; Worden, 1982). However, the aggressive behaviors observed in the young children in the present sample may have been less motivated by anger than by the desire for attention. Lewis and Volkmar (1990) suggested that bereaved children may use aggressive behavior to ward off depression, giving rise to a masked depression. Parents may pay less attention to the bereaved child because of their absorption in their own grief, and the child may respond to intrapsychic feelings of loss by seeking attention from his or her parents.

A child’s death represents a major change in the family: Not only has the surviving child’s brother or sister gone away, but the parents’ behavior is altered by their profound grief. The parents’ grief may rob them of their usual energy and vitality in fulfilling their parenting role with their surviving children. The younger child, unable to comprehend the changes, may feel unsure, un- settled, and insecure. Within the interpersonal context, Fulmer (1983) described children’s misbehavior as “collusive mischief’ and rigged in response to their mother’s depression or apathy. Children may interpret the parents’ behavior as dangerous and may misbehave so as to arouse the parents and reassure them- selves (Fulmer, 1983). Attention-seeking behaviors identified in the present study may also reflect the young child’s need for reassurance and comfort.

Support for our findings of aggression comes from qualitative research by Walker (1988) on young bereaved siblings. She iden- tified responses and coping strategies in 26 children who expe- rienced the death of a sibling. In her work, parents reported observing physical manifestations of grief that included acting out and aggression, verbal expressions of grief that included ar- guing and swearing, and attention-seeking behaviors in their

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50 D. E . McCmtn and B. Davies

children. Walker interviewed the bereaved children themselves and conceptualized their attention seeking as a coping strategy within the domain of self-focusing behavior.

In our study, the younger children showed more aggressive behaviors than did the older children. This finding corresponds with the increased cognitive ability of teenagers to understand death as a final universal and a personal event and to understand and benefit from symbolic and cultural rituals associated with death. This mature understanding contributes to the more typi- cal grief responses of withdrawal, sadness, and sullenness ob- served in the teenagers we studied. It is also possible that the enlarged interpersonal peer group network of the teenager pro- vides the external social support needed to facilitate behavioral adjustment in the older child. This hypothesis is supported by Davies (1988), who found fewer behavior problems in children whose families were engaged in social, cultural, recreational, and religious activities .

It is important to put the behaviors identified in this popula- tion of bereaved children into perspective with those of other children. Achenbach (1991) reported the percent of frequency of behavioral problems in children referred for psychiatric/mental health intervention and in nonreferred children. For an item-by- item account of the percentages, refer to the Manual fm the ChiEd Behavior Chcklist 4-18 and 1991 ProfiL (Achenbach, 1991). The percentages of bereaved children in our study who exhibited the frequently identified behavior problems most closely approxi- mated the patterns of the referred group for “Argues a lot,” “Demands a lot of attention,” and “Disobedient at home.” For one behavior, “Self-conscious or easily embarrassed,” the bereaved group’s item score fell between those of the referred and nonre- ferred groups. On this item, the bereaved girls’ scores were com- parable to that of the referred children. Finally, for the item “Stubborn, sullen, or irritable,” the bereaved children demon- strated a lower percentage of occurrence than did both the re- ferred and nonreferred children. However, on this item, young girls scored similarly to the referred children.

Finally, we found that grief responses were manifested differ- ently by boys and girls, although both sexes showed predomi- nantly aggressive behaviors characterized by instrumental atten-

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Grief in Children after the Death of a Sibling 51

tion-seeking actions. Girls also frequently demonstrated an internalizing, depressive behavior. In contrast, boys reflected a high frequency of “Can’t concentrate,” a hyperactivity, external- izing behavior.

The reward for aggression is attention, attention may have been exactly what these bereaved children were seeking and needed. Professionals who work with bereaved families can alert parents and others to the young child’s need for attention after the death of a brother or sister. Families can be instructed about the increased likelihood of nightmares and about strategies such as the use of nightlights and sharing of dreams to help overcome them. Other family members and friends can be enlisted to help meet the needs of bereaved children and their parents.

Limitations of the Present Study and Recommendations for Further Study

The present study reveals the need for further clarification of the relationships among aggression and attention seeking and grief in children. The present study was limited to the behaviors listed on the CBCL, which do not represent the total scope of behaviors available to grieving children. Certain behaviors such as health fears and not mentioning the deceased have been described as problems for surviving children. Although the CBCL allows par- ents to write in behaviors they noted in their children that are not listed in the tool, none of the parents in our study did so. They may have lacked initiative to include more information, or the tool may have included the range of behaviors they observed. Clarification in this area is recommended. The two-year post- death time frame might have allowed for other significant events to occur that also might have affected a child’s behavior. Certain causes of a sibling’s death may carry more impact than other causes on specific behaviors of surviving children. In the present study, we relied on grieving parents’ perceptions of their chil- dren’s behavior, and the parents may not have been aware of the full range of their children’s feelings and behaviors. Further- more, the parents’ own grief may have colored their perceptions of the behaviors they observed in their children. Obtaining in-

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52 D. E. McCouvi andB. Davks

formation directly from the children themselves or from objective observers might add to the evidence regarding grief in children. A clear picture of specific childhood grief behaviors would help those who care for grieving children understand the children’s behavior and give them the help and support they need.

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