Suicide-bereaved children and adolescents: a controlled longitudinal examination

Emotion regulation in children and adolescents: boundaries between normalcy and bipolar disorder

Much controversy has surrounded the diagnosis of bipolar disorder (BD) in children and adolescents. However, recent work from an affective neuroscience perspective has advanced what is known about the boundaries of emotion regulation in BD compared to typically developing youth. In this article, we first briefly review the clinical issues that have contributed to this diagnostic controversy. Second, we discuss our phenotyping system, which can be used to guide neurobiological research designed to address these controversial issues. Third, we review what is known about the fundamentals of emotion regulation in human and nonhuman primate models. Fourth, we present recent data demonstrating how children and adolescents with BD differ from those without psychopathology on measures of emotion regulation. Taken as a whole, this work implicates a neural circuit encompassing the prefrontal cortex, amygdala, and striatum in the pathophysiology of pediatric BD.

The prediction of bereavement outcome: Development of an integrative risk factor framework

We propose an integrative risk factor framework to enhance understanding of individual differences in adjustment to bereavement and to encourage more systematic analysis of factors contributing to bereavement outcome (e.g., examination of interactions between variables and establishing pathways in the adaptation process). The examination of individual differences in adaptation to bereavement is essential for practical (e.g. targeting high risk individuals for intervention) and theoretical (e.g. testing the validity of theoretical claims about sources of differences) purposes. And yet, existing theoretical approaches have not led to systematic empirical examination and empirical studies in the current literature are fraught with shortcomings. Derived from Cognitive Stress Theory [Lazarus, R. S. & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer] and the stressor-specific Dual Process Model of Coping with Bereavement [Stroebe, M. S., & Schut, H. A. W. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23, 197-224], the framework incorporates an analysis of stressors, intra/interpersonal risk/protective factors, and appraisal and coping processes that are postulated to impact on outcome. Advantages of using the approach are outlined. Challenges in undertaking such research are addressed.

Effective communication with bereaved child survivors of suicide

TOPIC

While bereavement is considered by many to be among the most stressful life events, it becomes even more distressing when it is related to the suicide of a loved one. Further, the death of a parent is traumatic for anyone, but it may be especially intensified for young children. This points to a strong need for the recognition and treatment of psychiatric and social problems associated with childhood bereavement.

PURPOSE AND SOURCES

The purpose of this paper is to review the literature and present a synopsis of the psychosocial outcomes of childhood suicide survivor bereavement and outline communication issues that emerge when talking with young suicide survivors.

CONCLUSIONS

A case is made to develop and test interventions designed to meet the mental health needs of this important group of individuals.

Aggression and substance abuse in bipolar disorder

OBJECTIVES

The goal of this retrospective study was to examine factors differentiating persons with bipolar disorder who did or did not have comorbid lifetime substance use disorders (SUD) at an index assessment. We also explored the chronology of onset of mood and SUD.

METHODS

We studied 146 subjects with DSM-defined bipolar disorder. Subgroups with and without lifetime SUD were compared on demographic and clinical measures.

RESULTS

Substance abuse disorders in this bipolar sample were associated with male sex, impulsive-aggressive traits, comorbid conduct and Cluster B personality disorders, number of suicide attempts and earlier age at onset of a first mood episode. In a multivariable logistic regression analysis, male sex and aggression and possibly earlier age at mood disorder onset were associated with SUD. In those with or without SUD, the first mood episode tended to be depressive and to precede the onset of SUD.

CONCLUSIONS

In persons with bipolar disorder, an earlier age of onset and aggressive traits appear to be factors associated with later development of comorbid SUD.

Childhood bereavement: psychopathology in the 2 years postparental death

OBJECTIVE

Although the death of a parent is one of the most significant stressors a child can experience, the psychiatric sequelae of parental death are not fully understood.

METHOD

A total of 360 parent-bereaved children (ages 6-17) and their surviving parents were directly interviewed four times during the first 2 years following the death (at 2, 6, 13, and 25 months). Data collection occurred from 1989 to 1996. Psychiatric symptomatology was compared among the bereaved children, 110 depressed children, and 128 community control children and their informant parents. Additional analyses examined simple bereavement without other stressors versus complex bereavement with other stressors and anticipated versus unanticipated death.

RESULTS

Bereavement following parental death is associated with increased psychiatric problems in the first 2 years after death. Bereaved children are, however, less impaired than children diagnosed with clinical depression. Higher family socioeconomic status and lower surviving parents' level of depressive symptoms are associated with better outcomes. Complex bereavement was associated with a worse course, but anticipation of the death was not.

CONCLUSIONS

Childhood bereavement from parental death is a significant stressor. Children who experience depression in combination with parental depression or in the context of other family stressors are at the most risk of depression and overall psychopathology.

Pharmacotherapy of adolescent substance use disorders: a review of the literature

OBJECTIVE

Substance use disorders (SUD) are increasingly conceptualized as developing during adolescence. Moreover, adolescent SUD are viewed as one of the most difficult mental health conditions to treat. The role of pharmacotherapy for adolescents with SUD is not well delineated. We systematically reviewed existing pharmacotherapy studies of adolescent SUD.

METHODS

A computerized search of the literature addressing the pharmacotherapy of SUD in adolescents was performed. Data from relevant peer-reviewed scientific presentations were also included.

RESULTS

Five case reports (n = 8 subjects), six open studies that primarily addressed SUD with comorbid psychiatric disorders (n = 73 subjects), and five placebo-controlled studies (n = 156 subjects) on the pharmacological treatment of youths with SUD were identified. Pharmacological agents appear to reduce comorbid psychopathology with a milder reduction in SUD symptoms. The most robust evidence exists for the treatment of SUD comorbid with affective disorders. There is a limited database supporting the use of agents to reduce substance craving and the preventative effects of pharmacotherapy on subsequent SUD development in adolescents with specific psychiatric disorders.

CONCLUSION

Further controlled studies directed at reducing drug use and craving, and guiding the integration of pharmacotherapy and psychosocial interventions for SUD with the treatment of comorbid psychiatric illness, are necessary.

Suicidal behavior in the family and adolescent risk behavior

PURPOSE

The purpose of this study was to examine the prevalence and sociodemographic characteristics of adolescents exposed to suicide attempts and suicide deaths by a family member and to evaluate the separate associations between exposure to a family member's suicide attempts or suicide death and risk behaviors, social-emotional functioning, and family connectedness.

METHOD

We performed a cross-sectional analysis of data collected in 1995 for wave I of the National Longitudinal Survey of Adolescent Health (n = 5,918). The independent variable was the exposure to suicidal behavior by a family member during the past 12 months (death by suicide, suicide attempt, and no suicidal behavior). The dependent variables were substance use, suicidal behavior, violent behavior, perceived shortened life expectancy, emotional distress, and parental and adolescent reports of family connectedness.

RESULTS

In the year before the survey, 3.9% of adolescents experienced a family member's suicide attempt whereas 1.2% experienced a family member's death by suicide. In regression analyses adjusting for sociodemographic variables, adolescents who had experienced the suicide attempt of a family member were more likely than those with no exposure to report the following: cigarette and marijuana use, alcohol misuse, suicidal ideation and attempts, fighting and inflicting injuries, decreased life-expectancy, emotional distress, and decreased adolescent reports of parent-child and family connectedness. Adolescents who had experienced a family member's death by suicide were more likely to report marijuana use and alcohol misuse, suicidal ideation and attempts, inflicting severe injuries, and emotional distress.

CONCLUSIONS

Adolescents who have experienced suicide attempts or suicide deaths in the family show high levels of at-risk behaviors, most notably their own suicidal ideation and attempts.

Childhood mourning: prospective case analysis of multiple losses

Multiple losses within short time periods make one question life and can exponentially influence one's coping skills. But what are the effects on a child and what should be done when the next loss occurs? This case addresses the multiple losses suffered by a child while assessing coping skills of the child and coping strategies used by the parents to assist the child.

Treating childhood traumatic grief: a pilot study

OBJECTIVE

To examine the potential efficacy and specific timing of treatment response of individual child and parent trauma-focused cognitive-behavioral therapy for childhood traumatic grief (CTG), a condition in which trauma symptoms impinge on the child's ability to successfully address the normal tasks of grieving.

METHOD

Twenty-two children and their primary caretakers received a manual-based 16-week treatment with sequential trauma- and grief-focused interventions.

RESULTS

Children experienced significant improvements in CTG, posttraumatic stress disorder (PTSD), depressive, anxiety, and behavioral problems, with PTSD symptoms improving only during the trauma-focused treatment components and CTG improving during both trauma- and grief-focused components. Participating parents also experienced significant improvement in PTSD and depressive symptoms.

CONCLUSIONS

The timing of improvements in CTG and PTSD symptoms lends support to providing sequential trauma- and grief-focused interventions and to the concept that CTG is related to but distinct from PTSD. The results also suggest the benefit of individual treatment for CTG and for including parents in the treatment of CTG. Randomized, controlled trials are needed to further test the efficacy of this treatment model.

Depression in adolescence

Major depressive disorder is a common problem for adolescents. It has a wide array of symptoms affecting somatic, cognitive, affective, and social processes. Academic failure, poor peer relationships, behavioral problems, conflict with parents and other authority figures, and substance abuse are some of the consequences of major depressive disorder in this age group. Effective treatments include nontricyclic antidepressants and coping skills training. The nurse is key to depression detection and suicide prevention, especially in primary care settings. Through psychoeducation, nurses can promote recovery from depression by encouraging a healthy lifestyle, enhancing social skills, and assisting the adolescent to identify and use sources of social support. These measures can prevent premature death and promote long-term well-being of the adolescent.

The grief experiences and needs of bereaved relatives and friends of older people dying through suicide: a descriptive and case-control study

BACKGROUND

Little is known about grief experiences of individuals bereaved through suicide of older people. Legal procedures may be one source of distress. Studies have suggested that guilt feelings, and a sense of rejection, shame or stigma, are probably more frequent in relatives bereaved through suicide than in those bereaved through other modes of death.

METHODS

We examined (a) problems experienced during legal procedures after death and (b) grief experiences, in 85 relatives and friends bereaved through the suicide of person 60 years old or over. In a case-control study the bereavement reactions in a subgroup of 46 people were compared with those of a control group bereaved by the natural death of an older person. Interviews, carried out 6-21 months after the deaths, included a semi-structured assessment of problems following the death, the Grief Experience Questionnaire (GEQ) and the Montgomery and Asberg Depression Rating Scale (MADRS).

RESULTS

Thirty-six (42.4%) of those bereaved through suicide reported problems in their dealings with the coroner's office, and 33 (38.8%) described distress caused by media reporting of the inquest. Depression scores were similar in the group of individuals bereaved through suicide and those bereaved through natural causes. The former scored higher on subscales of the GEQ measuring stigmatisation, shame, sense of rejection and "unique reactions" compared with those bereaved through natural death.

LIMITATIONS

The participation rate of potential subjects was somewhat low, especially in the control group. Proportions of different kinships to the deceased differed in the study and control groups.

CONCLUSIONS

Problems in the media reporting of coroners' inquests and in inquest procedures are a frequent source of distress for bereaved relatives. The common themes of stigma, shame, and sense of rejection in bereavement after suicide suggest that these areas should be specifically addressed in the counselling of relatives bereaved in this way.

Group intervention for children bereaved by the suicide of a relative

OBJECTIVE

This study evaluated efficacy of a manual-based bereavement group intervention for children who suffered suicide of a parent or sibling.

METHOD

Seventy-five families (102 children) were screened from medical examiners' lists of suicide victims. Fifty-two families (75 children) were eligible and assigned in alternating order to receive (27 families, 39 children) or not to receive (25 families, 36 children) the intervention. Intervention efficacy was evaluated as change in children's symptoms of anxiety, depression, posttraumatic stress, social adjustment, and parents' depressive symptoms from initial to outcome assessments.

RESULTS

Changes in anxiety and depressive symptoms were significantly greater among children who received the intervention than in those who did not. A greater dropout of children assigned not to receive (75%) than to receive (18%) intervention led to an imbalance in retention of intervention and nonintervention participants.

CONCLUSIONS

A bereavement group intervention focusing on reactions to death and suicide and strengthening coping skills can lessen distress of children bereaved after parental or sibling suicide. Such intervention may prevent future morbidities.

Children of suicide: the telling and the knowing

Amidst the still limited literature on survivors of suicide, and the particularly scanty literature on children of parental suicide, little focal attention has been given to the special issues surrounding surviving parents telling the children that their deceased parent's death was a suicide. Those few papers that deal with this topic have primarily emphasized the destructive consequences of not telling of the suicidal nature of the death, with imperatives to tell the children the whole truth and do so promptly post-death. Based primarily on clinical and preventive work with children of suicide, this absolutism and one-size-fits-all approach is questioned, the difference between being told and knowing accented and illustrated, and the nature and effects of surviving parent explanatory frameworks for the suicide--the 'why' of it--explored.

Do community-based support services benefit bereaved children? A review of empirical evidence

AIMS

To consider the evidence of effect from English language, empirically based quantitative evaluations of community-based interventions for bereaved children; community-based interventions being understood as those taking place outside a clinical setting.

METHODS

MedLine, PsychInfo, Applied Social Sciences Index and Sociological Abstracts were searched for documents containing the words 'child', 'bereavement' and 'program', 'group', 'intervention', 'support' or 'evaluation'. The criterion for inclusion was that studies use a control group or pre- and post-test measurements using a standardized instrument.

RESULTS

Nine relevant studies were identified. However, empirical evidence of positive outcomes for children was limited and compromised by methodological weaknesses in the design of the studies. Small sample sizes, irregular attendance, high levels of attrition, short time scales between pre- and post-testing and difficulty in developing appropriate instrumentation, including assessment of adherence to the agreed intervention programme, all created problems.

CONCLUSIONS

The case for universal inclusion of this group of children in such support programmes remains unproven, and further exploration of the outcomes of a range of different community interventions is required, with a specific focus on long-term and/or unwanted effects and evaluation of the basis for referral.

Posttraumatic stress symptoms in parentally bereaved children and adolescents

OBJECTIVE

To compare parentally bereaved children with a disaster comparison group and a nontrauma control group on measures of emotional adjustment.

METHOD

Children and adolescents who had lost a parent (n = 39), had experienced a tornado disaster (n = 69), or were coping with an ongoing social or academic stressor (n = 118) completed measures of posttraumatic stress disorder (PTSD) symptoms, anxiety, and depression. Risk factors for symptoms among the bereaved children also were evaluated.

RESULTS

Parentally bereaved children reported significantly more PTSD symptoms than the disaster and nontrauma control groups. Among the bereaved children, girls, younger children, and children living with a surviving parent who scored high on a measure of posttraumatic stress reported more symptoms.

CONCLUSION

Children and adolescents who have lost a parent could be vulnerable to PTSD symptoms.

Suicide-bereaved children and adolescents: II. Parental and family functioning

OBJECTIVE

The current study extends the authors' earlier examination of suicide-bereaved (SB) children from the Grief Research Study, a longitudinal study of childhood bereavement after parental death, by examining the children's family history of psychopathology and family environment before and after death.

METHOD

Twenty-six SB children, aged 5 to 17 years, and their 15 surviving parents were compared with 332 children bereaved from parental death not caused by suicide (NSB) and their 201 surviving parents in interviews 1, 6, 13, and 25 months after the death.

RESULTS

Suicide completers evidenced more psychopathology than parents who died from reasons other than suicide. Contrary to expectations, surviving SB parents were not more impaired than NSB parents. Before the death, SB families were less stable than NSB families and relationships with the decreased SB parent were compromised. However, no differences were detected between groups in children's relationships with their surviving parents. Likewise, few differences were found in social support or changes in religious beliefs.

CONCLUSIONS

SB children generally come from families with a history of psychopathology and substantial family disruption. However, surviving SB parents do not exhibit higher rates of psychopathology than other bereaved parents and many have positive relationships with their children.