Identifying Bereavement‐Related Markers of Mental and Behavioral Health Problems Among Clinic‐Referred Adolescents

The childhood bereavement field is currently in a nascent phase, as evidenced by its limited capacity to differentiate between adaptive versus maladaptive responses to loss and to identify reliable predictors of adaptive and maladaptive responses in bereaved children and adolescents (9). Nevertheless, recent evidence points to the value of exploring whether bereavement‐related contextual variables could serve as early risk markers of mental and behavioral health problems among bereaved youth.

This study drew upon both previously identified predictors of adolescent mental health issues in the context of bereavement 5, 16 and recent theory‐building studies of risk and resilience in bereaved youth 7, 9, 19 to evaluate whether bereavement‐related contextual variables may be associated with mental and behavioral health problems in bereaved adolescents above and beyond the effects of other traumas. We examined potential associations between three variables (number of deaths, cause of death, and relationship to the deceased) and various mental and behavioral health problems (suicidal thoughts or behaviors, non‐suicidal self injury, depression symptoms, posttraumatic stress symptoms, alcohol use, and substance use), while controlling for other forms of trauma, in a national clinic‐referred sample of bereaved youth (20). We hypothesized that the likelihood of experiencing mental and behavioral health problems would increase as a function of total deaths (Hypothesis 1), exposure to suicide or homicide compared to deaths due to natural causes (Hypothesis 2), and closeness to the deceased (defined as death of a parent compared to a friend or other relative; Hypothesis 3).

Table 1 provides demographic characteristics for the total sample. Most youth (91%) reported at least one additional traumatic event besides the death of a loved one (overall mean=4.3, median=4 total trauma types). Relationship to the deceased included non‐parent adult relative (49.5%), parent (38.1%), non‐sibling youth (21.6%), sibling (10.5%), and unrelated adult (9.9%). Regarding cause of death, 44.7% identified natural causes, 19.7% homicide, 16.5% accident, 7.26% suicide, and 11.9% were unknown or missing.

This study builds upon prior research on childhood bereavement by examining bereavement‐related contextual factors in relation to mental and behavioral health problems among treatment‐seeking adolescents while accounting for demographics and other types of trauma. Our findings suggest that specific bereavement‐related factors are differentially associated with certain mental and behavioral health problems. Identifying bereavement‐related risk markers that co‐occur with mental and behavioral health problems represents a first step toward improving case identification and, if replicated longitudinally, prevention.

Our study is consistent with other research in identifying important demographic differences in mental and behavioral health risk. Specifically, compared to younger youth, older youth (those above age 14) were more likely to endorse a number of mental and behavioral health issues including substance use (5), alcohol use (5), suicidal thoughts and behaviors (6), depression (24), and PTSD (25). Also consistent with previous literature, females were significantly more likely to exhibit non‐suicidal self‐injurious behaviors (26), depression (27), and PTSD (25).

Similar to other studies focusing on racial differences in suicidal ideation (28), the current study found that Black youth were less likely to be at risk for suicide than White youth. This finding could be attributable to cultural differences in coping with adversity. For example, studies have found that Black adolescents, compared to White adolescents, tend to cope with problems by seeking spiritual support (29), which often involves a focus on social connectedness, religious beliefs, and cultural proscriptions against suicide in particular (30). Studies also suggest that Black youth may have better access to additional protective factors, such as perceived family connectedness, emotional well‐being, and higher levels of self‐esteem (29).

In addition, the number of traumas experienced was significantly associated with all mental health outcomes. Specifically, youth who had experienced more than four traumatic events were consistently at greater risk for each of the mental and behavioral health problems examined. This is consistent with prior findings 1, 2, including ACEs studies, linking the accumulation of childhood traumas and other adversities with problematic outcomes (10).

Our findings partially supported our first hypothesis—that the likelihood of mental and behavioral health problems would increase as a function of total number of deaths, above and beyond the effects of other traumatic experiences. However, this finding emerged for PTSD only. These findings are again consistent with ACE study findings (10) of dose‐response relations between number of childhood adversities (including losses) and PTSD in particular 11, 13.

We found partial support for our second hypothesis, in that suicide and homicide deaths, compared to natural causes, were differentially associated with distinct mental and behavioral health problems while controlling for other forms of trauma. Although few studies have explicitly examined associations between cause of death and post‐death functioning among bereaved youth, a greater number of studies call attention to ways in which traumatogenic factors embedded within the circumstances of the death can evoke psychological distress and interfere with bereaved youths' ability to grieve adaptively (31). In addition, highly traumatizing or stigmatized deaths (e.g., suicide or homicide), may induce surviving caregivers to conceal the true cause of death to “protect” bereaved youth—a circumstance that can both impede caregiver grief facilitation, limit open, and honest communication between family members, and increase risk for persisting distress among children and adolescents (32).

Consistent with recent studies of adults bereaved as children (8), our findings indicate that youth bereaved by suicide were more likely to experience suicidal thoughts and/or behaviors themselves. Exposure to suicide death was the only bereavement‐related variable associated with suicidal thoughts or behaviors among bereaved youth. Notably, not all youth bereaved by suicide in this sample were related to the deceased; approximately 23% of suicide‐related deaths were peer deaths, suggesting that the link between suicide bereavement and suicide risk in youth cannot be explained by shared familial environment or biology alone. Instead, evidence points to other potential mechanisms such as contagion or imitation (17). For example, studies of adolescents who have either attempted or died by suicide tend to report prior suicide deaths occurring in close temporal proximity (33). The Interpersonal Theory of Suicide (34) suggests that both perceived burdensomeness and thwarted belongingness are likely to lead to increased suicidal ideation. A recent study showed that thwarted belongingness in particular mediated the relation between bereavement and suicide risk in adolescents (35), suggesting that youth bereaved by suicide may feel especially isolated and alone following the death. It is also possible that for youth who lost a loved one due to suicide, increased suicidal thoughts or behaviors represent reenactments or fantasies as the individual attempts to understand and adjust to the loss. Similarly, depending on one's spiritual beliefs, some youth may wish to die as a means of reuniting with the deceased, as opposed to being driven primarily by a desire to hurt oneself or die (16).

Although the current study design did not permit examination of youth's grief reactions, it is reasonable to hypothesize that youth bereaved by violent or otherwise intentional deaths may experience higher levels of maladaptive grief reactions, as well as guilt, remorse, or anger, which may then lead to greater mental and behavioral health problems in youth (35) and adults (36). The current study found significantly increased risks for alcohol use among youth bereaved by suicide, and for substance use among youth bereaved by homicide. This indicates that there may be differential relations between cause of death and distinct behavioral health problems. Perceived stigma can also produce feelings of disenfranchised grief, raising the risk for mental and behavioral health problems among bereaved youth. The potential role of stigma was underscored by a recent longitudinal study, which found that the statistical association between bereavement by suicide and future suicide attempts became nonsignificant after accounting for perceived stigma (14).

Youth bereaved by suicide or homicide were no more likely than youth bereaved by natural deaths to experience higher levels of depression or PTSD. This finding contrasts with those from other studies linking violent deaths to higher levels of anxiety, depression, and PTSD in adolescents (37). However, recent work has demonstrated that youth who lose a loved one due to anticipated death also tend to exhibit high levels of PTSD (32). This may be due to the traumatogenic features inherent in anticipated deaths, such as witnessing the slow, painful, and/or progressive deterioration of a loved one, the causal potency of which can often be overlooked 31, 32.

Consistent with prior studies of bereaved youth, those who lost a parent experienced higher levels of depression than youth who lost an adult relative or an unrelated adult (5). Depressive symptoms are not only common after losing a close loved one; they can also mimic grief reactions. These reactions include separation distress (yearning for the person who died) and existential/identify distress (feeling empty or that life is meaningless, now that the person is gone), which are both common reactions to the death of a parent 9, 31. In contrast, youth who lost a peer were more likely to engage in alcohol use or substance use compared to those who experienced the death of a parent. The most common cause of death among peers was accidental death, which may involve reckless behavior and/or substance use. Thus, it is also possible that substance use problems may have preceded the experience of losing a peer if they were already engaging in these behaviors with their peer group. Adolescents' grief reactions can take the form of engaging in behaviors associated with the lost relationship (including substance use) as a means of identifying with the deceased, preserving their memory, and carrying on their role, regardless of whether those behaviors are adaptive or maladaptive 9, 31.

This manuscript was developed under grant numbers 2U79SM054284‐12S (PI: Pynoos) and SM062111 and SM16008 (PI: Kaplow) from the Substance Abuse and Mental Health Services Administration (SAMHSA). We would also like to acknowledge the 56 sites within the National Child Traumatic Stress Network that have contributed data to the Core Data Set and the children and families who have contributed to our growing understanding of child traumatic stress. Drs. Kaplow, Layne and Pynoos receive royalties from Cambridge University Press for their book, Trauma and Grief Component Therapy for Adolescents: A modular approach to treating traumatized and bereaved youth. Drs. Steinberg and Pynoos are Chief Science Officer and Chief Medical Officer, respectively, of Behavioral Health Innovations, LLC, a company designed to develop and distribute evidence‐based assessment tools for traumatized and bereaved youth. Drs. Kaplow and Layne receive payment from Behavioral Health Innovations, LLC for sales of their measure, the Persistent Complex Bereavement Disorder (PCBD) Checklist. All remaining co‐authors report no financial relationships with commercial interests. Substance Abuse and Mental Health Services Administration, (Grant/Award Number: “2U79SM054284‐12S,” “SM062111,” “SM16008”).