PSYCHO-ONCOLOGY

Psycho-Oncology 9: 110 (2000)

CHILD SURVIVORS OF PARENTAL DEATH

FROM CANCER OR SUICIDE: DEPRESSIVE AND
BEHAVIORAL OUTCOMES
CYNTHIA R. PFEFFERa,*, DANIEL KARUSb, KAROLYNN SIEGELb and HONG JIANGc
a

Weill Medical College of Cornell Uni6ersity, White Plains, New York, USA
b
Center for the Psychosocial Study of Health and Illness,
Joseph L. Mailman School of Public Health of Columbia Uni6ersity, New York, USA
c
Program of Children at Risk for Suicidal Beha6ior, New York Presbyterian Hospital-Westchester Di6ision,
New York, USA
SUMMARY
Depressive symptoms, social competence, and behavior problems of prepubescent children bereaved within 18
months of parental death from cancer (57 families, 64 children) or suicide (11 families, 16 children) were compared.
Most children reported normative levels of depressive symptoms. Children whose parents died from suicide,
compared with those whose parents died from cancer, reported significantly more depressive symptoms, involving
negative mood, interpersonal problems, ineffectiveness, and anhedonia. Parental reports of childrens competence
and behavior were similar to a normative sample of children and did not differ between the children bereaved by
parental cancer or suicide. Additional research should focus on other factors, such as family psychopathology,
stresses, and impact of stigma, which may influence the course of bereaved children. Copyright 2000 John Wiley
& Sons, Ltd.

INTRODUCTION
Although death of a parent is one of the most
stressful life events for children (Osterweiss et al.,
1984), few empirical studies have investigated childrens psychosocial outcomes after parental
death. In general, depressive symptoms appear to
be the most consistent adverse outcome in bereaved children (Lutzke et al., 1997). Such symptoms may be evident for extended durations
(Cheifetz et al., 1989; Vida and Grizenko, 1989;
DelMedicao et al., 1992). This is illustrated by the
results of a study suggesting that approximately
one-third of 38 children suffered symptoms of
major depressive disorder within the first 2
months after parental death from such causes
including cancer, cardiopulmonary arrest, stroke
or accident, and that these depressive symptoms
lasted up to 14 months after parental death in
many cases (Weller et al., 1991; Sood et al., 1992).
* Correspondence to: New York Hospital-Westchester Division, 21 Bloomingdale Road, White Plains, NY, 10605, USA.
Tel.: + 1 914 9975849; fax: +1 914 9978685; e-mail:
pfeffer2@rs1.med.cornell.edu

CCC 10579249/2000/01000110$17.50
Copyright 2000 John Wiley & Sons, Ltd.

Furthermore, epidemiological investigations of

community populations suggest that parental
death prior to adolescence imparts significant adverse consequences for psychosocial development,
especially the onset of mood disorders in late
adolescence and young adulthood (Breier et al.,
1988; Tennant, 1988; Kendler et al., 1992; Kessler
and Magee, 1993).
The specific cause of parental death may be an
important factor in predicting the outcome of
bereaved children. For example, children whose
parents died from cancer have been reported to
exhibit symptoms of depression and associated
psychological problems involving anxiety, behavioral problems, decreased social competence, and
lower self-esteem (Siegel et al., 1996). In contrast,
children who experience unexpected, sudden, or
violent forms of parental death, including
parental suicide, have been reported to manifest
not only symptoms of depression but also severe
anxiety, hyperarousal, and intrusive thoughts
within the first year after parental death (Pynoos,
1992; Pfeffer et al., 1997). A central issue believed
to complicate childhood bereavement resulting
from a sudden, unexpected cause of parental
death, such as suicide, is the formation of
Recei6ed 3 August 1998
Accepted 13 May 1999

C.R. PFEFFER ET AL.

childrens traumatic expectations about the world

and a sense of worry about personal integrity and
the security of interpersonal relationships (Pynoos
et al., 1995). Such responses are associated with
severe and chronic symptoms of depression (Brent
et al., 1993, 1995, 1996; Pynoos et al., 1993; Clark
and Goebel, 1996).
Clinical observations of individuals who were
bereaved as a result of suicide suggest that longterm psychosocial adjustment may be more problematic than after other forms of death (Cain and
Fast, 1972; Stroebe and Stroebe, 1987; Ness and
Pfeffer, 1990; Worden, 1996). Empirical research
comparing the behavioral outcomes of children
who experience different causes of parental death
may be informative for elucidating influential factors on the process of bereavement, identifying
children who may be particularly at risk for adverse outcomes, and developing targeted interventions that may decrease the likelihood of
psychopathological outcomes. This paper aims to
address this issue by exploring whether the cause
of parental death distinguishes the outcomes of
children after their initial months of parental loss.
It is hypothesized that after the initial period of
bereavement, children whose parents died as a
result of suicide would have more severe depressive and behavioral symptoms than children
whose parents died as a result of an anticipatable
cause of parental death, such as cancer. A review
of the literature yielded no research findings on
this particular issue.

METHODS
Subjects
Data regarding children bereaved after the
death of a parent as a result of suicide were
obtained from a study involving prepubescent
children and young adolescents, whose parents
had committed suicide within 1.5 years preceding
the research assessment. This study aimed to evaluate the adaptation of children after the suicidal
death of a parent. Families for this study were
identified from the records of the local medical
examiner. Assistance in locating and enlisting
families into the study was aided by extensive
advertising and collaboration with community resources, such as schools, pediatric and psychiatric
practitioners, clergy, police and fire departments,

Copyright 2000 John Wiley & Sons, Ltd.

and funeral directors. During the initial contact

with the surviving parents by telephone, a brief
explanation of the study was provided. Among
such families contacted, those in which the children knew that the cause of death was suicide
were considered eligible for the study. Subsequently, in an initial meeting with the eligible
surviving parents and children, the study was
discussed in greater detail, children were told that
we wanted to learn about how they feel after their
parent died, and written informed consent from
the parents and assent from the children were
obtained.
Children whose parent died of cancer were
obtained from two different studies of bereaved
families with school-age children, which utilized
analogous eligibility criteria and similar assessment instruments. The field period for case identification and data collection for the two cancer
studies overlapped, reducing the likelihood that
any period effects (e.g. advances in cancer treatment/survival) were introduced by combining the
samples, as could have occurred if the studies
were conducted years apart. The first study investigated the nature and intensity of psychological
symptomatology in a cross-sectional sample of
bereaved children who were interviewed 314
months following the parental death. The second
study was a longitudinal investigation assessing
the efficacy of a preventive intervention program
in facilitating the adjustment of school-aged children to the terminal illness and subsequent death
of a parent. Families were randomly assigned to
either the intervention program or the notreatment control group. Families completed
three research interviews to evaluate the childrens
psychosocial adjustment. A pre-death interview
was conducted with the family during the final
months of the parents illness and two post-death
interviews were conducted within the first 14
months after the parental death. To maximize the
number of subjects for the purpose of these analyses, data from the first post-death interview conducted with control group families only were
combined with data from the post-death interview
completed by the families in the cross-sectional
study.
Participants in the cross-sectional study were
identified from hospital records of recently deceased patients; while participants in the intervention study were accrued by contacting patients
identified from hospital medical records as having
advanced cancer who had an expected survival

Psycho-Oncology 9: 110 (2000)

CHILD SURVIVORS OF PARENTAL DEATH

time of 46 months. For both studies, parents

were approached by a clinician to determine eligibility, discuss the study, and, if the family was
eligible, obtain written informed consent from the
parent and assent from the children. As was the
case with the suicide sample, children were told
that we wanted to learn about how children feel
after their parent died.
Participation in the suicide and both cancer
studies was limited to families with two-parent
households prior to the parents death. Another
shared eligibility criteria was that there be at least
one child in the household between the ages of 6
and 13 and that family members were fluent in
English. For the present report, data analysis was
restricted to children who were 5 12 years old at
the time of parental death and assessed within 18
months of the death.

Social competence and beha6ior problems.

Parental reports of the children were obtained
with the Child Behavior Checklist (CBCL), a
measure that yields T scores for scales of childrens competence and behavior problems
(Achenbach, 1991). The CBCL yields a score of
Total Competence as well as scores for specific
competencies in activities, school, and social domains, and a score of Total Behavior Problems,
and scores for subscales reflecting two broadband behavior problem syndromes, involving internalizing and externalizing behaviors, and nine
narrow-band behavior problem syndromes indicative of withdrawal, somatic complaints, anxiety/
depression, social problems, thought problems,
attention problems, delinquent problems, aggressive behavior. Normal, borderline, and clinical
ranges of T scores are identified for all CBCL
scales.

Research instruments and clinical assessments

The research instruments used in this study are
widely used in stress research with children to
assess varied levels of psychological distress and
psychopathology. They are reliable and valid
measures that have normative scale scores for
children in the general population, which can be
compared with the scores of the currently studied
children. Although other factors, such as levels of
anxiety, may have been important to study, these
research instruments were the only ones used in
the present samples of parentally bereaved
children.
Depressi6e symptomatology. Children in both
samples completed the Childrens Depression Inventory (CDI) (Kovacs, 1992), a 27-item selfreport questionnaire for children and adolescents
to rate severity of symptoms of depression present
within the previous 2 weeks. Responses to the
CDI yield raw scores for a total summary scale
and five subscales: negative mood, interpersonal
problems, ineffectiveness, anhedonia, and negative self-esteem. For descriptive purposes, the raw
CDI scores can be converted into age- and gender-specific linear T scores, with higher scores
indicating higher levels of depressive symptomatology. Normative data used in the computation
of T scores were from children of 7 12 years of
age attending public school (Kovacs, 1992). An
age- and gender-specific T scores 5 61 for the
summary scale and the five subscales are suggestive of clinically significant symptomatology.

Copyright 2000 John Wiley & Sons, Ltd.

Statistical analysis
The unit of analysis was the family. To avoid
overweighing the experiences of families in which
multiple children were assessed, all cases were
weighted by the reciprocal of the number of children in the family (Siegel et al., 1992, 1996).
Furthermore, to control for differences between
the cancer and suicide samples with respect to
gender of the deceased parent and the length of
time between the parents death and the research
interview [ B 9 months ( B 272 days) versus 918
months (273549 days)], the weights for each
child in the cancer sample were further multiplied
by a factor equal to the proportion of all cases in
the suicide sample in the subgroup (i.e. based on
the gender of the deceased parent and length of
time since death) divided by the proportion of all
families in the cancer samples in his/her subgroup.
A similar weighting strategy was employed for
comparisons of data from the longitudinal cancer
sample with data from a community sample
(Siegel et al., 1992, 1996).
Chi-square tests were used to assess the statistical significance of bivariate associations between
categorical variables. However, the association
between pairs of dichotomous variables were assessed with Fishers exact test given the small
number of cases in the suicide sample. One-way
analysis of variance was used to compare continuous variables. To determine whether the findings
were sensitive to the imbalance in sample sizes

Psycho-Oncology 9: 110 (2000)

C.R. PFEFFER ET AL.

between the suicide and the cancer sample, all

analyses were run twice. One analysis included
all children in the cancer sample and one included only a subsample of children from the
cancer sample matched to the suicide sample
with regard to not only gender of the deceased
parent and length of time since the parents
death, but also with regard to gender and age of
the child. Both sets of analyses yielded identical
results with regard to children who lost a parent
to cancer, and the trends observed with regard to
differences between the suicide and cancer samples were the same for both sets of analyses.
Based on this consistency of analyses, results of
analyses that included all children from the cancer sample are presented, since they may be more
representative of the range of children experiencing parental death from cancer.

RESULTS
Subjects
There were 11 families having a total of 16
children whose parents committed suicide and 57
families having a total of 64 children whose parents died from cancer. Table 1 compares the
demographic characteristics of the families in
both samples using weighted data. Weighting assured equal distributions in both samples with
regard to the gender of the deceased parent (55%
male) and the proportion of the children who
were interviewed within 272 days (actual range
60273 days) of their parents death (55%) versus 45% interviewed 273 537 days after the
death. Parents in both samples were similarly
distributed with regard to educational attainment. While the average number of children in
each sample was comparable (mean= 1.2 among
parent cancer families versus 1.5 among parental
suicide families, p = 0.151), the proportion of
families including more than one child was significantly higher among those in which the parent committed suicide (46% versus 12%,
p = 0.024).
The distributions were not significantly different with regard to the gender of the child (p =
0.656). Approximately three-quarters of the
children in both samples were White nonHispanic. Children in both samples did not differ
significantly with regard to their age at the time

Copyright 2000 John Wiley & Sons, Ltd.

of parental death (mean age= 9.5 years among

children in the parental cancer sample versus 8.9
years among children in the parental suicide
sample, p = 0.360) with nearly equal numbers of
younger (59 years) and older (1012 years)
children in both groups. There was also no significant difference in the mean age of the two
child survivor groups at the time of research
assessments (10.4 years among children in the
parental cancer sample versus 9.5 years among
children in the parental suicide sample, p=
0.178).
Parents deceased from cancer varied with regard to the primary sire of the cancer and length
of time from diagnosis to death. Most parents
(72%) were diagnosed with cancer in one of four
sites: lung (21%), breast (18%), genitourinary
(17%), or leukemia (16%). The mean length of
time from the parents cancer diagnosis to death
was just under 3 years (mean= 1044.7 days,
SE= 959.3 days), with 30% dying within 1 year
of diagnosis, 29% living 12 years, 26% 34
years, and 15% living 5+ years. Preliminary
analyses found no bivariate association between
parents length of survival and childrens scores
on the CDI or any of its subscales. Unfortunately, systematic information regarding where
the death occurred and whether the child was
present when the parent died were not collected.
Methods used to commit suicide were predominantly violent (82%): gunshot (37%), hanging
(27%), cutting wrists (9%), and burning (9%)
compared with non-violent (18%): overdosing.
None of the children witnessed the suicide or
saw the deceased parents body at the time of
death; but all of the children attended the funeral
of the parent.
The refusal rate was approximately 30% of
parents approached regarding participation in
the cross-sectional cancer study and 35% of parents approached to participate in the longitudinal
cancer study. A similar refusal rate (30%) of
eligible parents was observed in the suicide sample.
Psychiatric symptoms and social competence
Table 2 presents mean T scores of children in
both samples for the total CDI scale and subscales. Mean CDI total and subscale scores for
both samples were similar to those reported by
Kovacs (1992) for the community normative
sample. Children bereaved by parental suicide
reported significantly higher summary T scores

Psycho-Oncology 9: 110 (2000)

CHILD SURVIVORS OF PARENTAL DEATH

than children bereaved by parental cancer (F =

8.57, df = 1,66, p5 0.005) as well as on subscales
indicating negative mood (F = 5.71, df=1,61,
p 5 0.02), interpersonal problems (F = 10.61, df =
1,64, p 5 0.002), ineffectiveness (F = 4.71, df=
1,64, p 5 0.03) and anhedonia (F = 9.82,

df= 1,62, pB0.003) but not negative self-esteem

(p5 0.27). In response to an item of the CDI
regarding suicidal ideation, approximately a third
of the children in both samples reported they
thought of killing themselves; a rate similar to the
community normative sample.

Table 1. Demographic characteristics and features regarding the death of participating families by sampleweighted data
Parental cancer
(n =57; %)
Gender of deceased parent
Mother
Father
Number of days from death to assessment
60272
273537
Mean
(SD)
Gender deceased by time from death to study
B272 Days
Father
Mother
273549 Days
Father
Mother

Parental suicide
(n =11; %)

N/A
45
55

45
55

55
45
303.6
(120.9)

55
45
248.8
(155.0)

N/A

0.193
N/A

18
36

18
36

36
9

36
9

Educational attainment of surviving parent

High school
Partial college
College graduate

30
38
32

46
27
27

Number of children/family
1
23
Mean
(SD)

88
12
1.2
(0.6)

54
46
1.5
(0.5)

Gender of child
Male
Female

51
49

36
64

Race/ethnicity of child
White
Non-White

76
24

73
27

Age of child at parents death

59 years
1012 years
Mean
(SD)

48
52
9.5
(2.0)

50
50
8.9
(2.5)

Age of child at assessment

69 years
1013 years
Mean
(SD)

33
67
10.4
(1.9)

41
59
9.5
(2.4)

Copyright 2000 John Wiley & Sons, Ltd.

p Value

0.601

0.024
0.151
0.656

0.020

1.000

0.360
0.880

0.178

Psycho-Oncology 9: 110 (2000)

C.R. PFEFFER ET AL.

Table 2. T scores the CDI: parental cancer vs. parental

suicide samples

Summary scale
Mean
SD
Subscales
Negative mood
Mean
SD
Interpersonal problems
Mean
SD
Ineffectiveness
Mean
SD
Anhedonia
Mean
SD
Negative self-esteem
Mean
SD

Parental
cancer
(n= 52)

Parental
suicide
(n = 11)

42.5
6.2

49.4
10.6

0.005

44.1
5.7

49.6
11.3

0.020

45.2
4.8

51.1
8.0

0.002

43.9
5.9

49.0
11.5

0.033

43.3
7.3

51.7
10.6

0.003

45.3
6.5

47.9
9.1

0.270

CBCL scores for both samples were similar to

normative sample scores (Achenbach, 1991) for
competence and behavior problems. Nor, as
shown in Table 3, did they differ significantly
between the suicide and cancer samples. Prevalence of clinically significant problems in total
competence and total behavior problems in the
suicide sample were 19% and 23%, respectively,
and 12% and 19%, respectively, in the cancer
sample. There was no significant difference between the 32% of the suicide sample and the 15%
of the cancer sample that had clinically significant
internalizing scores (p =0.404). There were lower
rates of clinically significant scores on the externalizing scale, namely 9% for the suicide sample
and 7% for the cancer sample. Only 5% of children in the cancer sample was in the clinical range
on at least one behavior subscale compared with
18% for the children in the suicide sample (p=
0.356).
DISCUSSION
The findings of this study suggest that the majority of children bereaved between 2 and 18 months

Copyright 2000 John Wiley & Sons, Ltd.

after parental death from cancer or suicide reported levels of depressive symptoms that were
comparable with a normative sample. These results contrast with other reports, which found
many bereaved children to have extended durations of depression and other psychological distress (Cheifetz et al., 1989; Vida and Grizenko,
1989; DelMedicao et al., 1992). Similarly, surviving parents in both samples of this study reported
their children had normal or high levels of social
competence and normal or low levels of behavioral problems.
The relatively low levels of psychological distress reported by the children in both samples
suggest that most of the children exhibited what
would appear to be a high level of resilience
following their loss of a parent, whether that loss
was due to cancer or suicide. While intuitive, such
a result might have been unexpected. It is consistent with earlier reports regarding the larger cancer sample from which the cancer sample used in
this report was selected (Siegel et al., 1996; Raveis
et al., 1999, in press) as well as other investigations of bereaved children (Van Eerdewegh et al.,
1982; Silverman and Worden, 1992; Sood et al.,
1992; Sanchez et al., 1994; Worden, 1996). Such
findings are not necessarily evidence that the loss
of a parent has little impact on the emotional
wellbeing of children. For example, it has been
suggested that the manifestations of problematic
adjustment to parental loss, at least for children in
the period covered by these data, are more subtle
than those assessed by the CDI, the CBCL, and
other measures of emotional states (Siegel et al.,
1996; Raveis et al., 1999, in press). Other types of
measures, such as reports of changes in childrens
thinking or behavior that arise following the
death of a parent, could perhaps better identify
those children who experience difficulty adjusting
to parental death. It was also possible that the
children in this sample were either denying or
were reluctant to acknowledge problems in the
emotional domains assessed, for reasons which
were directly or indirectly related to the loss of
their parent. For example, they may have been
reluctant to acknowledge their own feelings of
depression for fear that doing so would upset
other family members. Similarly, reports of bereaved parents of their childrens psychological
distress and symptoms of depression have been
reported to be lower than childrens reports of
their distress and psychiatric symptomatology
(Weller et al., 1991). Bereaved parents may be so

Psycho-Oncology 9: 110 (2000)

CHILD SURVIVORS OF PARENTAL DEATH

Table 3. T scores for measures of social competence and behavioral problems from the CBCL:
parental cancer vs. parental suicide samples

CBCL competence scales

Activities
Mean (SD)
% in clinical range
Social
Mean (SD)
% in clinical range
School
Mean (SD)
% in clinical range
Total competence
Mean (SD)
% in clinical range
CBCL behavior problems scales
Internalizing
Mean (SD)
% in clinical range
Externalizing
Mean (SD)
% in clinical range
Total behavior problems
Mean (SD)
% in clinical range
CBCL behavior problem subscales
Withdrawn
Mean (SD)
% in clinical range
Somatic complaints
Mean (SD)
% in clinical range
Anxious/depressed
Mean (SD)
% in clinical range
Social problems
Mean (SD)
% in clinical range
Thought problems
Mean (SD)
% in clinical range
Attention problems
Mean (SD)
% in clinical range
Delinquent behavior
Mean (SD)
% in clinical range
Aggressive behavior
Mean (SD)
% in clinical range

Copyright 2000 John Wiley & Sons, Ltd.

Parental cancer
(n =52)

Parental suicide
(n = 11)

p Value

47.2 (6.9)

43.0 (10.3)
10

0.123
0.419

46.7 (6.8)

44.8 (8.7)
6

0.503
1.000

46.9 (7.7)
5

43.1 (8.7)
5

0.174
1.000

47.7 (9.3)
12

42.0 (10.1)
19

0.123
1.000

50.5 (11.7)
15

56.5 (11.7)
32

0.134
0.404

48.7 (10.7)
7

52.7 (8.1)
9

0.251
1.000

49.6 (11.6)
19

56.3 (10.8)
23

0.092
1.000

54.5 (6.3)
2

57.1 (10.9)

0.296
1.000

54.7 (8.0)
2

58.4 (10.7)
14

0.216
0.411

55.4 (7.1)
2

52.7 (11.8)

0.330
1.000

55.4 (7.3)
3

55.2 (12.3)
4

0.932
1.000

52.8 (6.0)
2

55.6 (14.2)

0.317
1.000

53.8 (6.1)
2

58.4 (12.7)
14

0.089
0.411

54.4 (5.1)

55.8 (6.7)

0.450
1.000

53.6 (5.7)

52.0 (12.5)

0.531
1.000

Psycho-Oncology 9: 110 (2000)

C.R. PFEFFER ET AL.

overwhelmed by their own grief and mourning

that they are not fully aware of the distress of
their children, or they may not be able to cope
with the issues necessary to intervene with their
childrens psychologically distressed states.
The findings that children in both samples reported relatively low levels of depressive symptoms may also result from the timing of these
interviews. A longer period of follow-up may be
required to identify children who experience a
delayed grief reaction to parental death. For example, Worden (1996) found that childrens risk
of developing serious emotional or behavioral
problems attributed to the experience of parental
death doubled between 1 and 2 years post-death
(Worden, 1996). It may also be possible that, as
additional lifestyle changes associated with the
death occur over time, such as the surviving parent remarrying or changes that occur throughout
the lifespan, such as the bereaved child graduating
from school or getting married, these events may
trigger a grief response or depressive disorder. It
is also conceivable, as some have argued, that
developmental or maturational limitations in children could result in only part of a clinical syndrome being initially expressed, while other
aspects become manifest at a later point in time
(Carlson and Gerber, 1986; Cicchetti and
Schneider-Rosen, 1986; Kranzler et al., 1990).
As expected, children bereaved by parental suicide reported higher levels of depressive symptomatology than children bereaved by parental
death from cancer. This may be related to complications in the process of bereavement after suicide, such as traumatic thoughts about the
suddenness and manner in which the suicidal
death occurred. Symptoms of post-traumatic
stress may intensify and prolong the duration of
depressive symptoms in children (Goenjian et al.,
1995). An alternative explanation may be that
a greater intensity of depression occurs before
the parents death during the period when children begin to anticipate their parents death from
cancer and observe the deteriorating condition
of their terminally ill parent (Siegel et al., 1992).
In contrast, when a parent dies suddenly
and unexpectedly, such as a result of suicide,
children often do not have an opportunity to
anticipate their parents death; therefore, they
may be in a different phase of bereavement than
children who experience parental death from
cancer.

Copyright 2000 John Wiley & Sons, Ltd.

Strengths, limitations, and implications

While this study provides new empirical insights regarding the impact of cause of death on
childrens adjustment to the loss of a parent,
limitations of this study must be noted. The small
samples may have decreased the likelihood of
identifying contrasts with normative samples. Although there were uneven sample sizes, preliminary analyses to explore this issue produced a
similar set of results. Thus, although the number
of children bereaved by parental suicide was
smaller than that of children bereaved after
parental death from cancer, the significant differences in childrens depressive symptoms identified
between these samples suggest the strength of
these distinctions. Owing to the relatively large
range in the length of time from the parents
death to the childrens assessments and the use of
child and parent reports rather than clinician
reports of childrens symptomatology, these data
may have limited diagnostic specificity regarding
psychiatric disorders and the timing of the onset
of symptoms. Furthermore, while child reports on
the CDI and parental reports on the CBCL may
yield reliable and valid assessments regarding the
constructs they measure, the prevalence of specific
symptoms that are expressions of or associated
with grief or another bereavement-related outcome may vary among individuals when they are
measured with these instruments. Thus, the development of instruments that are more sensitive to
the processes of grief and mourning in children
could potentially increase the ability to identify
children who experience more complex forms of
psychosocial distress, which place them at risk of
adverse outcomes. In addition, prospective research is needed to determine whether differential
outcomes occur over longer follow-up periods
between such groups of children and to clarify the
risk of adverse outcomes imparted by family psychopathology, life stresses, and the impact of the
stigma associated with parental death, especially
after parental suicide.
ACKNOWLEDGEMENTS
This study was funded by The William T. Grant Foundation, a fund established in the New York Community
Trust by DeWitt-Wallace, the Klingenstein Third Generation Foundation, NIMH (MH41967), the American
Cancer Society (PRB-24A), and the van Ameringen
Foundation.

Psycho-Oncology 9: 110 (2000)

CHILD SURVIVORS OF PARENTAL DEATH

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