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July 5, 2010

Health Risk Behaviors in Parentally Bereaved Youth

Author Affiliations

Author Affiliations: Child and Adolescent Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Arch Pediatr Adolesc Med. 2010;164(7):621-624. doi:10.1001/archpediatrics.2010.101

Objective  To investigate whether parentally bereaved offspring are more likely to engage in health risk behaviors than nonbereaved control offspring.

Design  Controlled population-based study.

Setting  Bereaved families were recruited from coroner records and by advertisement. Control families were recruited using random-digit dialing and by advertisement.

Participants  At 9.0 months after the death, 186 offspring aged 7 to 25 years of parents who died of suicide, accident, or sudden natural death were compared with 167 nonbereaved control offspring.

Main Outcome Measures  The association of bereavement with health risk behaviors was examined. The prevalences of health risk behaviors on the Youth Risk Behavior Questionnaire were compared between bereaved and nonbereaved offspring. Risk behaviors surveyed were related to unintentional injury, violence, sexual behavior, cigarette smoking, and alcohol or other drug use.

Results  No statistically significant difference was noted in the examined health risk behaviors between bereaved and nonbereaved offspring.

Conclusions  Bereaved offspring did not engage in more health risk behaviors compared with nonbereaved offspring. Primary care physicians counseling youth should inquire about health risk behaviors in general.

It is estimated that 4% to 7% of children younger than 18 years experience the death of a parent, with approximately 2.5 million US children in 2000 losing a parent.1 Strong evidence suggests that parentally bereaved children are at higher risk of negative sequelae such as mental health problems, including mood disorders, posttraumatic stress disorder (PTSD), and somatic complaints, as well as greater external locus of control, lower self-esteem, and more academic difficulties.2 Increased psychiatric problems have been reported up to 2 years following parental death.3 Retrospective findings show an association of family adversity (including parental loss) with multiple health risk behaviors and chronic health difficulties.4 Although the effects of parental bereavement on children's psychological well-being have been investigated, no previous studies to date have examined susceptibility to high-risk health behaviors.

Youth engaging in health risk behaviors are of particular public health interest. The Youth Risk Behavior Surveillance System of the Centers for Disease Control and Prevention5 monitors the prevalence and trends in health risk behaviors among high school students nationwide. The 2007 survey reported a high prevalence of health risk behaviors, including having sexual intercourse (47.8%), ever using marijuana (38.1%), being in a physical fight (35.5%), rarely or never wearing a seatbelt (11.1%), and driving after drinking alcohol (10.5%).

The objective of this study was to investigate whether parentally bereaved offspring are more likely to engage in health risk behaviors than nonbereaved offspring. We hypothesized that bereaved offspring are more likely to report higher rates of engaging in health risk behaviors, specifically in behaviors related to unintentional injury, violence, sexual behavior, cigarette smoking, and alcohol or other drugs.


The IMPACT (Impact of Sudden Parental Death on Children and Families) study is a longitudinal investigation of the effects of parental death on families. This study examines youth bereaved by suicide, accident, or sudden natural death at 2 to 19 months (mean, 9.0 months) after the death and compares bereaved with nonbereaved youth.

The original sample consisted of 240 offspring from 152 parentally bereaved families and 185 nonbereaved offspring from 102 control families. Analysis was conducted on 186 bereaved offspring and on 167 nonbereaved offspring for whom there were full data on variables of interest (Figure). The deceased parents were aged 30 to 60 years at the time of death, had biological offspring aged 7 to 25 years, and died within 24 hours of definite verdicts of suicide, accident, or sudden natural death. The nonbereaved control group consisted of families with 2 living biological parents and offspring residing at home and with no first-degree relatives who had died within the previous 2 years. The control families were recruited by frequency matching to the deceased parents on sex, age, and neighborhood.

Study protocol flowchart.

Study protocol flowchart.

The deceased parents and control parents were primarily male, of white race/ethnicity, and in their mid 40s (Table 1). In this sample, 90.3% of bereaved offspring were biological children of the parents, 7.6% were adopted, and 1.7% were stepchildren, and the deceased parental figure for 1 child (0.4%) was the custodial grandparent. The median number of offspring per family was 2 (interquartile range, 1). The mean (SD) period between the time of death and baseline was 9.1 (3.7) months. No statistically significant differences for socioeconomic status were found between the bereaved and nonbereaved groups.

Table 1. 
Demographic Characteristics of Deceased and Control Parents and Their Offspring
Demographic Characteristics of Deceased and Control Parents and Their Offspring
Recruitment and consent procedures

Bereaved families were recruited through coroner's records (46.4%) and by newspaper advertisement (53.6%). Demographically, those recruited through the coroner's office were similar to those recruited by advertisement. The most common reasons for bereaved families' declining to participate were refusal by next of kin (according to the coroner's records) to provide contact with the surviving parent or refusal by the surviving parent to have his or her children interviewed about the death.

Control families were frequency matched to deceased parents by sex, age, and neighborhood. Subjects were recruited using random-digit dialing and by advertisement. Further details on recruitment procedures were described previously.7 In previous reports from this study,7 we have showed that bereaved youth were more likely at 9 months and 21 months after the loss of a parent to have higher rates of depression than nonbereaved controls.

This study was approved by the University of Pittsburgh Institutional Review Board, Pittsburgh, Pennsylvania. After a complete description of the study, caregivers' consent was obtained for their participation and that of offspring. Assent or consent from offspring was obtained as appropriate for their age. Interviews were conducted at the participant's home or in our offices.


The Youth Risk Behavior Questionnaire is an adaptation of the Youth Risk Behavior Survey, which inquires about health risk behaviors that the Centers for Disease Control and Prevention has identified as being priority for surveillance, including those that contribute to unintentional injury, violence, and sexual behavior. The reliability of the Youth Risk Behavior Survey has been established, with 93.1% of items on the survey meeting criteria for at least moderate reliability (κ statistic, >41).8 The health risk behaviors assessed from the Youth Risk Behavior Questionnaire were as follows: wearing a seatbelt, having sexual intercourse, being in a vehicle during the past 30 days with a driver who has been drinking alcohol, and carrying a weapon, or being in a physical fight during the past 12 months. Responses for seatbelt use were recoded as dichotomous no (never or rarely) or yes (sometimes, most of the time, or always) answers. The total scores were computed and standardized.

Cigarette smoking and alcohol or other drug use are also health risk behaviors identified as priority for surveillance. Information on lifetime substance use was obtained from the Kiddie Schedule for Affective Disorders and Schizophrenia for School-age Children–Present and Lifetime Version.9 This schedule assesses lifetime and current episodes of Axis I psychiatric disorders, including cigarette smoking and alcohol or other drug use. Health risk behaviors evaluated were lifetime cigarette smoking, episodic heavy drinking of alcohol (defined as ≥2 drinks ≥4 in 1 week), and illicit substance use. Functional impairment was measured using the Global Assessment Scale10 for surviving caregivers and adult offspring and using the Children's Global Assessment Scale11 for younger offspring. A lower score on the respective Global Assessment Scale suggests greater impairment. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) diagnoses was administered to surviving caregivers to assess their lifetime and current psychiatric diagnoses.12

Self-reported depression, anxiety, and suicidal ideation were assessed in offspring younger than 18 years using the Mood and Feelings Questionnaire,13 the Screen for Child Anxiety Related Emotional Disorders,14 and the Suicide Ideation Questionnaire–Jr, respectively.15 Parallel measures in adult offspring were obtained using the depression and anxiety inventories by Beck et al16,17 and the Adult Suicidal Ideation Questionnaire.18 Intercurrent life events were assessed using the Life Events Checklist in offspring younger than 18 years19 and using the shortened Social Readjustment Rating Scale by Holmes and Rahe20 in offspring 18 years or older.21

Self-esteem was assessed using a subscale of the Weinberger Adjustment Inventory.22 Social support and coping style were evaluated using the Survey of Children's Social Support23 and the Kidcope,24 respectively, in offspring younger than 18 years. These domains were assessed using the Multidimensional Scale of Perceived Social Support25 and the Ways of Coping Questionnaire26 in older offspring. When different measures were used for offspring who were younger than 18 years vs 18 years or older, scores from these measures were standardized.

Abuse history, including physical and sexual abuse, was obtained using a measure based on the Abuse Dimensions Inventory.27 The severity of DSM-IV PTSD symptoms was assessed using the Child PTSD Symptom Scale28 interview for children and the parallel PTSD Symptom Scale29 interview for adults. Socioeconomic status and household income were rated using the scale by Hollingshead.6 Race/ethnicity was self-reported based on the National Institutes of Health format.30

Statistical analysis

Responses on individual items of the Youth Risk Behavior Questionnaire were compared between bereaved and nonbereaved groups using univariate statistical analysis. Bonferroni correction was applied for multiple comparison of individual items with an α of .007 based on 7 outcomes examined. We also looked at association of bereavement with seatbelt use, stratifying for different demographic and clinical characteristics; α was set at .003, correcting for the total of 16 comparisons conducted. Odds ratios with 95% confidence intervals were calculated.


In comparing bereaved with nonbereaved offspring, no statistically significant differences were found for individual health risk behaviors related to unintentional injury, violence, cigarette smoking, and alcohol or other drug use (Table 2). There was a nonsignificant trend for bereaved youth to be less likely to wear a seatbelt. In examining baseline characteristics of seatbelt use, race/ethnicity was found to be significant, with nonwhite offspring wearing a seatbelt less often than white offspring (odds ratio, 2.41; 95% confidence interval, 1.07-5.41). No difference was noted in seatbelt use by type of parental death among bereaved offspring (P = .11).

Table 2. 
Health Risk Behaviors of Bereaved vs Nonbereaved Offspringa
Health Risk Behaviors of Bereaved vs Nonbereaved Offspringa

Although there was no statistically significant difference between bereaved and nonbereaved offspring in seatbelt use, we examined the association of bereavement with seatbelt use, stratifying for demographic and clinical characteristics. No statistically significant differences in seatbelt use were found between bereaved and nonbereaved offspring in any of the subgroups.


In this study of bereaved youth, we found no association of bereavement with increased rates of health risk behaviors at 9.0 months after parental loss. However, there was a nonsignificant trend for bereaved youth to be less likely to wear a seatbelt.

Previous investigations demonstrated associations of recent trauma and early childhood adversity with subsequent health risk behaviors.4 Youth affected by familial suicide or suicide attempts have been reported to be more likely to engage in health risk behaviors.31 However, we found no difference in health risk behaviors based on type of parental death, despite previous research that found suicidally bereaved children to be more susceptible to subsequent psychiatric symptoms and behavioral problems than nonsuicidally bereaved children.2

Parental psychopathologic conditions are predictive of premature parental death. Melhem et al7 found higher rates of personality disorders and substance abuse disorders among bereaved youths than controls in the setting of sudden parental death. Conclusions from a review by Brent and Melhem32 support familial transmission of intermediate phenotypes for suicidal behavior, including impulsive aggression. This may suggest an increased genetic vulnerability for psychiatric disorders and health risk behaviors in bereaved youth by suicide that may manifest on further longitudinal follow-up.

To date, this is the first large, controlled, population-based study of the effects of bereavement and one of few studies2,3,7,3336 to assess health risk behaviors. The sample is representative of Allegheny County, Pennsylvania, and has similar demographic characteristics for racial/ethnic distribution. Also, the deaths among our study's deceased parents by suicide or accident were similar to those from these causes in Allegheny County.

This study is limited in the assessment of health risk behaviors to the past 12 months rather than an assessment of these behaviors before and after the parent's death. Therefore, it is unknown which behaviors the offspring were engaging in before the death or whether there were any changes in behaviors after the death. We recognize that this study includes only death by suicide, accident, or sudden natural death. Offspring bereaved by homicide or anticipated death (ie, cancer, AIDS-related death, etc) are excluded; therefore, our results may not be generalizable to all parentally bereaved offspring.

Follow-up studies are necessary to examine whether the effects of bereavement on health risk behaviors become more apparent with time, particularly as offspring age and are exposed to more situations involving violence and alcohol or other drugs. Age 14 years is a critical period for the initiation of sexual behavior and alcohol consumption, and seatbelt use has been shown to decrease with increasing age.37,38 Intercorrelations of health risk behaviors are recognized as a target for preventive interventions.39 It is also particularly important to address the family history of psychopathologic conditions and symptoms among youth that may suggest a psychiatric disorder, both of which may increase the risk of engaging in multiple health risk behaviors. As this group is followed up longitudinally, our goal is to better understand the trends of health risk behaviors within this population.

Correspondence: David A. Brent, MD, Child and Adolescent Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O’Hara St, Bellefield Towers Room FT 311, Pittsburgh, PA 15213 (brentda@upmc.edu).

Accepted for Publication: February 9, 2010.

Author Contributions:Study concept and design: Melhem and Brent. Acquisition of data: Melhem and Brent. Analysis and interpretation of data: Muñiz-Cohen, Melhem, and Brent. Drafting of the manuscript: Muñiz-Cohen, Melhem, and Brent. Critical revision of the manuscript for important intellectual content: Melhem and Brent. Statistical analysis: Muñiz-Cohen and Melhem. Obtained funding: Melhem and Brent. Administrative, technical, and material support: Brent. Study supervision: Melhem and Brent.

Financial Disclosure: None reported.

Funding/Support: This study was supported in part by IMPACT grant 5 R01 MH065368 from the National Institutes of Health (Dr Brent).

Haine  RAAyers  TSSandler  INWolchik  SA Evidence-based practices for parentally bereaved children and their families.  Prof Psychol Res Pract 2008;39 (2) 113- 121Google ScholarCrossref
Cerel  JFristad  MAWeller  EBWeller  RA Suicide-bereaved children and adolescents: a controlled longitudinal examination.  J Am Acad Child Adolesc Psychiatry 1999;38 (6) 672- 679PubMedGoogle ScholarCrossref
Cerel  JFristad  MAVerducci  JWeller  RAWeller  EB Childhood bereavement: psychopathology in the 2 years postparental death.  J Am Acad Child Adolesc Psychiatry 2006;45 (6) 681- 690PubMedGoogle ScholarCrossref
Felitti  VJAnda  RFNordenberg  D  et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study.  Am J Prev Med 1998;14 (4) 245- 258PubMedGoogle ScholarCrossref
Eaton  DKKann  LKinchen  S  et al. Centers for Disease Control and Prevention (CDC), Youth Risk Behavior Surveillance: United States, 2007.  MMWR Surveill Summ 2008;57 (4) 1- 131PubMedGoogle Scholar
Hollingshead  A Four-Factor Index of Social Status.  New Haven, CT Yale University1975;
Melhem  NMWalker  MMoritz  GBrent  DA Antecedents and sequelae of sudden parental death in offspring and surviving caregivers.  Arch Pediatr Adolesc Med 2008;162 (5) 403- 410PubMedGoogle ScholarCrossref
Brener  NDKann  LMcManus  TKinchen  SASundberg  ECRoss  J Reliability of the 1999 Youth Risk Behavior Survey questionnaire.  J Adolesc Health 2002;31 (4) 336- 342PubMedGoogle ScholarCrossref
Kaufman  JBirmaher  BBrent  D  et al.  Schedule for Affective Disorders and Schizophrenia for School-age Children–Present and Lifetime Version (K-SADS-PL): initial reliability and validity data.  J Am Acad Child Adolesc Psychiatry 1997;36 (7) 980- 988PubMedGoogle ScholarCrossref
Endicott  JSpitzer  RFleiss  JCohen  J The Global Assessment Scale: a procedure for measuring overall severity of psychiatric disturbance.  Arch Gen Psychiatry 1976;33 (6) 766- 771PubMedGoogle ScholarCrossref
Shaffer  DGould  MBrasic  J  et al.  Children's Global Assessment Scale (C-GAS).  Arch Gen Psychiatry 1983;40 (11) 1228- 1231PubMedGoogle ScholarCrossref
Spitzer  RLWilliams  JBGibbon  MFirst  MB The Structured Clinical Interview for DSM-III-R (SCID), I: history, rationale, and description.  Arch Gen Psychiatry 1992;49 (8) 624- 629PubMedGoogle ScholarCrossref
Angold  ACostello  EJMesser  SCPickles  AWinder  FSilver  D Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents.  Int J Methods Psychiatr Res 1995;5237- 249Google Scholar
Birmaher  BKhetarpal  SBrent  D  et al.  The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics.  J Am Acad Child Adolesc Psychiatry 1997;36 (4) 545- 553PubMedGoogle ScholarCrossref
Reynolds  W Suicidal ideation and depression in adolescents: assessment and research. Lovibond  PWilson  P Clinical and Abnormal Psychology. Amsterdam, the Netherlands North-Holland Elsevier Science Publishing Co1989;125- 135Google Scholar
Beck  ATWard  CMendelson  MMock  JErbaugh  J An inventory for measuring depression.  Arch Gen Psychiatry 1961;453- 63Google ScholarCrossref
Beck  ATEpstein  NBrown  GSteer  RA An inventory for measuring clinical anxiety: psychometric properties.  J Consult Clin Psychol 1988;56 (6) 893- 897PubMedGoogle ScholarCrossref
Reynolds  WM Psychometric characteristics of the Adult Suicidal Ideation Questionnaire in college students.  J Pers Assess 1991;56 (2) 289- 307PubMedGoogle ScholarCrossref
Brand  AHJohnson  JH Note on the reliability of the Life Events Checklist.  Psychol Rep 1982;501274Google ScholarCrossref
Holmes  THRahe  R The Social Readjustment Rating Scale.  J Psychosom Res 1967;11 (2) 213- 218PubMedGoogle ScholarCrossref
Lewinsohn  PMRohde  PSeeley  JRFischer  SA Age and depression: unique and shared effects.  Psychol Aging 1991;6 (2) 247- 260PubMedGoogle ScholarCrossref
Weinberger  DFeldman  SFord  MChastain  R Construct Validation of the Weinberger Adjustment Inventory.  Stanford, CA Stanford University1987;
Dubow  EUllman  DC Assessing social support in elementary school children: the Survey of Children's Social Support.  J Clin Child Psychol 1989;18 (1) 52- 64Google ScholarCrossref
Spirito  AStark  LWilliams  C Development of a brief coping checklist for use with pediatric populations.  J Pediatr Psychol 1988;13 (4) 555- 574PubMedGoogle ScholarCrossref
Zimet  GDDahlem  NWZimet  SGFarley  GK The Multidimensional Scale of Perceived Social Support.  J Pers Assess 1988;52 (1) 30- 41Google ScholarCrossref
Lazarus  RS Coping theory and research: past, present, and future.  Psychosom Med 1993;55 (3) 234- 247PubMedGoogle ScholarCrossref
Chaffin  MWherry  JNewlin  CCrutchfield  ADykman  R The Abuse Dimensions Inventory: initial data on a research measure of abuse severity.  J Interpers Violence 1997;12 (4) 569- 589Google ScholarCrossref
Foa  EBJohnson  KMFeeny  NCTreadwell  KR The Child PTSD Symptom Scale: a preliminary examination of its psychometric properties.  J Clin Child Psychol 2001;30 (3) 376- 384PubMedGoogle ScholarCrossref
Foa  ERiggs  DDancu  CRothbaum  B Reliability and validity of a brief instrument for assessing posttraumatic stress disorder.  J Trauma Stress 1993;6 (4) 459- 473Google ScholarCrossref
National Institutes of Health Web site, NIH policy on reporting race and ethnicity data: subjects in clinical research. http://grants1.nih.gov/grants/guide/notice-files/NOT-OD-01-053.html. Accessed April 13, 2010
Cerel  JRoberts  TA Suicidal behavior in the family and adolescent risk behavior.  J Adolesc Health 2005;36 (4) 352.e9- 352.e16Google ScholarCrossref
Brent  DAMelhem  N Familial transmission of suicidal behavior.  Psychiatr Clin North Am 2008;31 (2) 157- 177PubMedGoogle ScholarCrossref
Brent  DMelhem  NDonohoe  MBWalker  M The incidence and course of depression in bereaved youth 21 months after the loss of a parent to suicide, accident, or sudden natural death.  Am J Psychiatry 2009;166 (7) 786- 794PubMedGoogle ScholarCrossref
Harrison  LHarrington  R Adolescents' bereavement experiences: prevalence, association with depressive symptoms, and use of services.  J Adolesc 2001;24 (2) 159- 169PubMedGoogle ScholarCrossref
Thompson  MPKaslow  NJKingree  JBKing  MBryant  L  JrRey  M Psychological symptomatology following parental death in a predominantly minority sample of children and adolescents.  J Clin Child Psychol 1998;27 (4) 434- 441PubMedGoogle ScholarCrossref
Dowdney  L Childhood breavement following parental death.  J Child Psychol Psychiatry 2000;41 (7) 819- 830PubMedGoogle ScholarCrossref
Mulvaney  CKendrick  D Do maternal depressive symptoms, stress and a lack of social support influence whether mothers living in deprived circumstances adopt safety practices for the prevention of childhood injury?  Child Care Health Dev 2006;32 (3) 311- 319PubMedGoogle ScholarCrossref
Schootman  MFuortes  LJZwerling  CAlbanese  MAWatson  CA Safety behavior among Iowa junior high and high school students.  Am J Public Health 1993;83 (11) 1628- 1630PubMedGoogle ScholarCrossref
Brent  DA The rewards of reducing risk.  Arch Pediatr Adolesc Med 2004;158 (8) 824- 825PubMedGoogle ScholarCrossref