Anxiety and vulnerability in parents following the death of an infant

Scaadinavian Journd of Psychology. 1987, 28, Psychol 28 ( lf-2i Anxiety and vulnerability in parents following the death of an infant ATLE DYREGROV and STIG BERGE MAITHTESEN z. Uahnrsiry of Eergcn, Noruay 'd s, I Dyrcgrov, A. & Marthicscn, S. B.: Anxicty and vulncrability in parcnts folloring rhc death of an infant. Scandbuvbn t oumal ol Psychology, 1987, 26, lG25. Empirical dao on thc subjcctircly reporred anxicty rcactions of l17 parcnts who lost an infrnt st binh or durin3 the tirst ycar of life are prcscntcd. From a rctrospcctirrc survcy conductcd I to a ycers aftcr thc dcath it qas cvidcnt that parcnts expcricnccd a grcat dcal ofurricty follorirg tbc death oftheir child. Parcnts who cxpcricnccd a suddcn dcalh in the homc reported thc ltrrotrgcst urxicty, but othcr parcnts who lost thcir child in hospitd at binh or thcrceficr dro cxpcricnccd strong anxicty. The anxicty for surviving childrcn and latcr-bom childrcn uas cxtensirrc. In all arcus mothers expcrienced morc anxicly than fathcrs. Morc intcnsc and longer gricf in onc's panncr, the pcrccircd lack of suppon from othcn, bcing older. and bcing a fcmalc ntre significantly corrclatcd with anxicly. The results arc intcrprctcd as a confirmation that parents who lose thcir childrcn cxpcricncc a fundamcnral changc in thcir bclicfs about thcir family's future sccurity. Bcltcr lraining of hcalth pcrsonncl is rcquircd to sccurc an adcquate follow up offamilics that losc a child. A. Dyrcgran, Rescarch Ccntcr lor Occ'upatiouutr Health and Sdety, Uniursity of Ecrgen, Hans Tanks gt. I l, 50&) Bergcn, Noruay. l. o h I t. ,f d e t8 A sharp incrcasc in fcar and anxicty is one of the most common and distressing consequcnccs of a post-traumatic stress disorder (PTSD, Amcrican Psychiatric Association; Diagnostic and Statistical Manual of Mental Disorders, l9t0). A high level of fear and anxicty has bccn reported among survivors of concentration camps (Niedcrland, 1968), rape victims (Schcppclc & Bart, 1983), victims of torturc (Allodi & Cowgill, 1982), assault victims (Krupnick & Horowiu, 1980), and hostage victims (Ochbcrg, 1978). Thc ingrcasc of fcar and anxicty has becn linkcd to a loss of thc illusion of invulnerability (Janis, l!169; Janofr-Bulman & Frieze, 1983; Schcppclc & Bart, t9E3). This illusion rcfers to the inclination in pcople ro look at themsclrcs as less vulncrable than others (a review of rescarch is givcn by Pcrloff, l9t3). This stratcgy rcsults in a scnsc of control which allops thcm to copc with thcir daily activitics. Honcver, a pcrson can no longer hold on tp a fundamental bclicf in his futurc safety after an extrcmely strcssful event (Janis, 1969). Sercral'studi$ ha\rc rcportcd an increased anxiety in parcnts following the dcath of a child (Climan ct al., t9t0; DcFrain & Ernst, l9?8; Cornwell ct al., t977: Lqris, l98l). Fan authors have lookcd at anxiety and fear from the perspcctive of vulncrability. In this papcr wc will cxamine parental anxiety from the Jrerspccti\rc of vulnerability and explorc scvcral aspccts ofthe anxicty which parents experience following tbe dcath oftheir child. Thc following questions will bc addrcsscd: l) To what dcgree do parcnts rcact with anricty folloring their child's dcath? 2) ls lherc any dillcrence in the amount of anxiety rcporlcd among patuls who expcrienced diffcrent types of loss (stillbirth, nconatal death, Suddcn Infant Dcath Syndrome)? 3) Will thc death of a child lead to increased anxiety for surviving and later born childrcn? 4) To what cxtenl do parcnts expcricncc anxicty during a oew pr€gnEocy and birth? 5) What psychosocial conditions shorv thc stnongcst rclationship to anriety? Finally in the discussion nrc will address thc question: Docs thc dcath of a child lcad to a loss of the scnse of invulncrability in parcnts? Scand J Psychot 28 (t987) Aruiety and vulnercbit$ after a child's death METHOD Subjects Thc study uas carricd out at The univcrsity Hospital of Bcrgcn. This hospital provides scrviccs ro familics living on thc n€srcrn coast of Norway. o"p"n.enr of obsretrits rhere arc around 4000 dclirerics per ycar,.and thc Dcpanmcni p.ii"rri....rr.ar or impatieiis anu tsooo ourpas6r115 At fam'ics who rosi rheir chird due ro siirtbirrh3000 o, (a riving ch'd 'g'rarrv. transferrcd to thc Nconar4 Intcnsive care Unit wioiatcraical at the Dcpartmenr ofobsrerrics and thc Dcpartmcnt of Pcdiatrics rvithin a 3-ycar p..iJr*r" incruded in rhe srudy. In addirion sudden Infant D'cath syndromc (sIDS) familiesirr"i !"r"-1"'""ntacr with rhe Depanmenr of pediatrics in rclation to thc dcath uare included. Thit stoup;;;ri;rurcd around 802, ;i;i-l;;iies in rhe region rhat lost a child in sIDS during ttre timc peiJ L.r.r.J'tu"."a on a"t" r-rir," uilf rcgisrcry. a rotar of 28 familics nrcre excluded-wtren ottrirryfs oi"l-..r madc ir erhicaily and clinicaly difliculr ro subjcct thcm to thc inrcsdSarion, such family situalion, o, the erpecration of a new child in thc ncar future. "r "rtr"riiv "overse A total of 2t4 parents who.lost a clrjld a qucsrionnaire. of thcse, | | 7 parents who had losr a child I to 4 ycars previousty (M=27.'2o'on,r", -rcccived Sb-=s.20) rhe sroup consistcd of 55 couprcs and 7 morhcrs, ana the rcspondcnrs, age ."ng"a rro;ii rJ years 1u=29.1, SD =5'79)' 62vo of lhe parcnts were yortngcr lhan 30 veys. l6vy livcd in urban areas. All rhe fathcrs and 95 vo of thc mothcrs r+c5 manie-dl, negaraing ;.on, 23 % had rhcir hishesr "oucai inziv, had junior iii"-i,J,iniJ.,ii,, ",o, r,ieh schoor f'"lffi"ou.",ton,5sva ^na Thc samplc consists of thrce groups of bercavcd Aarylts. Thcse rhrce groups u€re t) a sliltbinh group (/V=3t),2) a nconarat group (N=57), and 3) a'SIDS All parcnts ntrc offcrcd assistance aftei the i*".tig.iio".eroup 1/V=29j.en intcruintion program ii ii. ";;,"t-;;";h - ,"";;;;';;i;;;",r", "orr"e";.;;r;io i in;il;;;;i was sbned ar the same time as this inrrcsrisation. e*""pt roi i irii"i".n"s, none oiiie il;;;;;;d reccivcd any systcmatic hclp prior to the.inrrcstigation. Qualitative dara from *r. int"r"Ition'progo* have been uscd to i[usrrare some of thc quairitative access ro informadon nor availablc through a gucstionnair" stud". "u...*ri*, ri; i.;il;ii;r.it'rli"'|",-*.0 Measures Thc parcnts nerc askcd to complctc a writtcn qucstionnaire. The questionnairc contained thrce pans dcsigncd to providc t) sociodcmograptric informaf a"t" ,"l"t"o t" ii.aiincluding rhe faTly rcactions to thc loss, anC l) Oara on pry.ii" *Jsomatic discomforr. Qucstions for thc instrument nrcre adaptci from the litcraturc on family rcactions to the dcath of a child (Kcnnctt cr al., t9?0; CuJt-bcrs, fC66;n;ciat., tqZA; ecnnctd cr al., t97E; Comwcll el at., l9?; Mandclt ct at', 1980). and frori cxplorat"ry mcctings wirh parcnrs rryho had rosr a child' subscquent rcvisions rrcrc madc. From tic "rd qucsrionnairc only data pcnarning morc crtensirc to anxicty rras uscd (sce Tabre t for spccific ansncrcd by rhc parcnrs rcgarding thc time thc loss (question A) and r","r tluir,i*JB and fnodjollowlng c)). eualitarira informalion collccrcd lhrough the intcrrrcndon program garrc additional information on thc difrcrcnt types of anricry expcricnccd by the parcnts. In addition thc qucstionnaire also includcd Spiclbcrgcr,s STAI Form X-t (Spiclbcrgcr er at., t970). In rhc srare rrcrsion of the A"ti"i; subjccts indicatcs thc inlensity of thcir .starc-Trair fcclings of anxicry ar a parricurar momcnr ncrc askcd ro rcpon how they fcrr zaz. Cronbach's alpha was 0.g. il ri"i.* i**il*r qil;;;; il;il;ry ;;iir;. 'il;;rcnts Procedure Onc urcck prior to scndins the qucstionnairc, a lctter nras scnt informing the parcnrs of thc main objcctiws.of the study; toincrcasc hcalth profcssionals, knorlcdge of family rcactions after thc loss of a child, and to improvc support for iuch families. Three ircks *""i"i"! rhe original questionnairc, non'rcsponding familics ntrc "r,". thcir response. In all scnt a follor,-up lcttcr rcqucsting communications parents n€rc offercd the assistancc of a pcdiatrician and a psychorogrsr (thc first author) it thcy fch thc nccd for asking qucstions, or for discussing thoughts or fcclings concerning thc loss. Mothcrs and fathcrs reccirrcd almost idcntical qucstionnaircs, and thcy wenc r.questcd ro fill thcm out scpamtcly' The molhcr's quc-stionnairc contained qucstions about sibling and factual gucstions that rcquircd ansntrs-from only one ofthc Thc lcngtb oithe qucsiionnaire nas thus lE pagcs for mothcrs, and 15 pagcs dor fathcrs. iarcnts. -- *"lii"*, t7 l8 A. Dyregrov and S. B. Manhiesen Send J Psychol 28 (t98?) Statistics The al., ds. ln, from the t t7 0uesdonnaircs ncrc codcd and cntcrcd on a pcrmancnr data firc. spss (Nic ct uas uscd for rbc sratisrical compuhri;;;'- -".. RESULTS About half (54.7%) of the parents neturned the guestionnai re (S3Va of the respondents were women). Based on hospitar records, taponding and non-responding mothers were compared on the chird's weighr ar uirttr, ttri chitd's -irrererife-span, ir,. iot-r,".;s age, and whether the family rived in rurar or u.u"n were no significant differences berrcen the groups (r>0.0j, two-tailed rest). The amount of subjectivery reponed anxiety varied with rhe child,s type of death. Thcre was a significant group efrect (F=tO.lO, df=21107,p<0.00t), parent,s "r", *i,f,f,. Table l. Frequency of awiery reactiow in parenrs who rost a child split in thrcc groups according to rypc of dcath. Tcstcd for sigrificancc betuecn thc groups Stillbinh Neonatal % Vo Qucstion A. To wh8r dcgcc did dcath SIDS Vo P you reect with anxictv foloving Uc aca'Of l. Nor ar all 2. Somc 3. Much 9 33.3 t4 51.9 4. Very much Non rcsponders 7.4 a 7.4 4 Mcan t8 32.7 n 40.0 8 14.5 7 r2.7 ) l.t9 r 7 13 7 3.6 8.0 4.4 N.o I 2.n 2.99 10.76... dt=2lrO B. Are you more enrious for your othcr children nor then bcforc thc dcarh? l. No 2. To somc cxtcnt 3. To a largc cxtent Non rcspondcn Mcan 4 t7.4 f0 .13.5 9 gil 39.t 2,21 t.7 1 U 54.3 t7 37.0 0 t t6 0.0 33.3 6.7 3 2.2t 2.6? 3.90. df=2D0 C. To what extcnt u€Fe you anrous during a nan pregnancy? l. Nor ar all 2. Vcry litrlc 3. Somc 4. Vcry much Non rcspondcn, Mcan ) 6.9 3 t0.3 9 3t.0 t5 5t.7 0 3.2t 2 ? l0 t5 03 3.r2 5.9 ms 29.1 4.1 0 2 t0 I 0.0 t0.0 50.0 ,().0 o.37 df=2/E0 variancc. g?^:,F, cxpccrcd or had got a ncw chird fouoving lJhfl:c,.IT'.":f"?:c"*T..91flg:,_t,h.l thc ross, uut oo not_ens.*r rJ; fi..-io;;:0dfffiiffi1,:l,.T,"T:;Jil"ili5 rcnus sIDS, using a raasc'tcsr 0sd-prccc.d;rql:;.ridaiit vcrsus SIDS, using a nngc-tcst (tsd-proccdurei: - -''-' for stilrbinh rtrsus SIDS, and nconaral " oncrrayenalysisof - Scend J Psychol 28 (1982) Anxiery and vulnerabilit-y after a child's death subjcctive cxpericnce of anxiety in the pcriod follorving the loss significantty higher in the "cribdcath" or sIDS (sudden Infant Dearh syndrome) group, rh;n in uott lhe sriflbirth and the nconatal group (Tabre l A). Although nor incrud;d in rt taui., ,,omen reponed more anxiety than men in all three groups. The percentage " of women versus men who reported'much'and.verymuch'anxietywasforrhestillbirthgroup;23.1 Vovs.T.lVo,for the neonatal Uoupi 40Vo vs. lZVo, and for the SIDS eroup; gi.gZ) vs. 50Va. The question A in Tabre l, did not specify the kind of anxiety rhar the panents ferr. Qualitative information from the intervention program indicated that the anxiety was both of an unspecilied kind. the parents felt anothei disaster was imminent, and more specific, as fear ofthe dark, fear ofbeing alone etc. Clinically' parents often expressed anxiety for their partner. This anxiety took the form of nceding r.assurance of he or she being weil or safe. Fear of oneseri having a tife_ lfrelening disease, most oftcn cancer, nras also reported, rogether with the fear ofown death' "I am afraid ofbcing seriousy ill, having to die and not being with the others. I rhink ofillness and dcath ncarly cvery day" (mother, neonatal death). Parent's anxiety were often triggered by intrusive images of rhe death. sreep disturbances frequcntly foliowed periods ofincreased anxiety. "Afier I have gone to bed I freguently see images-just rike srides being turned on and offon a screen. I can't stop them when I want to, and that,s why I lose conirot. Everything feels dark and sufrocating in my bedroom, my hearr s."n; beating iasier ano I get difficulties breating. I wanr to get our of bed, but it feels like being tie-d to the bed, and I can't move" (mother, neonatal death). Parents also reponed of something happening to surviving or ratcr born children. lear SIDS parcnts rcported significantty higher levels of anxiety foriheir surviving childrcn than the othcr two gFoups (F=3.9r0, df=2tg0,p<0.05, see Table t B). one father who lost his child in cribdcath r"id th"r his fear for their suwiving child could be compared to clinging to two ropes up in the air. Ifone rope broke, he would despcratery cling to the other. A m4iority the couples tried to conccive a ncw child soon after the death of the child. -In our sample of78vo of the wrents eitber had or expccted a new child at the time of study ( r to 4 ycaf,s folloving the ross). parents frequentry reponed anxiety in relation ro a new pregnancy and birth. as indicated in Table I C. when the percentages for the categories for "some" and "wry much" ncre taken together, SIDS parents r"[n"d more anxiety than the-other two groups of parents. Horvever, in rhe category ..very had the largest numbers t ;tt: ! .,]' ,. of much,,, stilrbirth p:*ents responders (Sl.|Vo), folloned by neonatal death parents (44.lvo) and the SIDS parenrs (,r0%). No signilicant group differences were obscrved. For the categorics "some" and "very much" taken togethcr, the percentages for women versus mcn on this question (question c) nrre respectivery: stilbirth group g6.7vo vs, 1EiVo, neonatal group 77 .7 Vo vs. 6.gVo, and SIDS group Knm vs. ll .-l m. Qualitative informalion indicated that the anxicty sometimes was extremery high, and expcricnccd simultaneously with sleep disturbances, nightmares, and intrusive, compulsive thoughts. If something was physically wrong with the ncw child, the anxiery rose sharply' If the child was admittcd to the Pediatric ward was it nor uncommon to find thar the mothcr cxpected a messagc about the child's death every time someone came through the door to her room. The fear of rcoccurrcnce was increased by similarities with the original traumatic situation, i.e. the new child was of the samc sex as the deceased, if there was physical similarities bctwecn the two childrcn (..God, I hope it will not be a girl that looks like her"), or the ncw child rryas born at the same timc of year as the deceased child. srAI-X (sumscore) shonrcd state anxiety (hop the parent fert now, I to 4 years follo'ing rhe dcath) to bc highesr in tle sms group (M=36.78, SD=r0.97), and rhe l9 m A. Dyregrov and S. B. Manhiesen Scand J Psychol 2E (198?) stillbirth group (M=36.28, sD=12.01) while the nconatal group had a lowcr mean score (M=33.71, SD=t0.12). No significant group effect was obscrrrcd. Tablc 2 prwidcs en o\rcrvicw of some psychosocial conditions that are believetl to bc of inportancc in grief rcactions. The rclationship betwccn these psychosocial condirions and state aDxicty for the wholc sample is prescnted. A total of 5 out of 16 psychosocial conditions shonred a significant relation to srare anxiety (using product momcnt corrclation). The morc difficult it was to communicate with the spouse follw'ing the death, and the stronger or longer grief the informant felt he/she cxpcricnccd comparcd to hiVhcr spouse, the more anxiety hc/she experienced at the time of study. More anxicty was also related to an experienced lack of iuppott from others. Therc ras also a postive comelation bcturcen anxiety and age. No rclationship betwecn state anxicty and thc numbcr of childrcn in the family was observed. As the intcrval betwecn the actual loss and the time of participation in this research raricd as much as I to 4 years, a partial correlation was computcd to control for this intcrral. As cvident from Table 2, whether the parents answered early or late in this time pcriod had only minor inlluence. Fig. I illustrates a multiple regression anatysis that shors the relative relationship betw€en statc anxiety (dcpendcnt or criterion variable) and some of the psychosociaVdemographic conditions (indepcndent variables or predictors) listen in Table 2. Relative Table 2. Demographiclpsychosocial rnriablcs, and their conelation and parrical conelation (conrrollcd for the intcnnl betueen death and participation in this research) with statc anxie ty ( Pearson product-nome nt conclat ion) Thc wholc 8!oup Qucstion l. Agc (ycars) 2. Educetion 3. Numbcr of childrcn 4. Scx 5. lntcrval bctrrtcn dcath and participation in rcscarch (months) 6. Better/*orse relationship to partncr 7. More dimcult ro tatk with partncr 8. lnfonnant fclt partncr rcactcd with mort intcDsc gricf thsn hirr/trcnclf 9. Informant fclt partner's gricfrcaction *as of longcr duration than his/hcrs 10. Informent cxpericnccd partncr's rcaction as dificrcnt from his/hcn Family aroided dcath in conwrsations t2. Fricnds avoidcd death in conrrrsations 13. Irckcd suppon from othcrs 14. Fost-loss conlact with hospital 15. Support from hospital 16. Satisfecrion with information ll. Statc anxiety (a= l l7) SD 29.t7 l.st 27.02 1.6;2 t.65 2.U 2.O t.n t.87 2.14 2.32 t.36 2.69 l.t3 5.79 . l9a .01 0.7r . tE. .(X .o2 .(N .23' .24' 9.20 0.84 0.7 | -.t2 0.t5 .30.. .30.. .24. ,E' .07 .(b .12 .t0 .t0 .t0 .35rr. .34.. .o2 -.03 .02 .02 .t6 .18 0.t9 0.69 0.7t 0.78 0.92 o.aE r.05 0.E4 .o7 . lE. .(B .t7 Norc. Qucstions Gl2, end 16 arc triscctcd, wirh the valuc I dcfincd as a posirirrc yzlue, ralue 2 dcfincd es ncithcr positivc rno negati\rc, and ralue 3 defincd .s nctrti\rc. Qucstions 13 and 15 are listed with four valucs, where raluc t dcnotcs vrry good suppon and vatuc 4 rrery tittlc supporf. ln qucstion 14 valuc I is dcfincd as lhc cxistcncc of postJoss conrecr with thc hospiral, whilc ntue 2 dcnotcs no such contrct. .p<0.05, .rp(0.01, ..tp(0.(X)1. ,.t .-, Scend J Ps'rchot 2S (lgfr) 4-yg and vuln rubility aftcr a child,s death R2 Frs' /' . .23 R2c = .2r D. .OOl Psychosocial variablcs with tlt: llgngcst prcdictor oonrribution to crplaincd \ariance of sratc nrc sis'mcanc"-il;;ffiilftffi?HffiJ'.f il#fl,,ilffi "i:l,gy11""hld.n;-;d;;;;-il,id;;";;;-;;;;,i*,,*,,i"r Hl'lHS corrctations (paniar r) and bcta.. (p). Thc circtc rcprescnts rhc varianc. dcnorcs variancc explaincd uv ir'rh;;;;;;; $"1lrff'fi: JiiILr" or,ir" p*ai""JliJ"r. rr,i-pr.litioi. iic shaded parr rorar cipraincJ-""1*..'ir'ri.,"d as thc relationship is cxplained as the uniquc contribution the differcnr predictors give to exprain observed variance in the criterion varibre, whcnthe other predictors are herd constant. Different combinations of thc psychoro"i"r listed in Table 2 were utilized in several regrcssion models' In trying "oiii,ions to isolarc the dcmographic/psychosociat variablcs that would yicld the optimal prediction equation, thc cutofrpoint was dctermined by sratistical criteria (Nie ct ar., r'i): r) that theovcral F,"iL of the equadon be significant, and 2) that the unique contribution (parital _d beta_weight) of each predicror in the final reg:rcssion moder be significant a"orr"f",ioi t s% i;;i.ae regrcssion moder in Fig. l iltustrates the psychosociar conditions which bcst p*oirtcJ.at. anxicty. Non-signilicanr (p>0.05) predicrors ncre excluded from thc ,noCit tU"t -rcights for the cxcluded prcdictors rary between 0.20 and -0.06, using a backnard cx"iu.ion paradigm). The psychosocial conditions included in this modct prcdictcd zln iiie variation in stare anxiety (f='.,tg, 82=0.23, R2c=0.21, F=ll.t4, df=yf f f,p<O.mty. fh. ,trong.st prcdicrors in cxptaining variations in anxicty nere &c prcdictors'"rack'of suppon from othcrs,,, ..agc,,, and "sex", in their nespcctive ordcr. DISCUSSION The results shorad that^ subjectirrry rcported anxiety nas rrcry common in parcnts following thc death of thcir child rrris rns .sp"cialv so with parcnts who expcrienccd a sudden death in the home (sIDs), but arso rolo,ring death ar birth and thcrcafter. The anxiety for surviving and ratcr-born children was cr€n mone cxtensive. Anxicty nas arso present during a ncrv pnegnancy and birth, and in the timc folloving rhe binh. In ail thesc 2l l h2r )/ t/ i/ 22 A. Dyregrov and S. B. Manhiesen Scand J Psychol 28 (198?) areas womcn cxperienccd more anxiery than men (sce Dyregrov 09E5) and Dyregrov & (1e87) for more extensive dara and discussion sex differences ilt$;:*" reia;s,";;;;;;t Anxicty uas rerated to probrems of communication among the two panners, ro differin their respective grief reactions, to the perception of others as unsupponive, to increasing enccs age, arid to sex. During the clinical intervention program many forms of anxiety have been noted, such as anxiery for one's spouse and for one's own heatth. orren tie ;;-;.;; was ferr as an cverprcsent, gnawing insecurity. our results confirm those of otier;tG"" er al., l9E0; DeFrain & Ernsr, r97g; cornweil et al., rsTi;-iewis, rgEr) showingin.r"r"o anxiety in parcnts forlowing the death of a chitd. parents who experiencedllDs reported more anxiety on all questions-than the other two g-upr. our materiar shows rhar as many as 50vo of the fathers and 93vo of themothers w-hoexperienced a SIDS death reported srrong to very strong anxiety after the death. A SIDS death gives no rime for pripuratron. in most perinatar and neonatar deaths. Most SIDS deaths occur in the home, ,uirr, ,r,. parents "s finding their baby. Many parents deveroped aversive reactions towards ,h"i. or housc where the death took ptace. "I felt ir smeiled of corpse inside. I did nor"pp"r,,n.n, dare rvalk into the h-ouse for days afterwards, and it took several weeks before I could enter the room where I found her. I shivered" (motber, sIDs). sIDs represenrs a highry unpredictabre event' it occurs without warning or a crear expranation, and it is difficurt to guard against reoccunence. The sex differences in anxiety reported here arso confirms the generar impression from other studies where mothers have bten found to experience more intense and long-lasting grief than fathers (cryman et ar., tgt0; Hermrarh & steinirz, lgTE; wirson et at., rgE2; Walwork, 1985). See also Dyregrov & Matthiesen (19g7) for furtil;";;;.' we found a rerationship beiween anxicty expressed at the time of study and the difficulty the parent fert communicating with on",, ,pou." foilowing rhe Jeam. Anxiety was also rerated to the perception ofone's spouse reacting ronger ,no,. strongry than oneself' Although the correlation does "nd not imply any causal dirccdon, it seems justiliable to hlieve that the intrafamiliar communication will afrect one,s cmotional reaclions. communication seems necessary in securing suppon and care from one,s spouse, and rack ofsuch suppon makes one prone to more anxiety. Being unabre to exchange information about one's reactions and seing the panner react iifierentry than oneserf, probabry adds to feclings of isoration and diminishcs trre ctrance of mutualy reducing insecurity and anxicty. The dcath of a ch'd leads to a strong increase in parentar fears rcgarding their othcr children, as evidenced in other studies (DeFrain & Ernst, t9?g; Clyman et al., tgt0; Kennell et ar., 1970). The unprcdictability otihe sIDS dearhs render these parenrs cspecially wlnerabre. In our intervention jrogram parents have rcportcd ovcrprotection of their other children, in an effort to lat nothing will happen to them, (see also DcFrain & Ernst, 1978; Cornwell ct al., ""r*. 1977; Clyman er al., l9E0; Kcnncll et at., 1970). Others rcportcd the need rc be physicalfy to their children for comfon (as also reponed in Mandet ct al., rgg3). These "lor",in "parenring" changes may hamper rhe identiry dcvelopment of the child, and ir is reasonabie ro think thar the paf,ents, anxiety read to incrcased anxiety in the children. The parcnts' fcar uas arso prcsent through a new prcgnancy, with SIDs parents reporting the most fear. Again, the unpredictabitiry of these diaths must bearthe responsibitlity for rhis. This fear has_bcen notid in many itOS srudics (cf. Blueglass, tgEl; Lcwis, l9tl)' and the anxicty of SIDS mothcrs rr"rL* found to be more-than a rransitory phcnomenon (Lcwis' r98r). But arthough sIDS parents gcnerary experienccd mosr anx- Scrnd t Pryctrol 26 (t987) .ffi Aruiety and vulnerabiliry after a child,s death trequently. This nas to be cxoecrea rc,rr- r-_.L ^, place during their g;il,,H;"":";:T:::Filfi ;";[",Tj:ffiT,H::;HIJ""; trffi last pregnancy. both. surviving and later-born;hil;: "',K T^ryty seemcd to derelop an anxietypreparedness; thus thusbeingreadvro'.r'e,,,o'.i';;;;#;.;:'.'"'#:i:"1;,::ril:H:,J; being rcadv for rhe MRr r^ .^_-:Ts all I'iilXjffi three groups. , Multipte rcgression analysis showed that al predictedr'oip'vcr,oro"i"r"oioi,ion'ff 'T1tJ"t;j.',,?:1';::,l':i::.rjff ^*i",v :!fiqfl#,"*'J:;ill"TiiT":i#""1#l,l r, tisisl who ro Benfietd in"."",.i-*iir,-"i,.n"rng ,.t",ionriTj:|'.tf "r. theirstudy,ho*cver,thcydidr",ir.*1""'""X',0.y:ffi found no we noted rhat younger parents more ofren than order the ruture and *' "r'""J "i,i"m, llff:*il:il|?: ',::l* our findins *as in opposition "g., "na Hfi;:i,rTfl?:,fl f ;i; scer.il;;;;;frce,,,ffimore apt ress,"lri"e i i*;r on the negative It shourd be emphasized that a rerativety rarg,: pan ofthe variance predicted from rhe psychosociar in anxiety was not ori"ui*'i,irir.a..r, i"r, murdpre regression emprrasizea rut i. ,n"rr,oJ."prrr.ing d.g... or *Lli"l,o.,rryeen bles' and it does not impry " varia_ any rire- metroa is descriptive or an interpretadon inoepenoent chosen rrom "gt:ir ""u*i*. ff;"5':"*r*H:: t97t'-D';;;;; ;;; our resurts confirm mitigaring efrects of social suppon in loss where rack *r""a ,"L"rl"adaption probtems situarions, in boii widorvers and (Vachon ct al., ter2; . * c"uu,lliilli"i I_"*rr-i"-ii, i';;; Jl,lff"":: :. :Hr, :T,r#":: ;".il:: (Kraus & Kcnncr, uio, study rcceivcd very little foilow unexpected thar thcir oerception :ff'.::f?*T,o,"#Y t'" received vai;#;" the- of sociar suppon is found_ro yi9*' "i."-il ";;;';;;iryn.torn or ruppo., no-nr rhc health professionats, it is not hospitar fi;;"htionship ro ;J; oL",', ro"i"r ,uoouno,n . (spouse """tiii-Jr-tr," "ro,"rt ,rt* for long-term anxietv ,r*-."0*r, and care from hearth,#i[,lTfr*t uo parcnts lose their I"T:fi ifi :Tffi"":rtr:'iil::T:i::ffi;::ffiH:lL:;l'5ffi ;rT:t::: assumcd feelings-of securiry 1",i.-J..io. following sIDS toss thparcnts' Especialy J,fl;m,m:itti*il;$i :Irrcmerirec'cnrs^n"l"ffl,lrffi T:fiffi relativerv uncompricared view -ochbcrg,'t;;ff;; of rhe to rivc, " rhc r+orJ.or-iu."o into pr"".-iuiioiuncertarnty, cognirive rrame ror ile cxperienced" ;;i;;;"d ro be an ff;"r::v',il."fiil Krupnick & Horovirz, t980; world as a "safe" pracc *: men.r..scr,,*"d;#;1,::1;hff?f manv this impricd a rhorough change; ffi:":tr*#:ffi ni*:ffil;* ;;;;;"1about the norrd and rhe future; ..The truth is that lifc is on loan, even my ovn. This is increasingly clcar to me. I am cautious, *lo-"^::t_ a lo.ns time atcad tr"trr.r,-i.i"Jt"r tll. *'J:,::T::'ff i dcath). '::?i,Tsfl,,:sffJrg,ffi1,l;nxl,';;ffi;:".H:,* accounr of underteponing og painfui rccfings ii Although nany parcnts railco ro- iium othcr srudies conducred the ross cxperience. "-'*"]ril,*. our nesponse rate was sim'ar to ,:*q y?., "" f"U*,i", '"".il"""ne, Jr" loss of a lorrcd one (see Shanfield, Bcnjamin & swain' r9&4). Dcspitc ir",ir'r"iianxi"rv reported by rhe parenrs in study' there is reason to bclier.c.thatail;;i;;il rhis ". rs e\cn higher if taken into account- othcr sudies rrarc srr#,-trrat non-rcsponders are non-responding panenb ere more 23 24 A. Dyrcgrov and S. B. Manhiesen Scend J Psychol 28 (198?) cmodonally afrccrcd folloving the loss than responding parents (Clarke & Williams, I979; Coopcr, t980). All in all this indicatcs that our cstimatcs of cmotional reactions probably arc lover than the true prrvalcncc of rcactions atnong parcnts who have rost theii child. CONCLUSION From thc results ofthis study it is evidcnt that par€nts experience a great deal ofanxiety folloving the death of their child. parcnts who experience a sIDS death repon more anxicty folloling the death than parents expericncing neonatal death and srillbirth. Re. Frding anxiousness for other children, and anxiousness during a new pregnancy, there is no over all group efrects. A multiple regression analysis shov ..sex", . age-", and ..lack of support from othcr" to be the strongest predictors in explaining nariations in state anxiety (sTAI). The results illustrate that anxiety experienced following the death of a child in many respects is comparable to the reactions shown to other traumatic life events. The illusion of invulnerability is vcry often badly shaken. while ur have focused on anxiety, this is true regarding other reactions as well, such as sadness and intrusive thoughts (see Dyregrov & Matrhiesen, t985). The anxiety was not just a transitory phenomenon but continued over time, and was prominent in relation to a new pregnancy and birth. In the literature on follow up of bereavcd parents anxiety rcactions aspects have reccivcd litlle attention. Health personncl are oftcn inadequately and insufficiently trained to undcrstand and handle the incrcase in vulnerability and anxiety among parents. To prcvent the post-traumatic anxicty problcms from turning into more pcnnanent problems, it is imponant to have bcttcr trained hcalth pcrsonnel, to provide familics with adequate follor-up from hospitals, primary hcalth providcrs and others. From a thcrapeuticat viwpoint it seems well adviscd to use therapeutic techniques and working mcthods devised in relation to other traumatic life crises (as cohcrently presentcd by Horowitz, 1976, and Schrignar, 1984). ltl_Is":rytt rvas supported by rhc Norrrcgian Rcscarch Council for Scicnce and thc Humanities (NAVF)' Thc authors thsnk Hlkan Sundbcry, Holgcr Ursin and Jcffrey T. Mirchcl for hclp with thc manuscript, and Gary R. Vandenbos for his advise during thc rcr.arci proccss. REFERENCES Alfodi' F. & Colgilt, G. Erhical and psychiatric aspccts of lorrure: A Canadian srtily. canadian Journal of Psychiatry, t982, 27, 9f-.1O2. Amcrican Psychiatric Association. Diagnostic and statisrica! nanua! of menta! disorders. 3rd ed. Washington, D. C.: ApA, 1990. Bcnficld' D. G.' Llib' S. A. & Vollman, J. H. Grief rcsponsc of parcnls to nconatal dcath and parcnt participation in dcciding carc. pediat rics, 197g, 62, l7 l-177. Bfucgfass, K. Psychosocial aspccls of thc suddcn infant dcath syndromc (..Cot dcath"). Journa! of Child Psychiatry, t981,22, 4tt42l. Clarkc' M. & Williams, A. J. Dcprcssion in rromcn aficr perinatal death. The Lancct, l979,April 2E, 9t6.9n. clyman' R. I., Grccn, c., Rona, J., Mikkclscn, c. & Araidc, L. Issucs concerning parenrs aftcr thc dcath ofthcir navborn. Critical Care Mcdicine,19E0. g, 2li-2t8 cobb' s. social suppon as a modcrator of life str€ss. psychosomaric Mcdicine, ln6, 3E,3flL314. coopcr, J. D. Parcntal rcactions to stillbirrh. British Journa! of socia! work, l9t0, ,0, 55-69. cornudl, J., Nurcombc, B. & stcrrcns, L. Family rcsponsc to loss of a child by suddcn infant dcath syndromc. The Mcdical Journal of Australia, gn, t , 656659. Cullbcrg' J. Rcaktioncr inf6r perinatal bamadtid (I): Psykiska fdtjdcr hos kvinnan. Likartidningen, t9f6. 63, 39E0-3986. Sc.nd J Ps],chot 28 (t9S7) rsmuy rractice; 6,9E!989. r#dca,hsyndromconsurviving li*,ii:tifnini',:r"I:H;i;!;i:i,,',:ffi A. ft^it" ri- 'v-"s' ur Dyrcgrov, _.d"ili;;'d;;;q:fi Dyregrow, A. & Maithicscn, oran inranr. rcaz uvrc,rw' ^..dcath A' & .19?8, l3,q.if {;:;,#,::::i,f.ru:"".11*ydmanusc,rprRescarch S. B. si"rl.r,i.r,"ioii aa*u^tiii"iri;;r;'r:;: ,:fif!!11':,!**,hcrs'gricrrolowingthe s..n. i,ititiiii,'i!iii,.r';;;r;;; ;;;i"^ rnfant Death Marthi-cse", syndrome n..""or,c*l.i ^fi"*"";'ii#;l;'nf:lilfig,:l;l;i,iprb,' p^svcotogicat ioi6l.up",ion"r Hcarrh ";:,"#fri..i Reuiew, teto,E7. zts-2st. it!?"#J i ;:*tl** gricving and thc failure suppon. Journal of hamily practice, or -- rtt. Horopitz, o, M. J. Srrcss r r_i.,ii.'',,*;;;";;3,ffi":i3?::_iff ,rJllParenol soclat J""JI,rr,lL1[*IJriL:"rix. ;;J*11L"'H;:",i" r",,ii"*o"aif i"",ion, ro vicrimiza-",#*i:#;tif"Eii:!ti'#',i^ni"nru:X"lA:ipann,srorhedea,horncwborn 1T;lrif,,Liffi;;|,1 il' Yi;tili"::n*:';t,[i*il'#;#; r' l tr''ripr.i"ircsion Krm' J' O' & Kohout' X,:i": 1 i i I t r rhcir newborn inrants. pediatric crinicsor anarysis lu.T-_glg :,#i#:ii.t i:iffr[*i:$?:ii.3]", r"a,), s-pss regression. tn N. H. Nie, ;;;;;i;;';;"te ro,he c. H. sociat d n ,Ti,q{&iri"i:"yaLl*il#l'ir:ry;:"osicarrcsponses,rrcarmcnrimpricas,ua.n,ri.cra,ur, reE2 fl;:''":S[.";{#i:f:::,;:4;;;td;;;;;i'i:,l"Juna, or bcrcaremcnr by Suddcn iniii'o""*, tt,oitt, i;;;i;i;'Y:?r"l1you"o"cs syndromc. .E' H' & carlson, A. unexpcctcd dcath of an infanr sibring. pediatrics, t983, :T::ifu#:Anultv' "it",,hl;Il{il"i1l;"r,,;"t"liffi: } T;l**rions of parcnur,Esponse to sudden unanricipar,i:l,T-* n;i:lp#;f * Bcnr, D H. spss. S,a,is,icat packoseror l' #-;l;;TLl,*,:: Nicdcrtand, w. G. Clinical oUrc.,arioisln fi;';;; or syndrome. Internatioaal Journa! of psy(xhDcrg. ^ .c.hoanallsis,lxs,;t, lr3-lre. F. M. Thc vicrimof rc_rrori1n. fie ferlotr' L' S' Pcrccptions of vutncrability. pracririoner, t{IiE,220,29:-i302. "i.,iriliiin Jouraa! of sociar Issues,r9E3. J9, 4r{r. r._& Ataidc, r-. Forror up orramirics who . d c, fi si cl I cl w c( CT Kr AI lT*.:'JSll;[;T"'.s"-"*1i..".'i..'ffigli. ,{:Fjiif*3.#.tldx,1#3TJ:a'SjJ$;,";;;.;"1*",""**,, scnngnaf,. C.B. post traumatic-strcss Shanlietd' s' B" Beni"orin' e,. q iiroirr.New york: M praeger, t9E4. i-*Ji;;: i#;Lcd-ons ro rhc death of an adult chird from Amcrican Journal of -a psychiatry, lfr)-ii," o_,-Tn".r. twz_two. "t'iffi"i,?"fa3;:"1iffil;l"t*1'il;l'ft;:'tt)'anuar ro, thc state-rrair Anxicry rnnnrory. gp'us'6i J' J" srDamcr' J. s. & Sheposh, J. p. Efrccrivt mfr-talggning foroving rhe dcarh of with canccr. Journat orpraud, a chird t, :rirrur. t"tonr M' L' s', Rogcn, J.,.Lvat, iiii;;:-d; * e. Il,'i."""i,"*. 1.. srr.toon, A. R. & Frccman. s. J. J. ;ffi:Tf #:orrclatcs of adaprau"n to coniGJ-iLr.ln"n,. American Journat of psychiatry, ... *"#.ji;i;lril,ilJ',t"1 orramlcs ,?,iffiip ornconarcs in whom tirc suppon ""1?i;*;'; ff1f,,1,1;t'jjff-*;"?fif ,::"*lrri. Rcccivcd 22 Scprcmbcr 19g6 $ias wirhdrawn. rhcdcathora ncwbom,win: Ananarysis (t H rg (J, el co: (Jr Hc rct I int He Vi( tha eta fatl 1 gml