Loss and Bereavement: A mental health perspective on children's and young adults' Double Bereavement of parental divorce and parental death

Introduction
This thesis develops knowledge about how children and young adults experience double bereavement, its consequences for their mental health and their need for support. The thesis also develops knowledge about health professional interventions suitable to promote children’s and young adults’ mental health following their combined experiences of parental divorce, cancer and death. Double bereavement refers to the loss experienced through parental divorce followed by parental critical illness and death. Facing the death of a divorced parent is a highly stressful life event. There is a risk of mental health problems and PG when children and young adults experience a divorced parent’s critical illness and death. When a divorced parent is dying of a critical illness like cancer, there is a need in clinical practice for policies and targeted support to these young people and their divided families. The purpose of this is to prevent mental health problems and promote well-being. When a parent has a critical illness and faces imminent death, the family functioning has a strong impact on children’s distress and well-being. It has been found in a US National survey that married biological families perceive greater family-centered care than other family structures in clinical practice.

Background
The issue of double bereaved children and young adults has been only sparsely addressed in bereavement and nursing research, despite the fact that almost 50% of the Danish and US children that lose a parent to death are from a divorced family. An integrative systematic review was conducted with the aim of investigating children’s and young adults’ experiences of double bereavement and its consequences for mental health and need for support. We only found 11 quantitative and qualitative studies that address double bereaved children’s and young adults’ experiences of double bereavement and its consequences on their mental health and need for support. The results showed that double bereavement is a multi-loss experience influenced by the young person’s age, gender and feelings. Furthermore, the bereavement is affected by whether it is the death of a custodial or non-custodial parent and the experienced support from parents and professionals. We found that the mental health problems caused by the double bereavement can be depression, PTSD, psychosis and severe mental disorders, indicating a 3-4 times significantly higher risk compared to children and young adults without double bereavement. The results from the review provided limited knowledge of how children and young adults experience double bereavement and its consequences for their mental health and need for support and we did not find did any specific interventions suitable to promote the mental health of children or young adults who had lost a divorced parent to death.

Methods
The study comprised a range of scientific methods to develop knowledge. The qualitative sub-studies were primarily epistemological, methodological and theoretically informed by the Phenomenological-hermeneutical approach inspired by the French philosopher Paul Ricoeur. A quantitative study was applied generating knowledge through statistical analysis. The PhD study consists of 4 sub-studies:

1. An integrative systematic literature review of 11 studies in which children’s and adolescents’ (Young adults) experiences of double bereavement, the mental health consequences and their need for support were reported. Results are presented in the Background section of the thesis.

2. An in-depth semi-structured interview study with 20 nurses from school health nursing, district nursing and hospital nursing deals with interventions targeting children of a divorced parent who dies from cancer.

3. In a survey, mental health and grief in 190 young adults who had lost a divorced parent compared to a non-divorced parent were compared. As measure instruments, the survey used a well-being index (WHO-5), a Prolonged Grief Disorder questionnaire (PG-13), a Brief Grief Questionnaire and a Common Mental Disorder Questionnaire (CMDQ).

 4. An ethnographic field study inspired by Spradley took place in a Danish Cancer Society Counseling Department. It consisted of 340 hours of participant observations of groups with children with parental cancer and young adults who had lost a parent. Furthermore, 28 interviews were conducted with participants and their relatives. The aim was to understand double bereavement, its consequences for their mental health and need for support.

The qualitative data from sub-study 1 were analyzed using the approach to integrative review analysis by Whittemore and Knafl. Sub-study 2 and 4 were analyzed by NVivo with a Ricoeur-inspired interpretation theory on three levels: Naïve reading, structural analysis and interpretation and discussion. The survey was statistically analyzed by using SPSS.

Results
The thesis presents evidence-based knowledge to understand children’s and young adults’ experiences of double bereavement, its consequences on mental health and need for support, and suitable interventions to promote double bereaved children’s and young adults’ mental health and to enhance the divorced family-focused care.
The integrative review gave some evidence-based knowledge to understand that double bereavement is a complex multiple loss experience and that double bereaved children and young adults have a profound need of varied support options.
In the survey we compared young adults who had experienced the death of a divorced parent with young adults who had experienced a non-divorced parent’s death. We found that having lost a divorced parent is associated with significant risk of PG, CG, bodily distress and alcohol misuse. We also found that there is a significant risk among young adults who have lost a divorced parent associated with having experienced the death of a divorced parent with mental illness or alcohol misuse.
The field study uncovered that double bereaved children and young adults are challenged in their grief with stress overload. Their experiences of stress resultant in mental health problems are related to navigating through multiple transitions and disruptions in and between the two family worlds and their coping capacity. The accessible support from close relationships and professionals in and between both family worlds predicts their mental health. Support must follow the child or young adult throughout the transitions when a parent is critically ill and dies, in order to reduce the impact of the loss and restoration stressors to prevent overload and mental health problems.
With regards to the interviews with nurses, four themes of interventions were apparent resulting in the formulation of: “The Divorced Family-Focused Care Model” that enables clinical practice to target support to double bereaved children and young adults who have lost a parent to death, including the divorced family perspective.

Implications
The results of the PhD study have several clinical implications. The double bereavement of children and young adults indicates a need for targeted support when a divorced parent is dying in a clinical practice or at home. Improved education and clinical staff training regarding knowledge on double bereavement and divorced family focused care are needed to support the divided families and prevent mental health problems in double bereaved young people. It is suggested that interventions targeting divorced families with parental critical cancer illness and death be tested, to prevent mental health problems in the children and young adults. The findings finally suggest that polices for health professionals targeting these families are needed.