Six-Year Follow-up of a Preventive Intervention for Parentally-Bereaved Youth: A Randomized Controlled Trial

Abstract

Objective

To evaluate efficacy of the Family Bereavement Program (FBP) to prevent mental health problems of parentally-bereaved youth and their parents six years later.

Design

Randomized controlled trial.

Settings

Arizona State University Prevention Research from 2002 to 2005.

Participants

218 bereaved youth (89.3% of 240 enrolled in the trial six years earlier) and 113 spousally-bereaved parents.

Interventions

FBP includes 12 group sessions for caregivers and youth; literature control (LC) condition includes bereavement books for youth and caregivers. .

Main Outcome Measures

Compared youth in FBP and LC on a measure of mental disorder diagnosis, five measures of mental health problems and four measures of competent functioning; compared spousally-bereaved parents on two measures of mental health problems.

Results

Youth in FBP had significantly lower externalizing problems as reported by caregiver/youth (adjusted mean, LC = .13, FBP = −.06; p = .02) and teacher reports of externalizing problems (adjusted mean, LC = 56.27, FBP = 52.69; p = .001) and internalizing problems (adjusted mean, LC = 56.27, FBP = 47.29; p = .002) and higher self-esteem (adjusted mean, LC = 31.91, FBP = 33.93; p = .005). Parents in FBP had lower depression scores than LC (adjusted mean, LC = 7.83, FBP = 5.48; p = .04). A significant moderated program effect indicated that for youth with lower baseline problems, rate of diagnosed mental disorder was lower for FBP than LC.

Conclusions

Study demonstrates efficacy of the FBP to reduce mental health problems of bereaved youth and their parents six-years later.

Approximately 3.4% of youth in the U.S. experience parental death.¹ Research has found that parental death increases children’s short-term and long-term risk for mental health problems and their parents’ risk for depression³. Given these negative outcomes, the development of effective preventive interventions has high public health significance. However, there is no empirical support from randomized trials for the efficacy of programs for parentally-bereaved children. A recent meta-analysis of 13 controlled trials found a non-significant overall effect size.⁴ Further, no studies assessed program effects longer than one year after program completion and few studies have addressed sub-group differences in benefits, issues of critical importance for prevention research⁵. Although several reviews have proposed that only survivors of traumatic deaths and those with elevated levels of symptoms would benefit,^4,6 there is limited evidence on this issue for bereaved youth.

This study presents findings from a six-year follow-up of a randomized experimental trial of the Family Bereavement Program (FBP), a brief dual-component intervention designed to improve outcomes for bereaved youth and their parents. The FBP was designed to prevent negative outcomes by changing multiple, empirically-supported risk and protective factors.⁷ The FBP demonstrated significant benefits at 11-month follow-up to reduce mental health problems for girls and youth with greater mental health problems at program entry⁸, and significantly reduced caregiver mental health problems at post-test.

It was hypothesized that at the six-year follow-up, the FBP as compared to a literature control (LC) would lead to lower prevalence of mental disorder, lower levels of mental health problems and higher levels of positive developmental outcomes of youth as well as reduce mental health problems of their spousally-bereaved parents. Although there is no evidence that bereaved children are at elevated risk for high risk sexual behavior and substance use, we examined these as secondary outcomes because of their developmental significance. Based on the findings from at the FBP⁸ and a meta-analysis of interventions for the bereaved⁹ we hypothesized that the benefits would be greater for those with higher initial levels of mental health problems, females, and those whose parent experienced a violent death. We also explored whether the FBP had differential effects across youth age.

METHODS

Sample

Participants were recruited by mail solicitation, presentations to agencies and media presentations. Referrals that met eligibility criteria assessed by phone were invited to participate in in-home recruitment visits. Eligibility criteria were: a) death of a biological parent or parent figure, b) death occurred between 4 to 30 months prior to the program, c) at least one youth was between eight and 16 years old, d) at least one youth and one caregiver (the term caregiver is used to refer to surviving parents and others in the parental role) were willing to be randomly assigned to the group or self-study program and participate in assessments, e) caregiver and youth could complete the assessments in English, f) neither caregiver nor youth was currently receiving mental health or bereavement services, g) youth were not in a special class for the mentally challenged, and h) family planned to stay in the area for the next six months.

Families were excluded and referred for treatment if the youth or caregiver endorsed suicidal ideation that included an intent or plan or met diagnostic criteria for mental disorders that might interfere with participation in the program (i.e., Major Depressive Disorder for caregivers; Conduct Disorder, Oppositional Defiant Disorder or Attention Deficit Hyperactivity Disorder not being treated with medication for youth assessed by Diagnostic Interview Schedule for Children – Child [DISC-C and Parent [DICS-P] Informant^11–14).

Following the pre-test eligible families were randomly assigned to the FBP or LC condition by a research assistant using a computer generated algorithm, with a greater proportion of families being assigned to FBP to ensure that the groups would be clinically viable. Enrollment occurred across six cohorts between 1996 and 1998. Groups ranged from five to nine individuals (caregiver mean = 8.1, SD = 1.11; child mean = 6.9, SD = 1.04; adolescent mean = 7.0, SD = 1.50).

As shown in Figure 1, of the 617 families referred, 156 (41% of those invited) were eligible and randomly assigned to the FBP (N = 90 families, 135 youth) vs. LC (N = 66 families, 109 youth). Using data from state death certificates, sample representativeness was assessed by comparing ethnicity, gender and cause of death in the study sample with those of deaths between ages 28 and 58 (range that included 90% of the study families) in the county where the program was conducted.¹⁵ No significant differences were found: ethnicity [χ² (5, N = 148) = 1.47, p = .91], gender [χ² (1, N = 153) = .17, p = .69], cause of death [χ² (2, N = 153) = 1.28, p = .53].

Figure 1.

Flowchart of Recruitment, Randomization and Assessment of Family Bereavement Efficacy Trial

Note: The number of families is the first number listed and number of youth assessed the second number listed and is always enclosed in brackets[].

At six year follow-up, data were collected on 218 adolescents/young adults in 140 families, 89.3% of youth and 89.7% of families randomly assigned to condition. Interviews were conducted with 209 youth and 143 caregivers; caregivers of nine youth who did not participate were interviewed, so data were available for 218 youth. Of the caregivers, 113 were spousally-bereaved. Rate of follow-up did not differ significantly across the FBP (87%) and LC (94%) (χ²[1, N = 156] = .12, p = .73).

Procedure

The study was approved by the institutional review board at Arizona State University. Prior to the interview, participants 18 years and older signed informed consent forms; those younger than 18 years old signed assent forms.

There were four assessments, pre-test, post-test, and 11 months and six years after post-test. Data for this study were collected six years after the post-test (2002 – 2005). Family members were interviewed (usually in their homes) by separate trained interviewers. Interviewers were kept blind to experimental group assignment. Responses to questions after the interviews indicated that 96% of the interviewers were blind to assignment.

Intervention Programs and Implementation

The FBP caregiver component focused on strengthening caregiver-youth relationship quality and effective discipline, and decreasing caregiver mental health problems, and youth’s exposure to negative events⁷. The child and adolescent components taught developmentally-appropriate skills to strengthen youth’s relationship(s) with their caregiver(s), increase adaptive beliefs about why stressors occur and positive coping, and decrease negative thoughts about stressors and the inhibition of emotional expression.

Led by two Master’s-level clinicians, groups met weekly for 12 two-hour sessions. Four sessions included conjoint activities for youth and caregivers. Two individual meetings were held with each family to review their use of program skills. Process evaluation data indicated a high fidelity of program implementation. More detailed information about implementation is available in previous publications.^7–8

Caregivers, children, and adolescents in the LC each received three books about grief and a syllabus to guide their reading at one-month intervals. Of the caregivers, 42% reported that they read at least half the books; 38% and 71% of the children and adolescents reported that they read at least half the books, respectively.

Measures

Diagnosis of Mental Disorder

Mental disorder in the past year was assessed using the computer-assisted caregiver, adolescent, and young adult versions of the DISC (child and adolescent scoring algorithm version N for DISC-C and DISC-P, and young adult version C of DISC-YA).¹⁶ Diagnosis was based on meeting symptom criteria according to caregiver or youth/young adult report, and meeting Criterion “D” for intermediate or severe impairment. An overall dichotomous score for mental or substance abuse disorder was calculated.

Internalizing Problems and Externalizing Problems and Disorder

The broad-band dimensions of internalizing problems and externalizing problems during the past six months were assessed using the Child Behavior Checklist (CBCL)¹⁷ and Youth Self Report (YSR)¹⁷ for youth younger than 18. The Young Adult Behavior Checklist (YABCL)¹⁸ and Young Adult Self Report (YASR)¹⁸ were used for youth 18 or older. Because the measures for adolescents and young adults are not identical, we applied item response theory (IRT) to conduct an equating transformation that selected conceptually-equivalent items and put the scale scores on a common metric¹⁹ using a large dataset obtained from Achenbach that contained self- and parent-report scores (n = 800) on the CBCL/YABCL and YSR/YASR. For internalizing problems, the resulting 23-item CBCL, 19-item YABCL, 22-item YSR, and 22-item YASR subscales had Cronbach’s alphas (α =, internal consistency) of .86, .90, .90, and .88, respectively. For externalizing problems, the resulting 35-item CBCL, 34-item YABCL, 32-item YSR, and 27-item YASR subscales had α’s of .92, .93, .88, and .87, respectively.

Using the DISC, dichotomous scores were calculated to indicate whether criterion was met for any broadband externalizing disorder and any internalizing disorder. The modules for internalizing and externalizing problems were identified using consensus classification of three clinicians. Also, a continuous score of total internalizing symptom and externalizing symptoms were derived as the number of symptoms reported by either caregiver or adolescent/young adult on the modules classified as internalizing or externalizing problems.

To reduce the number of measures, a two-dimensional multi-method, multi-rater measurement model of internalizing problems and externalizing problems as latent factors was tested with confirmatory factor analysis using scores from the DISC- symptom scores, CBCL/YABCL and YSR/YASR as manifest variables. We added correlations between the residuals of caregiver reports of CBCL/YABCL internalizing problems and externalizing problems and between the residuals of adolescent/young adult reports of YSR/YASR internalizing problems and externalizing problems to account for shared method variance due to common reporters. The fit of the two-factor model was adequate [χ² (6, N = 218) = 18.28. p < .01, CFI = .98, RMSEA = .09, SRMR = .06] and all loadings were ≥ .55. Composite scores were constructed by summing the standardized scores of internalizing and externalizing problems, weighted by the standardized factor loadings.

For youth in junior high or high school, teachers reported internalizing problems (α = .90) and externalizing problems (α = .90) (2001 Teacher Report of Form; TRF¹⁷). Of the 122 youth enrolled in school, 117 TRFs were collected (95%). The cutoff score¹⁷ of T ≥ 60 was used to identify participants who were above the marginal clinical level.

Self-esteem

Adolescents/young adults completed the Rosenberg Self-Esteem scale (RSE)²⁰ (α = .89).

Competence

Adolescent/young adult report of competence during the past month was assessed with the 6-item academic (α = . 87) and 7-item peer relationship (α = . 62) subscales of the Coatsworth Competence Scale.²¹ Data on academic competence were obtained on 154 of 159 (97%) adolescents/young adults who were in school when interviewed.

Grade point average

Grade point average (GPA) was calculated based on the average grade over the last two semesters in English, Math, Science, and Social Studies using transcripts of 114 of the 123 youth (93%) who had been in high school at least one year before the interview.

Risky Behaviors: Alcohol and Drug Use and High Risk Sexual Behavior

Items from the Monitoring the Future Scale²² were used to assess alcohol and drug use in the past year (7-point scale of times used [1 = 0; 7 = 40]). Polydrug use was assessed by counting the number of different drugs. Number of sexual partners in the past year was assessed by self-report. To maximize validity of responses items on drug use and sexual partners were self-administered.

Mental Health Problems of Spousally-Bereaved Parents

Nonspecific psychiatric distress was assessed using the Psychiatric Epidemiology Research Interview²³ (PERI, 27 items, α = .93). Depression symptoms were assessed with the Beck Depression Inventory¹⁰ (BDI, 21 items, α = .90). BDI scores of 10 or above indicate moderate or greater levels of clinical depression.²⁴

Baseline Covariates

The following variables assessed at baseline were used as covariates for the analyses of the same measures at six-year follow-up (α at baseline is provided): academic competence (α = .90), peer relationship competence (α = .77)²⁰, and parent mental health problems (BDI,¹⁰ α = .95; PERI,²³ α = .93), teacher report of externalizing problems and internalizing problems (1991 version of the TRF¹² [α = .92; α = .87]). The baseline measure of self-esteem was the global self-worth subscale of Self Perception Profile for Children²⁵ (α = .79). For measures not assessed at baseline (e.g., diagnosis of mental disorder) composite baseline scores of internalizing and externalizing problems were used as covariates using the mean of the standardized scores on caregiver and youth report measures. For this measure baseline caregiver and youth report of externalizing problems were assessed with the 1991 CBCL²⁶ (α = .87) and YSR²⁷ (α = .87) and internalizing problems were assessed with the 1991 CBCL²⁶ (α = .87), Children’s Depression Inventory²⁸ [CDI, α = .87] and Revised Children’s Manifest Anxiety Scale²⁹ (R-CMAS, α = .90).

Statistical Analysis

Attrition effects and group by attrition effects in relation to the baseline measures were evaluated using either 2(assessed or not assessed at six-year follow-up) × 2(FBP or control group) ANOVA’s for continuous measures, or chi-square or logistic regression for discrete measures.³⁰

Intervention main effects were examined with analysis of covariance (ANCOVA) for continuous measures, logistic regression for binary variables, and Poisson analysis for count scores, controlling for the corresponding baseline covariate. In addition, we examined the interactions between group and five potential moderators of program effects; 1) baseline composite scores of internalizing and externalizing problems, 2) gender, 3) youth age, 4) time since death, and 5) cause of death (dichotomized as violent death (accident, suicide, homicide) vs. death from illness ⁶). All analyses used an intent-to-treat approach³¹ based on Full Information Maximum Likelihood (FIML) estimation for handling missing data,²³ making use of all available data for all individuals. To adjust for multiple testing, the false discovery rate, which controls for the expected proportion of false positives among all significant hypotheses, was applied³³ for tests of effects on primary (adolescent/young adult mental health and competence; parent mental health) and secondary (high risk behaviors) outcomes separately.

All analyses on adolescent/young adult outcomes were done recognizing the clustering due to multiple offspring within families.³⁴ We used Mplus software³² for the analyses with continuous, categorical, and count outcome variables. Hypothesis tests were conducted using 2-tailed α = .05. Optimal Design³⁵ was applied for estimating power in clustered data. Assuming a correlation of .30 between baseline and follow-up measures, the power of the test for group differences for the current sample was over .80 for detecting small to medium effects, depending on the size of the intraclass correlation (ICC). Power analyses for dichotomous measures (i.e., diagnoses) assumed a base rate of 30% in the control group and that the intervention would reduce this to 10% (a reduction that is a medium effect size according to Cohen³⁶). The power of the test for this reduction was .82 to .95, depending on the ICC. The ICCs within families for baseline measures ranged from 0 to .62, with a mean of .22.

RESULTS

Sample Characteristics

Data were collected on 218 adolescents/young adults from 140 families (102 adolescents/young adults from 62 families in the LC; 116 adolescents/young adults from 78 families in the FBP). Of the adolescents/young adults, 54% were males; the mean (SD) age was 17.6 (2.42; range, 14–23) years; ethnicity was 67.7% white, non-Hispanic; 14.3% Hispanic; 6.4% African American; 3.7% Native American; 1.4% Asian/Pacific Islander; and 6.4% other. Of the 140 caregivers who were interviewed, 78% were female. The mean age of the spousally-bereaved caregivers was 47.79 years (SD = 6.97, range = 34–64). Mean annual income at follow-up was $30,466 (SD = $19,199, range = $1,050–$124,800). Parental death occurred with a mean of 10.81 (SD = 6.35, range = 3–29) months prior to the baseline assessment. Cause of death was 73% natural cause (i.e., illness) and 27% violent death (accident - 16%, homicide - 3%, suicide - 8%). Table 1 compares the FBP and LC groups on the demographic variables and baseline covariates. Of the 25 comparisons, one significant difference occurred; the percentage of non-Hispanic White was lower in the FBP than LC. No significant attrition or attrition × group effects were found on the 25 baseline continuous or demographic measures.³⁰

Table 1.

Demographics and Outcome Variables at Baseline

	Control	FBP	Difference
Demographics
Male youth, No. (%)	57 (52.3%)	73 (54.1)	P = .78
Youth mean age	11.32 (2.22)	11.45 (2.58)	P = .68
Youth Ethnicity			P = .04 X2[5] = 11.74
White, Non-Hispanic	78 (71.56%)	87 (64.44%)
Hispanic	11 (10.09)	26 (19.26%)
Black	7 (6.42%)	8 (5.93%)
Asian American/Pacific Islanders	0 (0%)	3 (2.22%)
American Indian	8 (7.34%)	2 (1.48%)
Other	5 (4.59%)	9 (6.67%)
Youth relationship to the caregiver			P = .14
Mother	65 (59.63%)	83 (61.48%)
Father	32 (29.36%)	25 (18.52%)
Stepmother	0 (0%)	1 (.74%)
Stepfather	0 (0%)	0 (0%)
Aunt/Uncle	5 (4.59%)	9 (6.66%)
Grandmother/Grandfather	6 (5.50%)	9 (6.67%)
Sister/Brother	0 (0%)	7 (5.18%)
Adopted mother/ Adopted father	1 (.92%)	0 (0%)
Other	0 (0%)	1 (.74%)
Youth relationship to the Deceased			P = .41
Mother	37 (33.94%)	49 (36.3%)
Father	63 (57.8%)	80 (59.26%)
Stepmother	0 (0%)	0 (0%)
Stepfather	3 (2.75%)	4 (2.96%)
Aunt/Uncle	0 (0%)	0 (0%)
Grandmother/Grandfather	4 (3.67%)	1 (.74%)
Sister/Brother	0 (0%)	0 (0%)
Adopted mother/ Adopted father	0 (0%)	0 (0%)
Other	1 (.92%)	1 (.74%)
Caregiver mean age	42.16 (7.32)	42.01 (9.09)	P = 91
Female caregiver, No. (%)	48 (72.83%)	75 (83.33%)	P = .11
Matched child and caregiver gender, No. (%)	46 (42.20%)	64 (47.41%)	P = .42
Matched child and deceased gender, No. (%)	64 (59.26%)	73 (54.48%)	P = .46
Caregiver ethnicity			P = .64
White, Non-Hispanic	49 (74.24%)	59 (65.56%)
Hispanic	7 (10.61%)	11 (12.22%)
Black	3 (4.55%)	8 (8.89%)
Asian American/Pacific Islanders	0 (0%)	2 (2.22%)
American Indian	3 (4.55%)	2 (2.22%)
Other	1 (1.52%)	1 (1.11%)
Missing	3 (4.55)	7 (7.78%)
Deceased ethnicity			P = .72
White, Non-Hispanic	48 (72.73%)	58 (64.44%)
Hispanic	8 (12.12%)	13 (14.44%)
Black	4 (6.06%)	8 (8.89%)
Asian American/Pacific Islanders	0 (0%)	1 (1.11%)
American Indian	2 (3.03%)	3 (3.33%)
Other	1 (1.52%)	0 (0%)
Missing	3 (4.55%)	7 (7.78%)
Caregiver education	4.66 (1.45)	4.60 (1.23)	P = .76
Family income	7.88 (4.99)	8.71 (4.92)	P = .31
No. of youth living at home	1.67 (.77)	1.50 (.75)	P = .18
Time since death (months)	9.61 (5.25)	10.57 (6.33)	P = .32
Cause of death			P = .42
Illness	48 (73.85%)	65 (73.07%)
Violent	17 (26.15%) )	24 (26.96%)
Outcome Variables – Youth
Externalizing Problems - Youth report	−.002 (.10)	.02 (.09)	P = .90
Internalizing Problems - Youth report	.01 (.09)	.01 (.08)	P = .97
Externalizing Problems - Caregiver report	.06 (.11)	.07 (.10)	P = .92
Internalizing Problems -Caregiver report	.04 (.12)	.20 (.10)	P = .31
Self-esteem – Youth report	.01 (.10)	−.01(.09)	P = .85
Academic competence – Youth report	−.13 (.12)	.03 (.10)	P = .32
Peer competence – Youth report	−.03 (.09)	−.02 (.08)	P = .94
Outcome Variables – Spousally-Bereaved Caregiver
Depression (BDI)	9.76 (6.87)	11.42 (7.82)	P = .17
Anxiety (PERI)	2.34 (.59)	2.45 (.72)	P = .32

Comparison of FBP vs. LC on Adolescent/Young Adult Outcomes

As shown in Table 2 the main effect on rate of mental disorder was not significant. However, a significant Program × Baseline Mental Health Problem interaction was found. Post-hoc analyses indicated that the program benefit was stronger for those with lower baseline problems.

Table 2.

FBP Intervention Main Effects at Six-year Follow-Up

Measures	FBP	Control	p-value (Cohen’s d)2	p-value False Discovery Rate
	Actual Proportion (CI) / Actual Means (CI)1
Diagnosis of Mental or Substance Abuse Disorder
Mental disorder or substance abuse disorder	33.64% (24.81, 42.47)	41.05% (31.16, 50.94)	.28	28
Mental Health Problems
Externalizing disorder3	15.45% (8.70, 22.20)	27.37% (18.40, 36.34)	.04 (OR = 1.57)	.09
Externalizing Problems (cg + a/ya)	−.07 (−.20, 05)	.13 (.01, .25)	.02 (d = .31)	.05
Externalizing Problems (t)4	52.39 (50.57, 54.21)	56.28 (54.65, 57.91)	.001 (d = .59)	.01
Internalizing disorder3	15.45% (8.70, 22.20)	13.68% (6.77, 20.59)	.76	.77
Internalizing Problems (cg + a/ya)	−.03 (−.14, .09)	.03 (−09, .14)	.57	.69
Internalizing Problems (t)4	48.12 (46.12, 50.11)	52.35 (50.42, 54.28)	.002 (d = .57)	.01
Competence
Self-Esteem	33.91 (32,96, 34.87)	31.90 (30.95, 32.84)	.005 (d = .40)	.02
Academic	3.02 (2.88, 3.16)	2.98 (2.82, 3.15)	.62	.69
Peer	3.28 (3.19, 3.37)	3.16 (3.07, 3.25)	.11	.18
Grade point average	2.52 (2.29, 2.75)	2.43 (2.18, 2.67)	.63	.69
Risky Behaviors
Substance abuse disorders	10.00% (4.39, 15.61)	13.68% (6.77, 20.59)	.68	.88
Marijuana or alcohol use	2.56 (2.22, 2.91)	2.50 (2.13, 2.87)	.89	.89
Polydrug use	1.57 (1.21, 1.94)	1.74 (1.25, 2.22)	.62	.88
No. of Sexual Partners	2.89 (1.79, 3.98)	2.06 (1.36, 2.77)	.21	.63
Surviving Parent’s Mental Health Problems of Spousally-Bereaved Caregiver5
BDI	6.05 (4.37, 7.73)	7.40 (5.36, 9.45)	.04 (d = .40)	.04
PERI	1.88 (1.73, 2.02)	2.04 (1.86, 2.21)	.03 (d = .42)	.04

¹The confidence intervals for the actual proportions and means did not control for the baseline covariate and did not reflect the FIML estimate of intervention effect.

²Cohen’s d was reported only for the finding with p ≤ .05.

³The modules for internalizing and externalizing problems were categorized by the 1^st, 2^nd, and 4^th authors, who were trained as clinical psychologists. Internalizing disorders include agoraphobia, eating disorder, generalized anxiety disorder, bipolar depression, major depression disorder, obsessive compulsive disorder, panic disorder, post-traumatic stress disorder, social phobia, and specific phobia. Externalizing disorders include attention deficit and hyperactivity disorder, conduct disorder with anti-social personality disorder considered, and oppositional defiant disorder.

⁴For 122 students who were still enrolled in junior or senior high school at least one month prior to the data collection, we were successful in collecting teacher report on 117 youth. We obtained teacher reports for 112 youth from teachers in English/Language, Social Studies/History or Government, Math/Science or any other major subject, and used the mean of the scores for the two teachers. We obtained only one teacher report on 5 youth.

⁵N = 113.

The FBP participants had significantly lower levels of externalizing problems on the composite of caregiver and youth report (adjusted mean, control = .13, FBP = −.06; p = .02; Cohen d = .31), and on the teacher report (adjusted mean, control = 56.27, FBP = 52.69; p = .001, Cohen d = .59) measures of externalizing problems. Those in the FBP had a marginally significant lower rate of externalizing disorder diagnosis after adjusting for multiple tests p = .09; FBP, 15.45%; 95% confidence interval [CI], 8.70%–22.20%; control, 27.37%; 95% CI, 18.4%–36.34%; adjusted OR = 1.57 (95% CI, 1.01–2.45); NNT³⁷ = 8.97. No significant difference was found for the internalizing disorder diagnosis or composite of caregiver and adolescent/young adult report of internalizing problems. Teacher reports of internalizing problems were significantly lower for those in the FBP than LC (adjusted mean, control = 56.27, FBP = 47.29; p = .002; Cohen d = .57). Fewer adolescents in the FBP than LC were above the marginal clinical cut point for teacher report of internalizing problems (p = .02; FBP, 5.00%; 95% CI, 0%–10.51%; control, 19.30%; 95% CI, 9.5%–29.55%; adjusted OR = 2.22 (95% CI, 1.56–3.13; NNT = 6.99). Adolescents/young adults in the FBP had significantly higher self-esteem than those in the LC (adjusted mean, control = 31.91, FBP = 33.93; p = .005; Cohen d = .40). There were no significant interactions with any of the predicted moderators after adjusting for multiple tests. No significant program effects were found for the secondary outcomes of risky behaviors.

Comparison of FBP vs. LC on Mental Health Problems of Parents

Parents in the FBP had lower scores than those in the LC on the PERI demoralization scale²³ (adjusted mean, control = 2.04, FBP = 1.84; p= .03, Cohen d = .42) and BDI (adjusted mean, control = 7.83, FBP = 5.48; p = .04, Cohen d = .40). Also, parents in the FBP were less likely to be above the cut point for moderate or higher level of depression³⁸ (FBP, 21.31%; 95% CI, 11.03%–31.59%; vs. LC, 34.62%; 95% CI, 21.69%–47.55%; adjusted OR = 1.69 (95% CI, 1.00–2.22; NNT = 7.51)), p = .05).

COMMENT

This is the first randomized trial to report significant long-term benefits of a preventive intervention for parentally-bereaved youth. Program benefits included lower levels of mental health problems, particularly externalizing problems, improved self-esteem and reduced rates of diagnosed mental disorder for adolescents/young adults who had lower levels of mental health problems at program entry Also, the FBP significantly reduced mental health problems of spousally-bereaved parents.

The convergence of findings across teachers (who were blind as to program conditions), caregivers and adolescents/young adults increases confidence in the program benefit to reduce externalizing problems. Because externalizing problems in adolescence/young adulthood are associated with a wide array of social adaptation and mental health problems later in development³⁹, the current findings have significant public health implications. The program effect on teacher report of internalizing problems is notable because it included reductions in the level of problems and likelihood of exceeding the clinical cut-point (OR= 4.48). The program effect on self-esteem is meaningful given that poor self-esteem is a risk factor for depressive disorders in young adulthood⁴⁰. These findings complement previously reported effects of the FBP to reduce problematic levels of grief and cortisol dysregulation at six-year follow-up.^41–42

Nearly all the significant program effects were main effects, which does not support the hypothesis^4,6 that bereaved youth with higher symptomatology and those who experienced traumatic deaths would benefit most from the FBP. The one significant interaction indicated a reduced rate of diagnosed mental disorder for youth with lower but not higher levels of mental health problems at program entry. This interactive effect raises caution about using the FBP with youth with clinical levels of mental health problems. Such youth likely require more intensive interventions. In light of evidence that young spousally-bereaved individuals are at risk for mental health problems many years following the death,³ the effect of the FBP to reduce such problems indicates that the program had a “double prevention” effect on parents and children.

Three limitations should be noted. First, the findings should not be generalized to families that were excluded from the trial, such as those receiving mental health services. Second, a placebo control or one that provided supportive assistance was not used. Thus, we cannot rule out that the effects are due to non-specific aspects of the program such as group support. Findings that the program effects to reduce youth mental health problems at earlier waves were mediated by improvements in positive parenting and child coping⁴³ provide evidence that program components designed to strengthen these factors were at least partially responsible for program effects. Nevertheless, future evaluations should test the FBP against supportive interventions that do not include the skills taught in the FBP. Third, the sample size precluded testing program effects across other subgroups such as those experiencing parental suicide, or ethnic minorities.