Abstract
Background and purpose:
Sibling loss can heighten children’s fears. Approximately two million children in the United States experience the death of a sibling each year, leaving 25% of them in need of clinical intervention and more than 50% with significant behavioral problems. Fear, guilt, anxiety, and even distance from parents are some of the reactions that children feel after experiencing the loss of a sibling. The purpose of this study was to describe children’s fears 2–13 months after their sibling’s death. Fears were examined by children’s age, gender, race/ethnicity, and time.
Methods:
Children completed two open-ended questions about fears and five fear items on the Spence Children’s Anxiety Scale. The sample consisted of 132 children.
Results:
Children’s top fears across age, gender, and race/ethnicity were daily situations (such as darkness, high places, and violent situations), bugs, animals, and medical examinations. Girls had more total fears than boys. These included fears of bugs and situations with parents and siblings. Boys and Hispanic children had more fears of daily situations. Black children had more fears of animals, whereas White children had more fears of bugs and medical examinations.
Implications for practice:
Children identify many fears after sibling death, including but not limited to fantasy creatures, common daily situations, bugs, animals, and medical examinations likely related to their sibling’s death. Identifying children’s fears early can help nurse practitioners assist families in better understanding and responding to children’s behavior after sibling death.
Keywords: Children fears, death, fears, siblings, sibling death
Introduction
Childhood fears are normal reactions to events. Losing a sibling, however, can heighten children’s fears. The surviving child is left to grieve the loss of a playmate, friend, and role model. Approximately two million children experience this each year in the United States, leaving 25% of them in need of clinical intervention and more than 50% with significant behavioral problems (Packman, Horsley, Davies, & Kramer, 2006). Children may feel guilt that they caused the sibling’s death and fear that someone else in the family will die (including themselves), as well as sadness, anxiety, loss, distance from parents, and confusion (Brooten, Youngblut, & Roche, 2017; Brooten & Youngblut, 2017). There is great need for health care providers to understand responses to sibling death from the child’s perspective at different ages and responses of children from different racial/ethnic groups where the meaning and traditions around death differ (Brooten et al., 2016; Lohan & Murphy, 2001; Roche, Brooten, & Youngblut, 2016) to provide the most appropriate and effective care for surviving siblings and their families. The purpose of this study was to describe fears that children identified from 2 to 13 months after their sibling’s Neo-natal intensive care unit (NICU)/Pediatric intensive care unit (PICU)/emergency department (ED) death, and how these fears differ by the surviving siblings’ age, gender, and racial group, and across time.
Children’s fears developmentally
Children universally experience fear. Fear is part of a normal reaction and can prepare children to go through more difficult experiences later in life. It can also help children seek safety when needed. According to Ollendick, King, and Muris (2002), fears change throughout children’s ages and development. They can be transitory and vary in frequency, intensity, and duration. The focus of fears tends to change as children get older (Robinson & Rotter, 1991). During infancy and early childhood, there is fear of strangers and separation from parents. When children get older, fears tend to shift toward robbers, muggers, kidnappers, and dark rooms. Muris, Merckelbach, and Collaris (1997) conducted a study examining the ranking and characteristics of childhood fears in a sample of 129 healthy children (74 boys and 55 girls) aged 9–13 years. These children had no previous traumatic events. The children’s 10 most common fears were contracting a serious illness, not being able to breathe, burglar breaking in, getting lost, bombing attacks, falling from a high place, getting hit by a car, death/dead people, fire/getting burned, spiders, and snakes.
Gender differences about fears have been reported by Muris et al. (1997). Girls exhibited more fears and anxiety than boys, and tended to fear different situations and objects. Both boys and girls, when asked to name their top five fears, named spiders as their number one fear. Boys’ fears were predators, being hit by a car, snakes, and burglars. Girls feared being kidnapped, parents dying, being in the dark, and seeing scary movies. Age was not examined in this study.
In a study of children’s fears in 294 low and middle socioeconomic status (SES) Hispanic and Anglo children aged 7–9 years, results demonstrated that girls and low SES children reported more intense and more frequent fears (Owen, 1998). There was no difference between Hispanics and Anglos. The most prevalent fears were danger, physical injury, and death, perhaps due to the neighborhoods in which they live. In another study (Wolchik, Tein, Sandler, & Ayers, 2006), 339 parentally bereaved children and adolescents from 207 families of various ethnic groups (non-Hispanic Caucasian, Hispanic, African American, Native American, and Asian or Pacific Islanders) reported fears of abandonment after parental loss. Non-Caucasian children reportedly had higher fears of abandonment than Caucasian children, and girls scored higher in fear of abandonment than boys.
Children’s fears after a death
Most research on children’s fears and anxiety has been conducted after the death of a parent. These studies indicate that the child’s normal routine is disrupted; there are changes within the family dynamics and structure, a loss of security, and often relocation with a new school and friends (Brooten et al., 2017; Brooten & Youngblut, 2017). These changes create stress for the child and have a negative impact on the child’s mental health (Thompson, Kaslow, Price & Williams Kingree, 1998). Children may have feelings of abandonment, become overly clingy, and not want to play alone or leave the parents’ side.
When a child is faced with the death of a loved one (parent, grandparent, or sibling), the event may exacerbate the grieving process and alter what was once considered to be “normal fear.” Gullone (2000) studied children 7 years of age through adolescence. They were given the Fear Survey Schedule and asked to rate to what extent each item provoked fears. Results showed that children, regardless of age, scored fear of death and danger very high.
Children who lose a loved one have a heightened sense of anxiety and fear of their needs going unmet due to the circumstances surrounding the death (Furman, 1964). Although grief after losing a loved one is part of the natural process, children who live with constant fear and anxiety raise concerns especially if it interferes with the children’s everyday activity. Children’s emotions may be magnified if the family chooses not to speak about the death. Showing emotions or feelings after a death may not be acceptable. Children may fear expressing their emotions believing that they may get punished. Nguyen and Rosengren (2004) interviewed 600 parents of pre-school and school-aged children regarding their child’s knowledge of reproduction, life, illness, aging, and death. They were also asked how comfortable they felt discussing these topics with their children. Parents reported feeling uncomfortable discussing reproduction and death; therefore, their children had the most misconceptions related to these topics. Yang and Chen (2006) explored the development of the concept of death among 204 Chinese children aged 11–16 years. They found that children in families that spoke about death openly had more positive thoughts about death. In contrast, children in families that never spoke about death not only had negative judgments about death but had shivers, sweating, and feelings of powerlessness when speaking about death. Some children may fear death, believing they too will die soon. Children may fear going to sleep thinking they will never wake up. This is especially true when someone’s death is described as “they went to sleep” and “may they rest in peace” (Yang & Chen, 2006).
Yang and Park (2017) studied 84 children’s cognitive understanding and emotional responses to death and bereavement through drawings in a sample of Korean, Chinese, and US children aged 5–6 years. Children drew swords or fire as a symbol of death. Others portrayed death as tragic with car crash scenes, recumbent dead bodies, cars slipping on an icy road, building collapses, as well as snakes and insect bites. Children also viewed death as due to crime and war. In this study, children described death as negative emotions, including fear, anxiety, sadness, depression, loneliness, and distress. They stated that the word death was “a bad word.”
Loss of a sibling
Most of the very limited research on children’s fears after losing a sibling has been done with children whose sibling died of cancer. Brooten and Youngblut (2017) found that school-aged children’s (6–12 years old) responses at 7 and 13 months after a sibling’s death included fearing something bad happening to them, their parents, or other siblings. They feared getting cancer (especially if the deceased died from cancer) and feared being snatched away by a stranger. The researchers found that these fears decreased from 7 to 13 months especially in the 7- to 9-year-old group.
In a study with 13- to 18-year-old adolescents after a sibling’s NICU/PICU death (Brooten et al., 2016), responses indicated that 13-year-olds had fewer fears than 14- to 18-year-olds over 7–13 months postdeath. Gender differences were consistent with those of Muris et al. (1997). More girls than boys reported fears as well as life changes in the family and themselves at 7 and 13 months after the sibling’s death.
Eilertsen, Eilegård, Steineck, Nyberg, and Kreicbergs (2013) reported that young adult siblings (12–25 years) had higher risk of anxiety if they perceived their need for social support by family and neighbors was not satisfied before or after the siblings’ death. Lack of social support was also found to be related to young adults not having worked through their grief after a sibling’s cancer death 2–9 years earlier (Lovgren, Jalmsell, & Wilegard, 2016; Sveen, Eilegard, Steineck, & Kreicbergs, 2014), whereas others had increased risk of sleep disturbances, low self-esteem, and low personal maturity (Eilertsen et al, 2013). After the cancer death of a sibling, surviving siblings have reported fear, behavior problems, and problems with friends and school (Sirki, Saarinen-Pihkala, & Hovi, 2000), whereas others report grief and psychologic vulnerability (Gibbons, 1992).
Research on fears of surviving siblings has the following shortcomings: Data obtained from the perspectives of parents not children (McCown & Davies, 1995), qualitative studies with small samples (Brooten et al., 2017; Brooten & Youngblut, 2017), and little minority or lower socioeconomic representation (Fanos, Little, & Edwards, 2009; Little, Sandler, Wolchik, Tein, & Ayers, 2009; McHale, Whiteman, Kim, & Crouter, 2007).
Methods
Design
This study is part of a larger longitudinal study examining children’s health and functioning 2 through 13 months after a sibling’s NICU/PICU/ED death. Data on children’s fears and anxiety were collected at 2, 4, 6, and 13 months after the sibling death using the Spence Children’s Anxiety Scale (SCAS)—Child Report Version and 2 open-ended questions that were part of the scale. Data obtained from the deceased infant’s/child’s hospital record included dates of birth and death, admitting diagnoses and condition, and mode (limiting treatment, withdrawing life support, unsuccessful resuscitation, brain death) and place of death (NICU/PICU/ED).
The study was approved by the University’s Institutional Review Board (IRB) and the IRBs of four South Florida hospitals. Children (6–18 years old) whose sibling (neonate through 18 years) died at least 1 hour after admission to the NICU, PICU, or ED and their parents (White non-Hispanic, Black non-Hispanic, Hispanic/Latino) were recruited from four South Florida children’s hospitals and published obituaries. All parents were at least 18 years of age and understood spoken English or Spanish.
Inclusion criteria.
Following are the inclusion criteria: 1) child lived with deceased sibling before PICU/ED admission or with the mother of the deceased neonate before NICU admission, 2) child lived with the same parent(s) since the death, and 3) they were in their age-appropriate grade in school ±1 year.
Exclusion criteria.
Exclusion criteria included the following: 1) conditions that render a child unable to participate verbally—for example, cerebral palsy, severe brain damage, severe autism—but the family’s other children remained eligible, 2) living in foster care before or after the death, and 3) death of a parent or more than one sibling in the same event because the child will be dealing with the deaths of more than one nuclear family member at the same time.
Procedure.
Clinical coinvestigators at the hospitals identified Hispanic/Latino, White non-Hispanic, and Black non-Hispanic parents whose infant/child died in their NICU/PICU/ED and met study criteria; they provided parents’ names and contact information to the project. Research assistants (RAs) searched online obituary notices to identify families and then online databases for their contact information. Clinical coinvestigators provided addresses and phone numbers for any missed families from their facility. At 6–7 weeks after the death, families identified through the hospitals and the obituaries were sent a letter (in Spanish and English) that described the study, identified the bilingual RAs on the project, and provided the study’s phone number and email address. About 1 week after the letter was sent, an RA called the family, further described the study, answered parents’ questions, screened for inclusion/exclusion criteria, ascertained whether the family was willing to be in the study, and made an appointment to go to the family’s home. At the home, the RAs again explained the study to the parent(s), answered any questions and obtained their signed consent for their participation, review of their deceased child’s hospital record, and for the RA to talk with their eligible children about the study. The RA explained the study to eligible children, answered their questions, and obtained their signature on an assent form. Children were not asked to participate if the parent did not give consent. Children who were 18 years old signed consent forms for their own participation. Those who became 18 years old during the study were re-consented at that time. Only children who signed the assent form after their parent(s) gave consent provided data.
Measures
Children’s fears.
The SCAS was developed to assess the severity of anxiety symptoms broadly in line with the dimensions of anxiety disorder proposed by the Diagnostic and Statistical Manual of Mental Disorders IV. The scale assesses six domains of anxiety, including generalized anxiety, panic/agoraphobia, social phobia, separation anxiety, obsessive compulsive disorder, and physical injury fears. We used the five items on the fears subscale of this instrument. Children were asked to rate on a 4-point scale involving never (0), sometimes (1), often (2), and always (3), the frequency with which they experienced each symptom. Five items on the “Fears” subscale of the SCAS asked about specific fears (dark, dogs, insects/spiders, health care provider visits, and high places). Children rated each of these specific fears from 0 (never) to 3 (always). Children also were asked 2 open-ended questions, “What are you afraid of?” and “How often are you afraid of this?” Children named their fears and the frequency of each fear (Spence, 1998). Surviving siblings’ age group was categorized as school age (6–12 years) and teens (13–18 years) based on the age they reported.
Parent demographics included (in the language of their choice, English or Spanish), data on: 1) the family— number of parents and children in the home and annual family income; 2) the parent(s)—age, race/ethnicity, education, and marital status; 3) each surviving sibling—age, gender, race/ethnicity, and grade in school; and 4) the deceased child—date of birth and death, gender, and cause of death collected from the hospital chart.
Data analysis
To develop initial categories and their operational definitions for children’s fears in the two open-ended questions, conventional content analysis was used. Two PhD prepared study team members, with relevant research and clinical expertise, independently categorized children’s responses to the two open-ended questions. Any inconsistencies in categories were reviewed and discussed by the two study team members; after reaching agreement, revisions were made. Interrater reliability was maintained at 85% or greater. Children’s fears were categorized as Fantasy (creatures, superheroes) and Reality (bugs, animals, parents, siblings, other people, other family, medical examination, and daily situations). Children’s responses to the five fears items on the Spence Fears scale were tallied and incorporated into the Reality categories. Results were then examined by child age (school age, teens), gender, race/ethnicity, and time (2, 4, 6, and 13 months). Data were presented using descriptive statistics.
Results
Sample
The sample consisted of 132 surviving siblings (76 girls and 56 boys), 70 mothers, and 26 fathers in 71 families (Table 1). The deceased siblings died in a PICU (n = 45, 63%), NICU (n = 17, 24%), or ED (n = 9, 13%) in one of 18 health care facilities throughout Florida. Deceased siblings, categorized by age, included: 37% teens, 37% infants, 21% school-aged children, and 5% preschoolers. Most died as a result of failed cardiopulmonary resuscitation and limiting treatment.
Table 1.
Characteristics of parents and surviving siblings
| Mothers (N = 70) | Fathers (N = 26) | |
|---|---|---|
| Parent characteristics | ||
| Age | ||
| Mean (SD) | 35.9 (7.13) | 39.0 (7.37) |
| Race/ethnicity | ||
| Hispanic, n (%) | 23 (33) | 8 (30) |
| Black non-Hispanic, n (%) | 30 (43) | 9(35) |
| White non-Hispanic, n (%) | 17 (24) | 9 (35) |
| Education | ||
| <High school, n (%) | 19 (27) | 8 (31) |
| High school graduate-some college, n (%) | 28 (40) | 13 (50) |
| College graduate, n (%) | 23 (33) | 5 (19) |
| Family income (N = 71) | ||
| <$20,000, n (%) | 28 (39) | |
| $20,000-$49,999, n (%) | 26 (37) | |
| $50,000 and greater, n (%) | 17 (24) | |
| Surviving siblings’ characteristics (N = 132) | ||
| Age | ||
| Mean (SD) | 10.6 (3.43) | |
| Gender | ||
| Male, n (%) | 56 (42) | |
| Female, n (%) | 76 (58) | |
| Race/ethnicity | ||
| Hispanic, n (%) | 39 (30) | |
| Black non-Hispanic, n (%) | 67 (51) | |
| White non-Hispanic, n (%) | 26 (19) |
Most parents were Black non-Hispanic or Hispanic with some education beyond high school; 39% of families had annual incomes below $20,000; 92% were 2-parent families. Most surviving siblings were female, school age, and Black non-Hispanic (Table 1).
Type and time of children’s fears.
The majority of children’s fears fell into the Reality category (Table 2). The Fantasy category consisted of creatures (monsters, vampires, clowns, zombies, Apocalypse, Chucky, red-eyed black dog, ghosts, evil spirits, skeletons, and dragons) and one superhero (Spiderman). The Reality fears category included daily situations (examples include fear of being left alone or lost, sleeping away from home, being in high or dark places, fear of strangers, and violent situations such as being robbed, held up at gunpoint, knifed or kidnapped, drowned, hit by a car, in danger, and death), bugs, animals, medical examinations (going to doctor or dentist, treatments, shots), and parent’s, siblings’, and other family member’s wellbeing (being hurt, losing a pregnancy). The top reality fears were daily situations (39%), bugs (23%), animals (19%), and medical examinations (15%; Table 2).
Table 2.
Children’s (N = 132) total fears
| Fears | 2 months | 4 months | 6 months | 13 months | Total |
|---|---|---|---|---|---|
| Fantasy | |||||
| Creatures | 13 (4%) | 5 (2%) | 8 (3%) | 8 (3%) | 34 (3%) |
| Superheroes | 1 (0.3%) | 0 | 0 | 0 | 1 (<0.1%) |
| Total | 14 (5%) | 5 (2%) | 8 (3%) | 8 (3%) | 35 (3%) |
| Reality | |||||
| Daily situations | 108 (37%) | 135 (42%) | 121 (38%) | 100 (36%) | 464 (38.6%) |
| Bugs | 64 (22%) | 73 (23%) | 71 (22%) | 71 (26%) | 279 (23%) |
| Animals | 54 (19%) | 61 (19%) | 64 (20%) | 52 (19%) | 231 (19%) |
| Medical examinations | 43 (15%) | 45 (14%) | 50 (16%) | 43 (16%) | 181 (15%) |
| Parents | 3 (1%) | 0 | 2 (0.6%) | 0 | 5 (0.4%) |
| Siblings | 3 (1%) | 0 | 1 (0.3%) | 0 | 4 (0.3%) |
| Other people | 0 | 0 | 1 (0.3%) | 1 (0.3%) | 2 (0.1%) |
| Other family | 0 | 1 (0.3%) | 0 | 0 | 1 (<0.1%) |
| Total | 289 (24%) | 320 (27%) | 318 (26%) | 275 (23%) | 1,202 |
| No. children responding | 88 (67%) | 110 (83%) | 103 (78%) | 91 (69%) |
More children reported fears at 4 months (110 children) and 6 months (103 children) after the sibling’s death. This was also true of the total number of fears reported; 320 fears at 4 months and 318 fears at 6 months. Fears in the Fantasy category (creatures and superheroes) were highest at 2 months after the sibling death; fears in the Reality category were highest in months 4 and 6.
Fears by age.
Both school-aged children and teens had more fears in the Reality categories than Fantasy categories (Table 3). School-aged children reported the highest number of fears of creatures at 2 months after the sibling death. In the Reality categories, daily situations, bugs, animals, and medical examinations were the top fears for both school-aged children and teens. An almost equal average number of fears were reported by school-aged children (mean = 9.12) and teens (mean = 9.05). Both groups reported slightly higher numbers of fears at 4 and 6 months after the sibling’s death.
Table 3.
Children’s fears by age group
| Fears | 2 months | 4 months | 6 months | 13 months | Totals—School Age (N = 96) | Totals—Teens (N = 36) | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| School Age | Teens | School Age | Teens | School Age | Teens | School Age | Teens | |||
| Fantasy | ||||||||||
| Creatures | 11 (5%) | 2 (3%) | 2 (1%) | 3 (3%) | 6 (3%) | 2 (2%) | 6 (3%) | 2 (3%) | 25 (3%) | 9 (3%) |
| Superheroes | 1 (0.4%) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 (0.1%) | 0 |
| Totals | 12 (6%) | 2 (3%) | 2 (1%) | 3 (3%) | 6 (3%) | 2 (2%) | 6 (3%) | 2 (3%) | 26 (3%) | 9 (3%) |
| Reality | ||||||||||
| Daily situations | 76 (36%) | 32 (41%) | 95 (42%) | 40 (43%) | 89 (37%) | 32 (40%) | 74 (37%) | 26 (35%) | 334 (38%) | 130 (40%) |
| Bugs | 42 (20%) | 22 (28%) | 51 (23%) | 22 (23%) | 53 (22%) | 18 (22%) | 52 (26%) | 19 (26%) | 198 (23%) | 81 (25%) |
| Animals | 41 (19%) | 13 (17%) | 43 (19%) | 18 (19%) | 49 (21%) | 15 (19%) | 39 (19%) | 13 (18%) | 172 (20%) | 59 (18%) |
| Medical examinations | 34 (16%) | 9 (12%) | 34 (15%) | 11 (12%) | 36 (15%) | 14 (17%) | 30 (15%) | 13 (18%) | 134 (15%) | 47 (14%) |
| Parents | 3 (1%) | 0 | 0 | 0 | 2 (1%) | 0 | 0 | 0 | 5 (0.5%) | 0 |
| Siblings | 3 (1%) | 0 | 0 | 0 | 1 (0.4%) | 0 | 0 | 0 | 4 (0.4%) | 0 |
| Other people | 0 | 0 | 0 | 0 | 1 (0.4%) | 0 | 1 (0.4%) | 0 | 2 (0.2%) | 0 |
| Other family | 0 | 0 | 1 (0.4%) | 0 | 0 | 0 | 0 | 0 | 1 (0.1%) | 0 |
| Totals | 211 (24%) | 78 (24%) | 226 (26%) | 94 (29%) | 237 (27%) | 81 (25%) | 202 (23%) | 73 (22%) | 876 (mean = 9.1) | 326 (mean = 9.1) |
| No. children | 62 (65%) | 26 (72%) | 77 (80%) | 33 (92%) | 74 (77%) | 29 (81%) | 64 (67%) | 27 (75%) | 277 (mean = 2.9) | 115 (mean = 3.2) |
Fears by gender.
Girls reported more total fears (745) than boys (457) and had a greater average number of fears (mean = 13.3) than boys (mean = 6.01; Table 4). Girls reported more Fantasy fears (45%) than boys (13%). These fears included creatures, evil spirits, ghosts, clowns, Chucky, and a superhero. Both boys and girls reported their top Reality fears as daily situations, bugs, animals, and medical examinations. Boys had a higher percent of fears in daily situations than girls, including fears of violent situations at 2, 4, and 13 months after the sibling’s death. At 6 months after the sibling’s death, both boys and girls reported equal numbers of fears of violent situations. These fears included being kidnapped, stabbed, shot by a gun, hit by a car, drowning, and being robbed. Girls, more than boys, were fearful of bugs and situations related to their parents, siblings, or others, including losing or disappointing a parent or sibling, and having a mother lose a pregnancy.
Table 4.
Children’s fears by gender
| Fears | 2 months | 4 months | 6 months | 13 months | Total Boys (N = 56) | Total Girls (N = 76) | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Boys | Girls | Boys | Girls | Boys | Girls | Boys | Girls | |||
| Fantasy | ||||||||||
| Creatures | 4 (4%) | 9 (5%) | 2 (2%) | 3 (1.6%) | 2 (2%) | 6 (3%) | 2 (2%) | 6 (4%) | 10 (2%) | 24 (3%) |
| Superheroes | 0 | 1 (0.5%) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 (0.1%) |
| Total | 4 (4%) | 10 (5%) | 2 (2%) | 3 (1.6%) | 2 (2%) | 6 (3%) | 2 (2%) | 6 (4%) | 10 (2%) | 25 (3%) |
| Reality | ||||||||||
| Daily situations | 48 (44%) | 60 (33%) | 53 (45%) | 82 (41%) | 53 (45%) | 68 (34%) | 43 (38%) | 57 (35%) | 197 (43%) | 267 (36%) |
| Bugs | 21 (20%) | 43 (24%) | 23 (19%) | 50 (25%) | 23 (19%) | 48 (24%) | 25 (22%) | 46 (28%) | 92 (20%) | 187 (25%) |
| Animals | 18 (17%) | 36 (20%) | 22 (18%) | 39 (19%) | 23 (19%) | 41 (21%) | 24 (21%) | 28 (17%) | 87 (19%) | 144 (19%) |
| Medical examinations | 14 (13%) | 29 (16%) | 19 (16%) | 26 (13%) | 17 (14%) | 33 (17%) | 18 (16%) | 25 (15%) | 68 (15%) | 113 (15%) |
| Parents | 1 (1%) | 2 (1%) | 0 | 0 | 0 | 2 (1%) | 0 | 0 | 1 (0.2%) | 4 (0.5%) |
| Siblings | 1 (1%) | 2 (1%) | 0 | 0 | 1 (1%) | 0 | 0 | 0 | 2 (0.4%) | 2 (0.2%) |
| Other people | 0 | 0 | 0 | 0 | 0 | 1 (0.5%) | 0 | 1 (1%) | 0 | 2 (0.2%) |
| Other family | 0 | 0 | 0 | 1 (0.4%) | 0 | 0 | 0 | 0 | 0 | 1 (0.1%) |
| Total | 107 (23%) | 182 (24%) | 119 (26%) | 201 (27%) | 119 (26%) | 199 (27%) | 112 (25%) | 163 (22%) | 457 (mean = 6.0) | 745 (mean = 13.3) |
| No. children | 35 (63%) | 53 (70%) | 45 (80%) | 65 (86%) | 46 (82%) | 57 (75%) | 37 (66%) | 54 (71%) | 163 (mean = 2.1) | 229 (mean = 4.1) |
Fears by race/ethnicity.
Children in each race/ethnicity category reported almost equal average numbers of fears: Black non-Hispanic (mean = 9.16), Hispanic (mean = 9.05), and White non-Hispanic (mean = 9.03; Table 5). Regardless of race, all children had more fears based in the Reality category than in the Fantasy category. Black children reported the highest number of Fantasy fears and White non-Hispanic children had the lowest. In the Reality category, top fears were daily situations, bugs, animals, and medical examinations. A higher percentage of Hispanic children (41%) reported fears of daily situations (being left alone, being in the dark, or sleeping away from home), followed by White children (37%) and Black children (37%). Black children had the highest percent of fears of animals and White children the lowest. White children had the highest percentage of fears of bugs and medical examinations; the latter was especially true at 2 and 13 months after the sibling death. Black non-Hispanic children had the highest number of fears of anything happening to their parent or family member.
Table 5.
Children’s fears by race/ethnicity
| Fears | 2 months | 4 months | 6 months | 13 months | Total Black (N = 67) | Total Hispanic (N = 39) | Total White (N = 26) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Black | Hispanic | White | Black | Hispanic | White | Black | Hispanic | White | Black | Hispanic | White | ||||
| Fantasy | |||||||||||||||
| Creatures | 5 (3%) | 5 (7%) | 3 (6%) | 1 (0.6%) | 2 (2%) | 2 (3%) | 3 (2%) | 3 (3%) | 2 (3%) | 5 (4%) | 1 (1%) | 2 (3%) | 14 (2%) | 11 (3%) | 9 (4%) |
| Superheroes | 1 (0.6%) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 (0.1%) | 0 | 0 |
| Total | 6 (4%) | 5 (7%) | 3 (6%) | 1 (0.6%) | 2 (2%) | 2 (3%) | 3 (2%) | 3 (3%) | 2 (3%) | 5 (4%) | 1 (1%) | 2 (3%) | 15 (2%) | 11 (3%) | 9 (4%) |
| Reality | |||||||||||||||
| Daily situations | 59 (36%) | 30 (40%) | 19 (39%) | 63 (41%) | 48 (45%) | 24 (41%) | 62 (39%) | 33 (36%) | 26 (38%) | 46 (34%) | 35 (44%) | 19 (32%) | 230 (37%) | 146 (41%) | 88 (37%) |
| Bugs | 37 (22%) | 15 (20%) | 12 (24%) | 34 (22%) | 24 (22%) | 15 (26%) | 35 (22%) | 19 (21%) | 17 (25%) | 35 (26%) | 20 (25%) | 16 (27%) | 141 (23%) | 78 (22%) | 60 (26%) |
| Animals | 38 (23%) | 12 (16%) | 4 (8%) | 36 (23%) | 16 (15%) | 9 (16%) | 31 (19%) | 20 (22%) | 13 (19%) | 29 (21%) | 13 (16%) | 10 (17%) | 134 (22%) | 61 (17%) | 36 (15%) |
| Medical examinations | 22 (13%) | 12 (16%) | 9 (18%) | 20 (13%) | 17 (16%) | 8 (14%) | 25 (16%) | 15(16%) | 10 (15%) | 20 (15%) | 11 (14%) | 12 (20%) | 87 (14%) | 55 (16%) | 39 (17%) |
| Parents | 2 (1%) | 0 | 1 (2%) | 0 | 0 | 0 | 2 (1%) | 0 | 0 | 0 | 0 | 0 | 4 (0.6%) | 0 | 1 (0.4%) |
| Siblings | 1 (1%) | 1 (1%) | 1 (2%) | 0 | 0 | 0 | 1 (1%) | 0 | 0 | 0 | 0 | 0 | 2 (0.3%) | 1 (0.2%) | 1 (0.4%) |
| Other people | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 (1%) | 0 | 0 | 0 | 1 (2%) | 0 | 1 (0.2%) | 1 (0.4%) |
| Other family | 0 | 0 | 0 | 1 (0.6%) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 (0.1%) | 0 | 0 |
| Total | 165 (27%) | 75 (21%) | 49 (21%) | 155 (25%) | 107 (30%) | 58 (16%) | 159 (26%) | 91 (26%) | 68 (29%) | 135 (22%) | 80 (23%) | 60 (25%) | 614 (mean = 9.2) | 353 (mean = 9.1) | 235 (mean = 9.0) |
| No. children | 50 (75%) | 23 (59%) | 15 (58%) | 52 (78%) | 37 (95%) | 21 (81%) | 46 (69%) | 33 (85%) | 24 (92%) | 43 (64%) | 28 (72%) | 20 (77%) | 191 (mean = 2.9) | 121 (mean = 3.1) | 80 (mean = 3.1) |
Discussion
This study described fears that children identified from 2 to 13 months after their sibling’s death. Most studies have reported parents’ perceptions of children’s responses after the death of a loved one (Nguyen & Rosengren, 2004; Youngblut, Brooten, Cantwell, del Moral, & Totapally, 2013). We also looked at how children’s fears differed by the surviving siblings’ age, gender, and racial group, and across time. The five items on the “Fears” subscale of the SCAS asked about specific fears, including bugs (insects/spiders), animals (dogs), health care provider visits, darkness, and high places. Children responded to the other two open-ended questions, providing children’s additional perspectives.
In the present study, the top four children’s fears were daily situations (fear of heights, being left alone or lost, enclosed dark places, strangers, and violent situations), bugs (ants, roaches, mosquitoes), and animals (dogs, lizards, and toads), and medical examinations across age, gender, and racial/ethnic groups. Ollendick, et al. (2002) found that fears tend to be age specific and change across stages of development. In our study, a slightly higher percentage of teenagers reported fears of daily situations and bugs than school-aged children. According to Robinson and Rotter (1991) during infancy through preschool, children tend to fear strangers, separation from parents, dark rooms, mystical creatures, and large animals. As the child gets older, these fears are replaced by fears of burglars, kidnappers, and even being alone (Eme & Schmidt, 1978; Robinson, Robinson, & Whetsell, 1988). When a child reaches school age, being aware of consequences begins to develop. Therefore, the child may associate going to the doctor with getting a shot and being kidnapped with getting hurt or even death. In one study (Youngblut & Brooten, 2013), parents reported that after sibling loss, their school-aged child feared their parents leaving their side because they might never return. In another study (Robinson & Rotter, 1991), as children moved into the teenage years, they continued to have some of the fears of the school-aged child; however, fears tended to shift to failure at school, personal relationships, war, sex issues such as pregnancy and sexually transmitted infections or AIDs, and family concerns. In our study, these fears were not concerns, perhaps due to the greater number of school-aged children in our sample. However, our study results agree with those of Owen (1998) who found that children aged 7–9 years were concerned with dangers, physical injury, and death.
In the present study, girls reported more total fears (745) than boys (457) and had a greater average number of fears (mean = 13.3) than boys (mean = 6.01). Forty-five percent of girls and 13% of boys reported fears of fantasy creatures, including monsters, clowns, zombies, Apocalypse, and Chucky. Both boys and girls reported their top reality fears as daily situations, bugs, animals, and medical examinations. Boys reported more fears of everyday situations (fear of the dark, high places, being left alone) and fears of violent situations (being shot, stabbed, kidnapped, robbed, and death) than girls. This differs from the work of Wolchik et al. (2006), who reported that gender was significantly correlated with fear of abandonment, self-esteem, and internalizing problems with girls reporting higher scores in fear of abandonment and internalizing problems.
In this study, White non-Hispanic children had the highest percent of fears in the Fantasy category as well as the fear of bugs and medical examinations. Black non-Hispanic children had the highest fears of animals (dogs, toads, or any four-legged animal), and fears of something happening to their parents or family member (losing a parent or family member, disappointing their parent). Black non-Hispanic children and Hispanic children feared violent situations equally, including fear of being shot, drowned, kidnapped, hit by a car, and robbed. These violent fears were also equally represented among school-aged children and teens. Hispanic children had the greatest percent of fears of daily situations (being left alone, high places, and the dark) than Black children and White children. This corresponds somewhat with findings from Wolchik et al. (2006) who reported that parentally bereaved non-Caucasian children had higher scores on stressors and fear of abandonment than parentally bereaved Caucasian children.
In summary, in this study, children identified many fears after the death of a sibling. These fears included developmentally “normal” fears (bugs, dark, animals, and imaginary creatures), fears about medical examinations perhaps related to their sibling’s Intensive Care Unit death, and fears of daily situations including those of a violent nature. The death of a loved one results in many emotions in a child, including fear of everyday situations and events, and feeling overwhelmed. Because they do not want to bring additional hurt to their grieving parents, children often pretend they are feeling well emotionally and physically. A study by Roche et al (2016), following a sibling’s death, found that parents perceived their remaining child to be healthier than did the child, indicating that obtaining children’s responses are key to understanding children’s fears and feelings.
Study limitations
The Spence scale includes the five identified fears, and all children responded to each item. In the open-ended questions, children may have underreported the number of fears, not having been prompted by an identified specific fear.
Implications for practice
Identifying children’s fears after a significant event such as the death of a sibling requires a team approach. Significant team members should include but are not limited to the nurse practitioner, child, caretaker, as well as possible other disciplines from outside referrals. As primary care providers, nurse practitioners play an essential role in helping children effectively work through their fears by making an early diagnosis, educating children and their caretakers about the grieving process, and helping them evaluate their treatment options (American Association of Nurse Practitioners, 2017). The nurse practitioner may need to facilitate a referral to a psychologist or psychiatrist when needed. If the latter is chosen, it is critical for the nurse practitioner to remain involved in the child’s care through coordination of services and integrating primary and specialist care.
As a nurse practitioner, it is necessary to engage these children and their families as active participants in the treatment plan through shared decision making and development of self-management strategies. The nurse practitioner must serve as an advocate for those children who do not have the financial resources needed to receive the necessary treatment. Knowing the resources in the community and promoting effective communication among all team members is critical and falls within the realm of the nurse practitioner.
Children will experience fears throughout their life, and this fear may intensify when faced with an adverse event such as a death of a sibling. Distinguishing normal fear from fears that require professional intervention is not always easy. However, if children’s fears interfere with their normal activities and are left untreated, psychiatric conditions may develop (Children’s fears and anxieties, 2004). It is evident from this study that children experience fears as early as 2 months after the sibling’s death. In this study, we had a total of 320 fears reported at 4 months by 83% of the bereaved children versus 289 fears reported at 2 months by 67% of the bereaved children. Perhaps, the increase at 4 months was the realization setting in of their sibling’s death.
In this study, girls reported more total fears than boys and they also reported more fears of anything happening to their parents or siblings. According to Steingard (n.d), brain scans have demonstrated that there are differences in the way that boys and girls process emotional stimuli. Emotionally girls mature faster than boys, which could make them at risk for greater anxiety and fears. Girls were also afraid of their mothers becoming pregnant and losing another baby or something happening to their surviving sibling. Anticipatory guidance (including behaviors to look for in children that may require therapy and/or support) should be provided to parents. Nurse practitioners who are knowledgeable about child bereavement could provide parents with creative activities that can help children overcome their fears. Activities could include reading books, identifying characters within the stories, and recognizing the characters’ coping strategies and how this relates to the child’s life.
In this study, both school-aged children and teens reported fears of medical examinations and daily situations. Some children reported feeling that they would contract the condition that resulted in their sibling’s death and were afraid of going to the doctor. In other cases, the sibling’s brother or sister died due to being hit by a car or “being gunned down,” resulting in fears of these situations remaining in the surviving children. Every opportunity should be taken to give factual information to remaining children about their sibling’s death in age-appropriate terms. Nurse practitioners should prepare parents to be open about discussing facts related to the sibling’s death. Parents need to look for physical clues and provide physical comfort to the children. By following these strategies, children will work through their fears and feel supported, thus improving both the child’s quality of life and that of their families. Unless fears and anxiety are identified early and interventions are implemented, what was once thought of as normal development can become a disruption and a disorder in the child’s life (Matthews, 2010).
Acknowledgments:
Funded by grant #R01 NR012675 from the National Institutes of Health, National Institute of Nursing Research.
Footnotes
Competing interests: The authors report no conflicts of interest.
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