Abstract
Background:
Approximately 50,000 US infants and children die annually, leaving surviving children and families with long-lasting effects. In most studies, children’s health is rated by parents, but not the children.
Purpose:
To compare the surviving children’s self-rated health with parents’ ratings at 2, 4, 6, and 13 months after sibling neonatal intensive care unit/pediatric intensive care unit/emergency department death death and identify the related factors.
Methods:
Children and their parents rated the child’s health “now,” “now compared with others your age,” and “now versus before” the sibling’s death.
Sample:
One hundred thirty-two children (58% girls, 72% school-aged, and 50% Black non-Hispanic), 70 mothers, and 26 fathers from 71 bereaved families.
Conclusions:
Children self-rated their health: “now” as lower than their mothers at 4, 6, and 13 months and their fathers at 2, 4, and 13 months; “now compared with others your age” as lower than their mothers at each time point and fathers at 4, 6, and 13 months; and “now versus before” their sibling’s death as higher than their mothers at 4, 6, and 13 months and fathers at 6 months. Ratings did not differ by age, gender, or race/ethnicity. At 6 months, children self-rated their health “now” as higher than their fathers in families with one to two surviving children but lower than their fathers in families with three to eight surviving children.
Implications for practice:
Parents often perceive their children as healthier than children perceive themselves after sibling death, especially in larger families. Talking with children separately can identify the children at risk for emotional and physical illnesses earlier, providing more timely and appropriate interventions and referrals.
Keywords: Child death, child-rated health, infant death, parent-rated child health
Introduction
More than 50,000 infants and children die each year in the United States (CDC, 2015). Death of a child is a life-changing experience with long-lasting effects on parents and remaining siblings (Kochanek et al., 2016). Most studies reporting effects on remaining siblings are from the parents’ perspective, with few from the surviving siblings’ perspective. Even fewer studies report comparisons of parents and remaining siblings’ perceptions of the effects of the death on the remaining sibling’s health. Such comparisons are important because they can influence the course and effectiveness of subsequent treatments for remaining siblings’ physical and emotional health following a sibling’s death.
Children’s responses
Death of a sibling is not a common event for children. Children do not completely understand why their brother or sister had to die. Like adults, the reactions of other children may be distancing themselves from the bereaved child, not knowing what to say and in fear of making things worse. Friends and supporters before the sibling’s death and their parents, grandparents, and other relatives may not be available to the bereaved child after the sibling’s death when they need them the most. All of these events add stress to the bereaved child.
Children’s responses to a sibling’s death mirror children’s responses to extremely stressful events, including changes in behavior, school functioning, and relationships with others. Children in stressful situations experience difficult and distressing emotional (anxiety, depression, or guilt) and physical (developmentally regressive behaviors, pain, or dyspnea) symptoms (Birenbaum, 2000). The frequency and severity of these symptoms vary with the child’s characteristics, the events of the sibling’s death, and the child’s behaviors toward the sibling before death. As with bereaved adults, children may regret their last conversations, behaviors and time with the deceased, often indicated by the child’s rumination and fixation on conversations, behaviors, and time spent or not spent with their sibling before death.
After a sibling’s death, children may experience loneliness, abandonment, and lack of availability of those who could help them most—parents, other siblings, grandparents, friends, and teachers. Isolation or distance in the child’s relationships with their parents, siblings, and grandparents deprives them of an important source of support and comfort (Youngblut & Brooten, 2013). Children often want to protect or shield their parents by hiding their own distress. Both of these situations likely affect the closeness of the parent–child relationship, making parents less reliable reporters of their child’s experiences, emotions, symptoms, and behaviors.
Brooten et al., 2018 found that parents reported 207 illnesses and 674 treatments or health services for 132 school-aged children and adolescents in the first 6 months after their sibling’s death. In the first year after their sibling’s death, Brooten et al., (2019) found that school-aged children and adolescents self-reported higher symptoms of anxiety; their parents characterized them as having more anxiety/depression, withdrawal, somatic complaints, and aggressive behaviors, which varied by child age, sex, and time since sibling death. Parents reported one to nine school detentions for 14 children, one to seven suspensions for nine children, and one to eight parent–teacher meetings for 59 children.
In the study by Brooten and Youngblut (2017), bereaved adolescents found that they had a difficult time getting through their siblings’ burial and were in shock and dis-belief. They experienced fear of losing someone else in their family especially during the latter part of the first year after the death. Bereaved adolescents report more changes within their family life as well as having to grow up quickly after the death of a sibling. They report having a difficult time finding meaning in normal life goals such as pursuing a career. One adolescent expressed, “I call it elasticity … You stretch elastic so far, and … you bounce back. You stretch it further and you bounce back, but if you stretch it too far, it’s hard to bounce back” (Funk et al., 2018). Adolescents show higher self-injury behaviors and higher rates of suicide during the first year after the death of a loved one (Grenklo et al., 2013). However, the effects of a brother’s or sister’s death may remain for years later into adulthood. Recent studies have found that losing a sibling as an adult is strongly associated with increased risk of myocardial infarction, stroke, and even suicide (Baker et al., 1992; Rostila et al., 2017; Rostila et al., 2012; Rostila et al., 2012, Rostila et al., 2013). Fletcher et al., (2012) found lower rates of high school graduation and post-high school education and higher rates of teenage pregnancy and non-employment among young adults with a sibling death during their childhood.
Age
Children have different understandings of the finality of death depending on their developmental stage. School-aged children are still learning to understand death. They may think death is temporary or that the person died because they did something bad. They may have blunt questions and ask where the person is now and what happened to them and to their body. Adolescents 14–18 years old may fear death in general or even the thought of losing someone (Brooten & Youngblut, 2017). Adolescents’ reactions to death may fluctuate between earlier age group reactions and those that are more adult reactions. Teens may engage in risk taking behaviors (drinking, drugs, driving recklessly, engaging in penile-vaginal intercourse) to escape feelings of reality (Malone, 2007).
Gender
Based on gender, children’s social functioning, school performance, and treatment outcomes may differ (Abdelnoor & Hollins, 2004; Paris et al., 2009) after sibling loss. Girls are reported to have more internalizing behaviors such as becoming withdrawn, depressed, or having greater anxiety, poor academic performance, and more conflicts with the family. Boys have more externalizing behaviors such as acting out and engaging in physical fights (Worden et al., 1999). Girls also reported experiencing more fears overall, talking more to the deceased sibling and reported more changes within their family structure after a sibling’s death more so than boys (Brooten and Youngblut (2017); Roche et al., 2016).
Race/ethnicity
There are very few studies that explore parent’s and sibling’s ratings of the remaining sibling’s health after sibling death across race. Existing studies of remaining sibling health includes samples of White parents and children. Laurie and Neimeyer (2008) found that Black African American college students who lost a loved one, maintained a stronger continued bond with the deceased, had more complicated grief symptoms, spent less time speaking to others, or getting professional support than Caucasians.
Parent versus child health perceptions
Roche et al., (2016) comparing parents and remaining children’s responses in the first 4 months after sibling death found that parents often perceived their child to be healthier than did the child. In a related study after a family stressor (living with a child with a chronic condition, loss of a child or parent), Foster et al. (2012) compared parent and child perceptions of child’s physical and mental health and found that parents reported more negative changes in their child’s physical and emotional behavior than the child reported. Children reported more positive changes that reflected adaptation to the environment and personal growth and more changes in sibling and peer relationships than parents reported (Foster et al., 2012). Given the very limited research that compares parents and children’s perceptions of children’s health after a sibling death, there is a need for further research in this area to help guide interventions.
In summary, death of a sibling has long-lasting effects physically and emotionally on the surviving child. It is important to understand the factors that may affect the surviving child’s health to manage the appropriate treatment. However, research on children’s responses to the death of a sibling is limited and what is available is from the parent’s perspective. Child’s self-report of their health and well-being is extremely limited. The purpose of this study was to 1) compare surviving children’s self-rated health with mothers’ and fathers’ ratings of the child’s health at 2, 4, 6, and 13 months; and 2) identify relationships of self-rated health and the child age, gender, race/ethnicity, and number of surviving siblings.
Methods
Parents and surviving siblings of infants/children who died in the neonatal intensive care unit (NICU)/pediatric intensive care unit (PICU)/emergency department (ED) NICU/PICU/ED were recruited from four South Florida children’s hospitals and through Florida obituaries. The study took place between June 2011 and December 2015. English- or Spanish-speaking parents who were at least 19 years old and self-reported their race/ethnicity as Hispanic, Black, or White were included in the study. English-speaking children who were 6–18 years old, in age-appropriate grade in school ±1 year, and self-reported their race/ethnicity as Hispanic, Black, or White were eligible for the study if they lived with their pregnant mother (neonatal deaths) or sibling before the death and the same parent(s) since the death. Children were excluded if unable to participate verbally, in foster care before or after the death, or death of a parent or more than one sibling in the same event.
Procedure
Approval was obtained from the institutional human participants’ review boards at the principal investigators’ university and four Florida children’s hospitals. Each participating hospital identified a clinical coinvestigator who identified potential participants that met study criteria and provided addresses and phone numbers for these families from their facility (public information by Florida law). Public online obituary notices (e.g., newspapers, funeral homes, and crematoriums) were searched by the study research assistants (RAs) to identify potentially eligible families and online databases for available phone numbers and addresses.
At 4–7 weeks after the death, identified families were sent a letter (in Spanish and English) explaining the study, identifying the project director (PD) and RAs, and provided the project phone number and email address. One week after the letter was sent, RAs fluent in Spanish and English called the parent(s), screened for inclusion/exclusion criteria, answered questions, and asked whether the parent(s) and their eligible children were willing to be in the study. The RA and consenting parents and children set a time for the first data collection visit in the family’s home. At the first meeting, the RA explained the study to the parent(s), answered their questions, and obtained their signed informed consent for participation of their eligible children and themselves and review of their deceased child’s hospital record. Noncustodial parents were invited to participate if their names and contact information were provided. The RA then talked with eligible children, answered their questions, and obtained their signature on an assent form; 18-year-olds signed consent forms for their own participation. Only children who signed the assent form after their parent(s) gave consent were interviewed. Of the 281 families contacted, 224 (80%) were eligible and 71 (32%) participated, a rate consistent with that reported by Hudson et al., (2017) in their systematic review of research with children with life-threatening illnesses.
Measures
Health ratings.
Children, mothers, and fathers (separately) rated the child’s health “right now” and “now compared with other children your [their] age” from 1 “poor” to 10 “excellent.” Ratings of 2 to 9 did not have word anchors children’s ratings on these two items were subtracted from ratings by their mothers and fathers (separately) on each item (Roche et al., 2016).
In these calculations for each parent-child pair on each item, a difference of “0” means that parent-child dyad agreed on their perceptions of the child’s health. A positive difference score means the parent’s rating on that item was higher (better) than their child’s rating. A negative difference means the parent’s rating on that item was lower (worse) than their child’s rating. Each mother-child and father-child pair were separately categorized as: parent higher (better) than child, parent and child agree on that item, and parent lower (worse) than child.
Children, mothers, and fathers also separately rated the child’s health “now compared with before the death” from 1 “worse than before the death” to 5 “about the same as before the death” to 10 “much better than before the death.” Ratings of 2 to 4 and 6 to 9 did not have word anchors. Difference scores were not calculated for this item.
Demographic data.
Parents and surviving children provided their age, gender, and race/ethnicity (White non-Hispanic, Black non-Hispanic, or Hispanic). Children were coded as “school age” (6–12 years) and “adolescent or teen” (13–18 years). Parents provided number of living children in the family, annual income, and marital status. Number of living children was categorized as one, two, or three or more living children.
Data analysis.
Descriptive statistics were used for the demographic data. Paired t-tests were used to compare child self-ratings of their health “right now” and “now compared with other children your [their] age” with their mother’s and father’s ratings (separately). Chi-square tests were used to compare each mother-child and father-child health rating difference categories (parent higher than child [better], parent and child agree [same], and parent lower than child [worse]) by child age, gender, race/ethnicity, and number of surviving children in the family (one, two, three or more). Bootstrap procedures with 2,000 resamples stratified by family were used in all inferential analyses to account for the 40 (56%) families with more than one child participant in the study.
Results
Sample
One hundred thirty-two surviving children (56 boys and 76 girls) who lost a brother or sister, and 70 mothers and 26 fathers from 71 families participated. Surviving children’s ages ranged from 6 to 18 years. Most of the surviving children were school-aged (n = 95, 72%), female (n = 76, 58%), and either Black non-Hispanic (n = 67, 50%) or Hispanic (n = 39, 30%). The mean age for mothers was 36 years (SD = 7.1) and for fathers was 39 years (SD = 7.4). Approximately 75% of families had an annual income of <$50,000, with at least 30% of parents having some college education. Seventy-four percent of the deceased children were either infants (37%) or adolescents (37%), male (62%), and Black non-Hispanic (42%; Table 1). The deceased siblings died in the NICU (n = 17, 24%), PICU (n = 45, 63%), or ED (n = 9, 13%) from the most common causes of child death in the United States: congenital/genetic anomalies, prematurity, infection, and trauma (Curtin et al., 2018; Kochanek et al., 2016).
Table 1.
Parent, child, and family characteristics
| Characteristics | Parents (N = 96) | Mothers (n = 70) | Fathers (n = 26) |
|---|---|---|---|
| Age in years (mean [SD]) | 36 (7.1) | 39 (7.4) | |
| Race/ethnicity (n [%]) | Black non-Hispanic | 30 (43%) | 9 (35%) |
| White non-Hispanic | 7 (24%) | 9 (35%) | |
| Hispanic | 23 (33%) | 7 (27%) | |
| Mestizo | 0 (0%) | 1 (0.03%) | |
| Education (n [%]) | Less than high school | 19 (27%) | 8 (31%) |
| High school graduate-some college | 28 (40%) | 13 (50%) | |
| College graduate | 23 (33%) | 5 (19%) | |
| Relationship status (n [%]) | Married/partnered | 54 (77%) | 24 (92%) |
| Single, not partnered | 16 (23%) | 2 (0.08%) | |
| Families (N = 71) | |||
| Annual family income (n [%]) | Less than $20,000 | 28 (39%) | |
| $20,000-$49,999 | 26 (37%) | ||
| ≥$50,000 | 17 (24%) | ||
| Surviving children (n [%]) | 1 child | 12 (17%) | |
| 2 children | 21 (30%) | ||
| 3 children | 15 (21%) | ||
| 4 children | 15 (21%) | ||
| 5–8 children | 8 (11%) | ||
| Surviving Siblings 6–18 Years Old (N = 132) | |||
| Sex (n [%]) | Boys | 56 (42%) | |
| Girls | 76 (58%) | ||
| Age group (n [%]) | School-aged children | 95 (72%) | |
| Adolescents | 37 (28%) | ||
| Race/ethnicity (n [%]) | Black non-Hispanic | 67 (50%) | |
| White non-Hispanic | 26 (20%) | ||
| Hispanic | 39 (30%) | ||
| Deceased Sibling (N = 71) | |||
| Sex (n [%]) | Boys | 44 (62%) | |
| Girls | 27 (38%) | ||
| Age group (n [%]) | Infants (≤12 mo) | 26 (37%) | |
| Preschoolers (12.001–60 mo) | 4 (5%) | ||
| School aged (60.001–144 mo) | 15 (21%) | ||
| Adolescents (>144 mo) | 26 (37%) | ||
| Race/ethnicity (n [%]) | Black non-Hispanic | 30 (42%) | |
| White non-Hispanic | 18 (25%) | ||
| Hispanic | 23 (32%) | ||
Children’s self-rated health versus parents’ ratings
Children’s self-rated health “right now,” “now compared with others your age,” and “now compared with before the death” were compared with their mothers’ and their fathers’ ratings. Children’s mean self-rated health “right now” was significantly lower than their mothers at 4, 6, and 13 months and their fathers at 2, 4, and 13 months after sibling death (Table 2). Children’s mean self-rated health “now compared with others your age” was significantly lower than their mothers at 2, 4, 6, and 13 months and their fathers at 4, 6, and 13 months (Table 3). Children’s mean self-rated health “now compared with before the death” was significantly higher than their mothers at 4, 6, and 13 months and their fathers at 6 months (Table 4) but significantly lower than their fathers at 4 and 13 months.
Table 2.
Parent-child comparisons on child’s health “right now” ratings on 1 (poor) to 10 (excellent) scale
| Pairs | Child (Mean [SD]) | Parent (Mean [SD]) | Bootstrap Paired Differences (Mean [SE]) | |
|---|---|---|---|---|
| 2 mo | Mother-child (n = 82 pairs) | 8.24 (1.97) | 8.23 (2.43) | 0.01 (0.30) |
| Father-child (n = 34 pairs) | 7.74 (1.71) | 8.53 (1.94) | 0.79 (0.25)b | |
| 4 mo | Mother-child (n = 98 pairs) | 8.49 (1.85) | 8.91 (1.79) | 0.42 (0.11)b |
| Father-child (n = 34 pairs) | 8.15 (2.05) | 8.79 (1.65) | 0.65 (0.22)b | |
| 6 mo | Mother-child (n = 97 pairs) | 8.56 (1.77) | 9.06 (1.56) | 0.51 (0.13)b |
| Father-child (n = 37 pairs) | 8.32 (1.84) | 8.70 (2.03) | 0.38 (0.21) | |
| 13 mo | Mother-child (n = 86 pairs) | 8.28 (2.16) | 8.66 (1.66) | 0.38 (0.16)a |
| Father-child (n = 27 pairs) | 7.74 (2.35) | 9.30 (1.30) | 1.56 (0.29)b |
p < .05.
p < .01
Table 3.
Parent-child comparisons on child’s health “now versus age-mates” on 1 (poor) to 10 (excellent) scale
| Pairs | Child (Mean [SD]) | Parent (Mean [SD]) | Bootstrap Paired Differences (Mean [SE]) | |
|---|---|---|---|---|
| 2 mo | Mother-child (n = 82 pairs) | 8.38 (1.99) | 8.32 (2.28) | 0.06 (0.14) |
| Father-child (n = 34 pairs) | 7.50 (2.23) | 8.65 (2.03) | 0.79 (0.25)b | |
| 4 mo | Mother-child (n = 98 pairs) | 8.19 (1.95) | 8.87 (1.90) | 0.67 (0.13)b |
| Father-child (n = 34 pairs) | 8.56 (1.93) | 8.53 (1.81) | 0.03 (0.18) | |
| 6 mo | Mother-child (n = 97 pairs) | 8.09 (2.06) | 8.80 (1.98) | 0.71 (0.16)b |
| Father-child (n = 37 pairs) | 7.54 (2.12) | 8.22 (2.14) | 0.68 (0.24)b | |
| 13 mo | Mother-child (n = 86 pairs) | 8.28 (2.16) | 8.66 (1.66) | 0.33 (0.13)a |
| Father-child (n = 27 pairs) | 7.48 (2.29) | 9.26 (1.32) | 1.79 (0.30)b |
p < .05.
p < .01
Table 4.
Parent-child comparisons on child’s health “now versus before the death” on a 1 (much worse than before) to 5 (same as before) to 10 (much better than before) scale
| Pairs | Child (Mean [SD]) | Parent (Mean [SD]) | Bootstrap Paired Differences (Mean [SE]) | |
|---|---|---|---|---|
| 2 mo | Mother-child (n = 82 pairs) | 5.52 (2.27) | 5.00 (1.21) | 0.52 (0.16)b |
| Father-child (n = 34 pairs) | 5.18 (1.59) | 5.38 (1.46) | 0.21 (0.21) | |
| 4 mo | Mother-child (n = 98 pairs) | 5.94 (2.05) | 5.44 (1.50) | 0.50 (0.15)b |
| Father-child (n = 34 pairs) | 5.24 (1.52) | 5.56 (1.66) | 0.32 (0.15)a | |
| 6 mo | Mother-child (n = 97 pairs) | 6.21 (1.99) | 5.60 (1.65) | 0.61 (0.13)b |
| Father-child (n = 37 pairs) | 5.97 (1.85) | 4.89 (.61) | 1.08 (0.20)b | |
| 13 mo | Mother-child (n = 86 pairs) | 6.26 (2.12) | 5.71 (1.78) | 0.55 (0.16)b |
| Father-child (n = 27 pairs) | 5.37 (1.42) | 6.07 (1.88) | 0.70 (0.19)b |
p < .05.
p < .01
Child rating by age group, gender, race/ethnicity, and number of surviving siblings
Mother-child and father-child differences (better, same, or worse) in ratings of their child’s health “right now” were compared for school-aged children and teens, girls, and boys, families with one, two, or three or more surviving child, and across Black non-Hispanic, White non-Hispanic, and Hispanic racial/ethnic groups. Mother-child ratings of the child’s health differed significantly by child age group at 2, 6, and 13 months. More mothers rated the school-age child’s health “right now” the same as the child at 2 and 6 months, but lower (worse) than their child at 13 months. More mothers rated their teen’s health “right now” higher (better) than the teens did at 2, 6, and 13 months. Mother-child differences by child gender, race/ethnicity, and number of living children were not statistically significant at any time point.
In families with one or two surviving children, more fathers rated their child’s health “right now” significantly lower (worse) than their child did. In families with three or more surviving children, more fathers rated their child’s health “now” significantly higher (better) than their child did (6 months only). Father-child differences by child gender, age group, and race/ethnicity were not statistically significant at any time point (Table 5).
Table 5.
Significant comparisons of parent–child differences in children’s health ratings by child sex, age, and race/ethnicity, and number of surviving children in the family
| Child Age Group | Mother Lower Health Rating than Child (nobs [nexp]) | Mother Same Health Rating as Child (nobs [nexp]) | Mother Higher Health Rating than Child (nobs [nexp]) | Total | χ2 | |
|---|---|---|---|---|---|---|
| 2 mo | School age | 16 (16.9) | 26 (21.1) | 17 (21.1) | 59 | 6.66a |
| Teen | 8 (7.1) | 4(8.9) | 13 (8.9) | 25 | ||
| 6 mo | School age | 12 (11.4) | 36 (31.2) | 23 (28.4) | 71 | 6.17a |
| Teen | 4 (4.6) | 8 (12.8) | 17 (11.6) | 29 | ||
| 13 mo | School age | 27 (21.6) | 16 (15.9) | 19 (24.5) | 62 | 9.23b |
| Teen | 3 (8.4) | 6 (6.1) | 15 (9.5) | 24 | ||
| Surviving Children in Family | Father Lower Health Rating than Child (nobs [nexp]) | Father Same Health Rating as Child (nobs [nexp]) | Father Higher Health Rating than Child (nobs [nexp]) | Total | χ2 | |
| 6 mo | 1 living child | 2 (0.5) | 0 (0.5) | 0 (0.9) | 2 | 11.52a |
| 2 living children | 6 (3.5) | 3 (3.5) | 4 (6.0) | 13 | ||
| ≥3 living children | 2 (5.9) | 7 (5.9) | 13 (10.1) | 22 |
p < .05.
p < .01.
Data from this study showed that child self-ratingsof their health right now and now compared with others their age were significantly lower than the perceptions of their parents. This is contrary to the findings from Foster et al. (2012) who found that after a sibling’s death, children reported more positive changes in their physical and emotional health, more than their parents reported. A possible reason for this may be that after losing a child, parents feel overwhelmed and engulfed in their own grief, with little time to notice subtle changes in their child. Our study is consistent with findings from Craft and Craft (1989) and Sweeting and West (1998), where children perceived their health worse than their parents did.
When children self-rated their health “now compared with before the death,” they rated their health better than their mother at 4, 6, and 13 months and fathers at 6 months, lower than their fathers at 4 and 13 months. This is likely the time that the surviving child may realize that their sibling will not come back. Children rated their health lower (worse) than their parents at 13 months, timing that coincides with the sensitive 1 year anniversary of the sibling’s death (Gill & White, 2018). Review of the literature indicates that the surviving child’s physical and emotional health is often overlooked and their physiological and psychosocial needs are unmet, leading to physiological and psychosocial distress (McDonald et al., 2019).
Data from this study showed that fathers from families that had one to two surviving children rated their surviving child’s health lower (worse) than the child, and in those families with three or more surviving children, father’s health ratings were higher (better) than then child’s health ratings. Parents in single child families tend to have authoritarian style parenting and can be demanding and controlling while their acceptance and accountability is low and they pay little to no attention to the child’s needs. In the study by Rezvankhah (2009), parents who had more than two children in the family were more logical and accepting of child behavior paving the way for supportive nurturing.
Study limitations
Limitations include an unequal distribution of race/ethnicity among the study’s children, with more Black non-Hispanic (50%) and Hispanic (30%) children than White non-Hispanic children (20%). Although a limitation, a study with 80% minority children addresses the gap left by studies of all or almost all White non-Hispanic children. Children and parents may have different definitions of “health,” leading them to consider different aspects of “health” to determine their ratings. Perhaps in future studies, children and parents can be asked on what they are basing their ratings. Also, more objective data can be collected through a thorough physical and emotional examination to corroborate the different ratings of health.
Implications for practice
Children’s responses to a sibling’s death will vary according to their developmental age. The physical and emotional feelings that they are experiencing after a sibling’s death is not always apparent by asking their parents (Roche et al., 2016). Most children regardless of age will choose not to exhibit their emotions in front of their parents in order not to cause them more hurt than they are already experiencing (Lovgren et al., 2016). Children suffer from anxiety more than depression especially during the first year after the death of a sibling. Girls are more affected than boys (Youngblut et al., 2019).
It is evident from this study that parent’s and children’s health ratings differ (right now, now compared others their same age) with the child’s perception of their own health lower than their parent’s perception especially in teens. According to Barrera et al., (2013), adolescents avoid expressing their feelings to their parents and instead engage in high-risk behaviors. Their physical and emotional well-being may deteriorate due to feelings of loneliness, changes in eating habits, and changes in the family structure (Brooten et al., 2017; Roche et al., 2016).
Results from this study provide nurse practitioners with an understanding of children’s perceptions of their health after sibling death and that differences do exist between parent report and child self-report. Most children will exhibit physiological and psychological symptoms especially during the first year after their sibling’s death (Roche et al., 2016). Relevant clinical knowledge will help nurse practitioners identify children at risk for emotional and physical illness after a sibling’s death. Additionally, appropriate and effective interventions can be developed within the context of the child’s developmental age, race/ethnicity, and gender to prevent negative outcomes.
Nurse practitioners need to understand that long-term effects after losing a sibling do exist. They can help parents and children become aware of how the experience of losing a sibling effects the child’s life and encourage and prepare parents to be open about discussing the facts related to the sibling’s death. Parents should look for physical clues and provide physical comfort to their children. Children should be screened for complications in processing their grief. Nurse practitioners can provide parents and children with contact information on resources including support groups, camps, spiritual support, and therapy interventions for children who have lost a sibling. By using these resources, children will be given the opportunity to express their feelings. These strategies will help children feel supported and will improve the child’s quality of life and those of their families.
Acknowledgments
Supported by grant R01 NR012675 from the NIH National Institute of Nursing Research.
Footnotes
Competing interests: The authors report no conflicts of interest.
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