Parental death in childhood and risk of adult depressive disorders: a review

Home First: Stability and Opportunity in Out-of-Home Care

In this report, the concept of “Home First” is introduced for those children who require long-term, non-kin placements. The term “Home First” connotes a placement engendering stability and continuity; this concept is introduced in conjunction with an evaluation of the historical, theoretical, and empirical evidence surrounding different forms of out-of-home placement, including group-care placements and foster family care. In light of these observations and studies, this report will argue that stability is a major factor, perhaps a necessary if not a sufficient condition, in successful child development. It will argue for the initiation of a new focus on the creation of long-term positive and stable residential placements within the out-of-home care system and show that such placements can and have contributed to the development of healthy, happy, and successful adulthoods. This report offers a bio-psycho-social perspective on child development in out-of-home care. It provides a brief overview of the multiple bio-psycho-social theoretical perspectives that inform us on the necessary role of stability in growth and development and the contribution of instability to dysfunction. This report considers stability in out-of-home care in relation to its associated outcomes and those factors believed to enhance or detract from these outcomes. It reviews the history of substitutive care provision for children and youth and the role of the “stability objective” in that history. Finally, it looks at how child welfare system priorities have influenced stability, and it offers some suggestions for ensuring more stable growth and development in child placement provision.

The Impact of Childhood Trauma on Developing Bipolar Disorder: Current Understanding and Ensuring Continued Progress

Childhood trauma (CT) has been repeatedly linked to earlier onset and greater severity of bipolar disorder (BD) in adulthood. However, such knowledge is mostly based on retrospective and cross-sectional studies in adults with BD. The first objective of this selective review is to characterize the short-term effects of CT in the development of BD by focusing on studies in young people. The second objective is to describe the longer-term consequences of CT by considering studies with adult participants. This review first outlines the most prominent hypotheses linking CT exposure and the onset of BD. Then, it summarizes the psychological and biological risk factors implicated in the development of BD, followed by a discussion of original studies that investigated the role of CT in young people with early-onset BD, youths at increased risk of developing BD, or young people with BD with a focus on subclinical and clinical outcome measures. The review considers additional biological and psychological factors associated with a negative impact of CT on the long-term course of BD in later adulthood. Finally, we discuss how the integration of information of CT can improve ongoing early identification of BD and mitigate severe clinical expression in later adulthood.

Epidémiologie de la dépression: données récentes. II — Epidémiologie analytique et épidémiologie d’évaluation

Les données provenant d’études récentes concernant l’épidémiologie analytique et l’épidémiologie d’évauation de la dépression sont examinées.

Au sujet de l’épidémiologie analytique, il peut être conclu de la littérature actuellement disponible que les principaux facteurs de risques pour la dépression majeure sont : a) Sociodémographiques, à savoir : être une femme, être jeune, séparé, divorcé, ou avoir des problèmes conjugaux (les auteurs soulignent en particulier que les différences entre les sexes, concernant la dépression, sont réelles et ne sont pas un artefact lié à la façon de relater les troubles ou au comportement vis-à-vis des soins), b) Environnementaux: facteurs prédisposants (les événements de vie qui surviennent durant l'enfance peuvent prédisposer un individu à la dépression à l’âge adulte) et facteurs précipitants (il y a relation entre la survenue d’événements de vie pendant la vie adulte et le début de la dépression), c) Familiaux: il y a une multiblication par 2 à 5 du taux de dépression majeure chez les parents de premier degré de sujets témoins par rapport à es témoins non malades. L’influence de l’hérédité génétique est supportée par des études de jumeaux et des études adoption, mais une large part de la variance ne peut être expliquée, d) Divers: qui concernent le cycle de reproduc- 10n de la femme (la période du post partum entraîne une augmentation du taux de dépression) et les variations saisonneres (pics au printemps et en automne).

En ce qui concerne l'épidémiologie d’évaluation, il est habituel de distinguer prévention primaire, secondaire et teriaie. Leur dessein est respectivement de diminuer l’incidence de la dépression, la prévalence de la dépression et les isques de chronicité et de la récurrence. Les efforts concernant la prévention primaire ne peuvent avoir qu’un effet imité. Dans le domaine de la prévention secondaire, il peut être conclu que beaucoup de dépressifs ne sont pas diaglostiqués ou ne sont pas traités. La prévention tertiaire a pour dessein de limiter deux risques: la chronicité et la récurence. Le premier pourrait être évalué à 15-20% à chaque épisode. Les facteurs de risques principaux seraient la présence un trouble psychiatrique non affectif ou d’une affection physique, une personnalité névrotique et un faible niveau le traitement. Pour le risque de récurrence, on peut considérer qu’entre 50 et 85% des patients ayant fait un épisode lépressif majeur feront au moins un autre épisode de dépression ultérieurement. Les facteurs de risques pourraient re un Stand nombre d’épisodes antérieurs, un antécédent d’épisode maniaque ou d’hypomanie, l’association à un ésordre psychiatrique non affectif ou à une affection physique, une histoire familiale de maladie affective ou un âge e début tardif.

Early parental loss in childhood and depression in adults: A systematic review and meta-analysis of case-controlled studies

BACKGROUND

Many researchers have concluded that early parental loss during childhood is a risk factor for depression in late life of adults; however others didn't find any association. The objective of this systematic review is to assess whether this association exists or not by conducting a meta-analysis of published studies.

METHODS

Nine published case-controlled studies were chosen through literature searches in PUBMED, and LIBRARY GENESIS. Newcastle-Ottawa Scale (NOS) have been used to assess the quality of studies included. Thereafter, data were extracted from each study and analysed using ProMeta.

RESULTS

Nine case-controlled studies (representing n = 2784, cases=716 and controls=2068) were included in meta-analysis. The overall random effects model results of parental loss [OR = 2.18, 95% CI, 1.63-2.90, p < 0.00; I² = 15.79%, df = 8, p = 0.302], parental death [OR = 1.76, 95% CI, 1.13-2.73, p = 0.012; I² = 0.00%, df = 3, p = 0.600] and parental separation [OR = 3.14, 95% CI, 1.92-5.15, p < 0.001; I² = 0.00%, df = 2, p = 0.675] showed a strong positive effect on developing depression in adults. Egger's linear regression test [t = 0.14, p = 0.895] and Begg and Mazumdar's rank correlation test [z = 0.63, p = 0.532] confirmed absence of publication bias of studies included in this meta-analysis.

LIMITATIONS

This systematic review was limited by a small number of case-controlled studies included in meta-analysis due to the differences in methodological designs of studies.

CONCLUSION

The study concluded that parental loss, parental death, and parental separation before age 18 are risk factors of depression in adulthood.

Early Parental Death and Risk of Psychosis in Offspring: A Six-Country Case-Control Study

Evidence for early parental death as a risk factor for psychosis in offspring is inconclusive. We analyzed data from a six-country, case-control study to examine the associations of early parental death, type of death (maternal, paternal, both), and child’s age at death with psychosis, both overall and by ethnic group. In fully adjusted multivariable mixed-effects logistic regression models, experiencing early parental death was associated with 1.54-fold greater odds of psychosis (95% confidence interval (CI): 1.23, 1.92). Experiencing maternal death had 2.27-fold greater odds (95% CI: 1.18, 4.37), paternal death had 1.14-fold greater odds (95% CI: 0.79, 1.64), and both deaths had 4.42-fold greater odds (95% CI: 2.57, 7.60) of psychosis compared with no early parental death. Experiencing parental death between 11 and 16 years of age had 2.03-fold greater odds of psychosis than experiencing it before five years of age (95% CI: 1.02, 4.04). In stratified analyses, experiencing the death of both parents had 9.22-fold greater odds of psychosis among minority ethnic groups (95% CI: 2.02–28.02) and no elevated odds among the ethnic majority (odds ratio (OR): 0.96; 95% CI: 0.10–8.97), which could be due in part to the higher prevalence of early parental death among minority ethnic groups but should be interpreted cautiously given the wide confidence intervals.

Examining longer-term effects of parental death in adolescents and young adults: Evidence from the national longitudinal survey of adolescent to adult health

Using longitudinal data spanning a 7-year period, we investigated the behavioral and psycho-social effects resulting from a parent's death during early childhood or teenage years on adolescent and early adulthood functioning. Findings confirmed previous work demonstrating various behavioral problems and social-psychological adjustment deficits during adolescence. Results suggested that most detrimental adjustment behaviors among parentally bereaved youth fade as they entered into young adulthood. Yet, premature school withdrawals and diminished interests in college attendance at Wave 1 left many of these young adults with diminished academic accomplishments, lingering economic disadvantages and for females a hesitancy to marry as their lives progressed into adulthood.

The Adjustment of Parentally Bereaved Children: I. Factors Associated with Short-Term Adjustment

Forty parentally bereaved youngsters (age 6–16; 22 girls, 18 boys) and their surviving parent were interviewed and administered standardized measures (BSI, CBCL, CDI, RCMAS, WISC) to assess their emotional adjustment approximately 18 months after their parent's death. The sample was predominantly middle class Caucasian, with children relatively free of prior confounding non-bereavement related major stresses. There were marked discrepancies between parent CBCL reports of their children's adjustment and the children's self-report, while teacher reports (TRF) were somewhat more closely correlated with parent reports. On average, these bereaved children appeared to be faring well, though with heightened internalizing problems: adolescent boys seemed to be having the most difficulty. Full sample means concealed important differences revealed in gender and age group analyses. Strikingly, the full sample of children scored below national norms for non-bereaved children on depression and anxiety measures. Parent adjustment was the best predictor of child adjustment.

The prevalence of family childhood adversities and their association with first onset of DSM-IV disorders in metropolitan China

BACKGROUND

The prevalence of family childhood adversities (FCAs) and their joint effects on the first onset of subsequent mental disorders throughout the life course are rarely examined, especially in Asian communities.

METHOD

Face-to-face household interviews of 5201 people aged 18-70 years in Beijing and Shanghai were conducted by a multi-stage household probability sampling method. The first onsets of four broad groups of mental disorders and six categories of FCAs were assessed using The World Mental Health Composite International Diagnostic Interview (WMH-CIDI). Joint effects of FCAs were analyzed by the best fitting of several competitive multivariate models.

RESULTS

FCAs were highly prevalent and inter-correlated. Half of them were in a family-dysfunction cluster. The best-fitting model included each of six types of FCA (with family-dysfunction FCAs being the strongest predictors), number of family-dysfunction FCAs, and number of other FCAs. Family-dysfunction FCAs had a significant subadditive association with subsequent disorders. Little specificity was found for the effects of particular FCAs with particular disorders. Predictive effects of FCAs reached the highest in ages 13-24 compared to ages 4-12 and ≥ 25. Estimates of population-attributable risk proportions indicated that all FCAs together explained 38.5% of all first-onset disorders.

CONCLUSIONS

Chinese children were exposed to a broad spectrum of inter-related FCAs, as found in Western countries. FCAs related to family dysfunction were especially associated with subsequent mental disorders. Biological and/or environmental factors that mediate these long-term effects should be studied in prospective research on broad groups of FCAs.

Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys

BACKGROUND

Although significant associations of childhood adversities with adult mental disorders are widely documented, most studies focus on single childhood adversities predicting single disorders.

AIMS

To examine joint associations of 12 childhood adversities with first onset of 20 DSM-IV disorders in World Mental Health (WMH) Surveys in 21 countries.

METHOD

Nationally or regionally representative surveys of 51 945 adults assessed childhood adversities and lifetime DSM-IV disorders with the WHO Composite International Diagnostic Interview (CIDI).

RESULTS

Childhood adversities were highly prevalent and interrelated. Childhood adversities associated with maladaptive family functioning (e.g. parental mental illness, child abuse, neglect) were the strongest predictors of disorders. Co-occurring childhood adversities associated with maladaptive family functioning had significant subadditive predictive associations and little specificity across disorders. Childhood adversities account for 29.8% of all disorders across countries.

CONCLUSIONS

Childhood adversities have strong associations with all classes of disorders at all life-course stages in all groups of WMH countries. Long-term associations imply the existence of as-yet undetermined mediators.

Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: associations with first onset of DSM-IV disorders

CONTEXT

Although significant associations of childhood adversities (CAs) with adult mental disorders have been documented consistently in epidemiological surveys, these studies generally have examined only 1 CA per study. Because CAs are highly clustered, this approach results in overestimating the importance of individual CAs. Multivariate CA studies have been based on insufficiently complex models.

OBJECTIVE

To examine the joint associations of 12 retrospectively reported CAs with the first onset of DSM-IV disorders in the National Comorbidity Survey Replication using substantively complex multivariate models.

DESIGN

Cross-sectional community survey with retrospective reports of CAs and lifetime DSM-IV disorders.

SETTING

Household population in the United States.

PARTICIPANTS

Nationally representative sample of 9282 adults.

MAIN OUTCOME MEASURES

Lifetime prevalences of 20 DSM-IV anxiety, mood, disruptive behavior, and substance use disorders assessed using the Composite International Diagnostic Interview.

RESULTS

The CAs studied were highly prevalent and intercorrelated. The CAs in a maladaptive family functioning (MFF) cluster (parental mental illness, substance abuse disorder, and criminality; family violence; physical abuse; sexual abuse; and neglect) were the strongest correlates of disorder onset. The best-fitting model included terms for each type of CA, number of MFF CAs, and number of other CAs. Multiple MFF CAs had significant subadditive associations with disorder onset. Little specificity was found for particular CAs with particular disorders. Associations declined in magnitude with life course stage and number of previous lifetime disorders but increased with length of recall. Simulations suggest that CAs are associated with 44.6% of all childhood-onset disorders and with 25.9% to 32.0% of later-onset disorders.

CONCLUSIONS

The fact that associations increased with length of recall raises the possibility of recall bias inflating estimates. Even considering this, the results suggest that CAs have powerful and often subadditive associations with the onset of many types of largely primary mental disorders throughout the life course.

The role of childhood parent figure loss in the etiology of adult depression: findings from a prospective longitudinal study

The underlying question of this study is whether childhood parental loss between infancy and sixth grade is a predictor of adult depression at age 26 years when a rating of loss severity is used. The loss rating considered the length of the separation/loss, the familiarity of substitute caregivers, the primary or supporting role of the lost parent figure, and traumatic features of the loss. The study also investigated the role of gender, developmental timing of the loss, life stress, SES, prior parental care and attachment history, and follow-up family relationships in the pathways between loss and depression. Results are reported from a prospective longitudinal study of children (N = 164) born into poverty. Measures were collected prenatally through age 26 years and included multiple methods and multiple reporters. Results indicated that the most robust predictor of adult depression was loss history between 5 years old and grade 2. Earlier and later measures of loss were not related to adult depression. However, intervening loss experiences predicted change in depression scores from childhood to adulthood. Loss continued to predict adult depression after controlling for SES, maternal life stress, participant life stress, gender, early caregiving, and follow up family functioning. This study found no significant gender differences. These results suggest that loss is a risk factor for adult depression for both boys and girls and that the quality of early and later caregiving do not entirely buffer children from the effects of parental loss.

Re-examining the long-term effects of experiencing parental death in childhood on adult psychopathology

This study examined whether the experience of the death of a parent in childhood increases risk for adult psychopathology. Participants consisted of 3481 men and women gathered through the Baltimore Epidemiologic Catchment Area study in 1981 and followed through 1994-1995. The Diagnostic Interview Survey was administered by trained interviewers and was used to assess DSM-III disorders including major depression, panic, and anxiety disorders. Maternal death was not a predictor of adult psychopathology. The death of the father during childhood more than doubled the risk for major depressive disorder in adulthood. This study did not find any significant interactions between gender of the deceased parent and gender of the participant nor did the current age of the participant or their age at the time of the death of a parent affect risk for adult psychopathology. The long-term effect on adult depression of the experience of the death of the father in childhood is attributed to likely financial stresses, which may have continued for years and possibly into early adulthood, complicating the family's adaptation to the initial loss.

Mourning or early inadequate care? Reexamining the relationship of maternal loss in childhood with adult depression and anxiety

Two population enquiries in Walthamstow and Islington, London, have shown that loss of the mother before the age of 17 years, either by death or separation for a year or more, doubles the risk of depressive and anxiety disorders among adult women. Furthermore, there was a particularly high rate of adult depression among those whose mothers died before they were 6 years old, and this was associated with a measure of childhood helplessness. There was no such link of either adult disorder or childhood helplessness with age at loss under 6 years for those losing a mother by separation. Two possible explanations were explored for these contrasting results. That concerning the adequacy of mourning of the mother's death received no support. However, evidence indicated that experience with the mother before the loss (usually affected by ongoing illness) explained the link of adult depression or anxiety with her early death. The failure of age at loss to relate in the separation group was probably due to the fact that among them age of separation was not a good indication of the quality of maternal care before age 6. Indirect evidence emerged which suggested that quality of early attachment (before age 6) to the natural mother before any loss relates to childhood helplessness. This in turn relates to a higher risk of disorder in adult life.

The effect of social support on mental and behavioral outcomes among adolescents with parents with HIV/AIDS

OBJECTIVES

We examined the associations between social support and mental and behavioral outcomes among adolescents whose parents were infected with or died of HIV/AIDS.

METHODS

Families (parents who were HIV infected and their adolescent children) were randomly assigned to a coping skills intervention or a standard care group. After completing the intervention, the parents and adolescents were assessed for 2 years.

RESULTS

Adolescents who had more social support providers reported significantly lower levels of depression and fewer conduct problems; adolescents who had more negative influence from role models reported more behavior problems. Reductions in depression, multiple problem behaviors, and conduct problems were significantly associated with better social support.

CONCLUSIONS

Our findings underscore the complex relations between social support and mental and behavioral outcomes among adolescents affected by HIV/AIDS. Future prevention programs must focus on increasing social support to reduce negative outcomes among adolescents affected by HIV/AIDS as well as the need to reduce influence from negative role models.

The effectiveness of bereavement interventions with children: a meta-analytic review of controlled outcome research

Grief therapies with children are becoming increasingly popular in the mental health community. Nonetheless, questions persist about how well these treatments actually help with children's adjustment to the death of a loved one. This study used meta-analytic techniques to evaluate the general effectiveness of bereavement interventions with children. A thorough quantitative review of the existing controlled outcome literature (n = 13) yielded a conclusion akin to earlier reviews of grief therapy with adults, namely that the child grief interventions do not appear to generate the positive outcomes of other professional psychotherapeutic interventions. However, studies that intervened in a time-sensitive manner and those that implemented specific selection criteria produced better outcomes than investigations that did not attend to these factors.

Parental death and bipolar disorder: a robust association was found in early maternal suicide

BACKGROUND

Previous studies have suggested that early parental death may be associated with the emergence of bipolar disorder in later life. However, it remains unknown whether this association applies specifically to parental death due to suicide or only to early parental death. The present study aimed to explore whether suicide as well as the non-suicidal death of father, mother, or siblings are associated with an increased risk for bipolar disorder, and whether the possible association is modified by the age at which the subject experiences such a death in the family.

METHODS

The subjects were born in 1960 or later and were first admitted to or had first contact with Danish psychiatric facilities between 1981 and 1998 with a diagnosis of bipolar disorder, and fifty age-matched controls per case were extracted. The effects of the deaths of relatives were estimated by means of a conditional logistic regression analysis.

RESULTS

Among 947 subjects with bipolar disorder and 47,350 controls, those having experienced the parental suicide were significantly associated with an increased risk for BPD (incidence rate ratios: 1.83 [95% confidence interval: 1.07 to 3.12] for paternal suicide, 3.44 [1.97 to 6.00] for maternal suicide), whereas the non-suicidal death of parents showed no such association. Those having experienced maternal suicide at some point before reaching 10 years of age were seven times as likely to develop bipolar disorder.

LIMITATIONS

The cohort members were followed until, but not exceeding, the age of 38.

CONCLUSION

Early parental, particularly maternal, suicide increases the risk for bipolar disorder in the offspring. Possible explanations include a family history of mental disorders as well as psychosocial factors.

Childhood parental separation experiences and depressive symptomatology in acute major depression

The aim of this study was to examine the pathoplastic effects of childhood parental separation experiences on depressive symptoms. Patients with acute major depression were identified in a large 31-center study of affective disorders in Japan. Information regarding the patients' childhood losses was collected using a semistructured interview, and their depressive symptomatology was assessed by the Center for Epidemiologic Studies Depression Scale (CES-D). Patients reported significantly higher CES-D total scores when they had experienced early object loss of the same-sex parent. In terms of the CES-D subscores derived by factor analysis, early object loss significantly aggravated symptoms that people normally could cope with but could no longer cope with when depressed (e.g. 'poor appetite', 'cannot shake off the blues' and 'everything an effort.'). Once depression develops, early object loss may act as a pathoplastic factor by making it severer especially by rendering people less able to perform what they normally could do.

Recent developments in understanding the psychosocial aspects of depression

Recent advances in the psychosocial understanding of depression have elaborated an already complex aetiological model. Yet each new strand seems to echo, and forge links with, themes uncovered earlier, making it easier to see what is common about the 'final common pathway' to onset. For example, although recent stressors have for some time been recognised predictors of onset, new insights about the origins of these stressors have overlapped with other new work on depression and childhood adversity to identify a group who 'produce' their own severe life events in response to early negative experience. And recent studies have traced the well-known gender difference in depressive prevalence to differences both in gender role involvement with the provoking life events and in styles of support-seeking/ support-giving. What emerges is the powerlessness, loss and humiliation characterising the final pathway. Both naturalistic studies and controlled trials suggest that psychosocial situations reflecting the opposite emotional meaning, that is new hope, characterise a similar pathway to remission. Conclusions speculate whether awareness of this pathway might enhance purely pharmacological treatment.

Erinnerungen älterer Menschen an das Erziehungsverhalten ihrer Eltern und Indikatoren des aktuellen Wohlbefindens

Zusammenfassung: Im vorliegenden Beitrag werden Ergebnisse zum Zusammenhang zwischen dem erinnerten elterlichen Erziehungsverhalten einerseits und subjektiven Körperbeschwerden, interpersonalen Problemen sowie der Lebenszufriedenheit andererseits vorgestellt, die an einer repräsentativen Stichprobe von n = 766 über 60jährigen Personen gewonnen wurden. Mit dem Fragebogen zum erinnerten elterlichen Erziehungsverhalten (FEE) wurde dabei ein neu konstruiertes Selbstbeurteilungsverfahren eingesetzt, das es gestattet, Erinnerungen an das Erziehungsverhalten der Eltern (jeweils getrennt für Vater und Mutter) bezüglich der faktorenanalytisch ermittelten Dimensionen «Ablehnung und Strafe», «Emotionale Wärme» sowie «Kontrolle und Überbehütung» zu erfassen. In unserer Studie ließen sich zahlreiche signifikante Zusammenhänge zwischen dem erinnerten elterlichen Erziehungsverhalten und den anderen Untersuchungsvariablen aufzeigen: Ältere Personen, die das Erziehungsverhalten ihrer Eltern als weniger emotional warm, stärker ablehnend und strafend sowie als stärker kontrollierend und überbehütend erinnern, äußern von der Tendenz her mehr körperliche Beschwerden, geben mehr Probleme im Umgang mit anderen Menschen an und zeigen sich aktuell weniger zufrieden mit ihrem Leben. Die Befunde werden mit Bezug auf Ergebnisse der autobiographischen Gedächtnisforschung sowie der gerontopsychologischen Reminiszenzforschung diskutiert.

Early parental separation experiences among patients with bipolar disorder and major depression: a case-control study

BACKGROUND

Although the association between childhood parental loss and later development of mood disorder has received much research interest in the past, the results obtained and conclusions drawn have been various, and inconsistent with each other. The present study aims to examine this old, yet unresolved, question among the Japanese.

METHODS

Patients with bipolar disorder (n = 73) and unipolar depression (n = 570) and community healthy controls (n = 122) were examined as to their psychopathology and childhood parental loss experiences with semi-structured interviews.

RESULTS

Stratified for sex and age, no statistically significant difference was observed in the incidence of paternal or maternal death or separation before age 16 between bipolar patients and healthy controls. Female patients with unipolar depression under the age of 54 experienced significantly more maternal loss than the corresponding controls. This excess in loss appeared to be largely due to the patients experiencing separation from their mothers.

CONCLUSION

Our findings concerning bipolar disorder have replicated the previous two studies reported in the literature. Those concerning unipolar depression appear to be in line with several recent studies on the subject but, as stated, many discrepant findings can also be found in the literature.

Childhood abuse, postpartum depression and parenting difficulties: a literature review of associations

OBJECTIVE

The aim of this paper is to obtain an understanding of the links between maternal postpartum depression, poor parenting and childhood abuse, and the subsequent development of adult psychopathology in children from these families.

METHOD

A literature review was undertaken of studies on postpartum depression looking at parental childhood abuse, parenting and child outcomes, as well as childhood abuse and its association with adult depression and parenting difficulties.

RESULTS

Considerable overlap is noted in predisposing factors for major depression, postpartum depression, inadequate parenting and childhood abuse. Links appear to begin in early infancy, suggesting postpartum depression as a possible mechanism for intergenerational transmission of psychopathology.

CONCLUSIONS

Further research is required to look at the outcome of children of women who are at high risk of chronic or recurrent depression and of difficulties parenting; the postpartum period is the optimum time for identification and intervention.

Social support and pregnancy: II. Its relationship with depressive symptoms among Japanese women

In a questionnaire survey among 1329 first-trimester pregnant women, both the husband support measures and unwanted pregnancy ('stressor' agent in pregnancy) showed significant effects on an elevated score of the cognitive disturbance subscale of the Zung's self-rating depression scale (SDS), while only unwanted pregnancies showed an effect on an elevated score of the dysphoric mood subscale of the SDS. However, no interaction was observed between the husband support measures and unwanted pregnancy, therefore the effect of the husband's social support on the cognitive disturbance score was not that of a buffer, but rather a main effector. Finally, multiple regression analyses showed that the dysphoric mood score was preceded by unwanted pregnancy, premenstrual irritability, public self-consciousness, and maternal overprotection; while the cognitive disturbance score was preceded by unwanted pregnancy, husband reduced 'given' and 'giving' support, maternal reduced care and overprotection, paternal reduced care, low annual income, low private self-consciousness, and smoking. These findings suggest that the husband's support for a pregnant woman is effective only in reducing cognitive symptoms, and that different symptomatic constellations have different sets of psychosocial correlates.

Reported parental behaviour and adult affective symptoms. 1. Associations and moderating factors

Associations between retrospective ratings of parental behaviour and adult affective symptoms were investigated in a British national sample. Symptom scores at ages 36 and 43 years showed low but significant correlations with care (negative) and control (positive), as measured by the Parental Bonding Instrument. Prevalence of high symptom scores was much greater in respondents with low care-high control (affectionless control) parents than in those with high care-low control parents, but there was no synergistic effect of combined care and control. Degree of affectionless control was progressively related to risk of depression. No significant gender differences were found in these associations. Findings could not be explained as spurious relationships resulting from association with other features of childhood adversity, and there was evidence that distorted recall arising from contemporaneous depressed mood was not responsible. Work is needed to establish the causal mechanisms underlying observed associations, including inter-relationships between parental style and other early adversity, and factors mediating or moderating the long-term of parental behaviour.

Disruptions in childhood parental care as risk factors for major depression in adult women

OBJECTIVE

The aim of this study was to examine the influence of different types of disruptions in childhood parental care before the age of 15 years as risk factors for major depression in women aged 18 to 44 years. The types of disruptions studied were parental death, parental separation or divorce, other types of loss (i.e. adoption, foster-care, etc.), and prolonged separation from both parents. Potential confounding factors were also examined.

METHOD

The data were obtained from a community probability sample. Caseness was determined by the use of the Diagnostic Interview Schedule (DIS) and both the current (one month) and lifetime prevalence periods were considered. Logistic regression was used to model the influence of each factor, singly and adjusted for the influence of other factors, on the risk for major depression.

RESULTS

It was found that in this population 17% had experienced some type of parental loss (parental death 4%, separations/divorce 10% and other types of loss 3%) and 11% had experienced prolonged separation from both parents. Parental loss was significantly associated with lifetime depression, but this effect was no longer significant when adjusted for other factors. However, prolonged separation from both parents was associated with an increased risk of current and lifetime depressive episodes of approximately three to fourfold, even when the risk was adjusted for other factors.

CONCLUSIONS

The results of this study suggest that prolonged separation from both parents has a stronger association with current or lifetime depression in women than do parental death, separation/divorce and other types of loss. Prolonged separation may be a marker for other risk factors and may not be a risk factor on its own.

Research: Bereavement

Raphael's (1983) survey of bereavement research encompassed more than four hundred published works. The present review focuses upon empirical research, counselling, and treatment conducted over the past decade. Results suggest that we cannot over-simplify the problem of bereavement. Mobilization of mutual support resources in the neighborhood and community can provide effective help for some people who are attempting to cope with bereavement-associated problems. However, there is also a substantial number of people who require other types of interventions. More must be learned about the complex sequence of events that lead to adverse physical, mental, or social consequences in bereavement, and about the types of intervention that are most effective in each situation.

Cumulative Loss, Current Stress, and the Family: A Pilot Investigation of Individual and Systemic Effects

While many clinical approaches to family therapy emphasize the impact of past stressors and losses on family functioning, there has been little empirical support for this position. This pilot study of twenty-four families examined the relationship between stressors and all deaths over four generations in a family's history, and the current functioning of family members. Results were mixed, but provided some intriguing findings about the differential impact of loss histories on mothers and fathers, and some evidence for the multigenerational and systemic effects of the stress/loss history. Methodological problems are discussed, and suggestions for future research are made.

Early loss of parents and early rearing experience among women with antenatal depression

The relationship of depressive disorders with early parental losses and rearing experiences was studied among 120 pregnant women. They were diagnosed following the Research Diagnostic Criteria using the Schedule for Affective Disorders and Schizophrenia. Loss experience was defined either as loss of a parent before the age of 16 by death, or separation for 12 months or longer. The perceived rearing experience was examined by administering the Parental Bonding Instrument (PBI). An onset of depressive disorders, antenatal depression, was observed among 19 (16%) women. Those women with antenatal depression were significantly more likely to have experienced bereavement of either of the parents (21%) than those women without it (5%). Discriminant function analysis revealed that two PBI scores, lower paternal care and higher maternal protection, were significant in predicting antenatal depression. Parental bereavement and 'affectionless control' (low care and overprotection) seem to be additive in predisposing to antenatal depression, though the small number of the samples render statistical analysis impracticable.

Family factors in adolescent unipolar depression

This paper reviews the current literature on the contribution of family factors to unipolar depression among adolescents. Research which examined the following factors was reviewed and evaluated: genetic transmission, parental depression, parental death, quality of attachment and family interaction. Studies had to meet the following criteria to be included: publication must have been between the years 1985 and 1992; the evaluation had to be empirical with some form of control; a dependent measure of family characteristics or functioning; the adolescent had to be between the ages of 13 to 19; and the adolescent had to meet the recognizable criteria for unipolar depression. Recent literature suggests that adolescents suffering from depression share a number of risk factors: a family history of affective disorder, inept or inadequate parenting, abrasive interactions within the family and insecure attachments. At this time, there is no evidence that these aversive interactions predate the disorder. Weaknesses in the current literature are identified and strategies for improving future research are proposed.

Early life experiences and residential stability: a ten-year perspective on sheltered care

The effects of early family losses and disruptions on the ability of seriously mentally disabled individuals to achieve stable living arrangements were investigated. Factors found to predict instability were early losses, early disruptions, psychological symptoms, and youth. Among factors found to predict stability were increased age and a diagnosis of schizophrenia.

Psychosocial adjustment of children with a terminally ill parent

Although a substantial number of children experience serious parental illness and death, the adjustment problems attendant to the stress of having a fatally ill parent have not been examined systematically. This paper compares the psychosocial adjustment of 62 school-aged children with a terminally ill parent (study sample) with that of children in a community sample, using several standard rating scales. Study children had significantly higher levels of self-reported depression (Children's Depression Inventory) and anxiety (State-Trait Anxiety Inventory) and lower self-esteem (Self-Esteem Inventory). Parents also reported study children's significantly higher behavior problems and lower social competence (Child Behavior Checklist). Increased professional attention to this vulnerable population is encouraged.

Childhood experiences of loss and suicide attempts: significance in depressive states of major depressed and dysthymic or adjustment disordered patients

Three hundred and twenty-eight patients aged 45 years and over with major depression, dysthymic disorder or adjustment disorder with depressed mood (according to DSM-III) were asked about childhood loss experiences (death of one or both parents or at least 1 year's separation) and their current state of health. No statistically significant relationships were found between experiences of loss in childhood and type of depression, sex and age at first episode. However, there was an increased incidence of suicide attempts in patients with experiences of loss in childhood, both by separation and by death of parents. The increased suicidal tendency could mainly be attributed to loss of the father.

The loss of a parent during childhood as a risk factor for depression

While the loss of a parent during childhood may put a person at risk for depression, many studies have failed to confirm the importance of this risk factor. Nevertheless, the relationship between the loss of a parent and depression is of clinical importance. This paper reviews studies of the loss of a parent as a risk factor for depression. In addition, relevant data from these studies were pooled using meta-analytic techniques. It was found that for females there was a significant association between the loss of one's mother before age 11 and depression, and that losing one's mother during early childhood may double their risk of depression.

The Camberwell Community Survey: a summary of results

The Camberwell Community Survey was carried out during 1978 and 1979 on a random sample of the population of Camberwell in south London. This is an inner city area with high deprivation indices. 800 members of the community and a random sample of 74 out-patients with affective symptoms were interviewed using the Present State Examination (PSE) and Life Events and Difficulties Schedule (LEDS) of Brown and Harris. The survey has resulted in many publications. The present paper summarises its aims, methods and results.

Adolescent bereavement following the death of a parent: an exploratory study

Eleven healthy adolescents, ages 13-18, were followed through the year following parental death. Semi-structured interviews were used in combination with standardized measures to complete in-depth evaluations at 6 weeks, 7 months and 13 months following parental death. Teacher reports and parent interviews and reports provided additional information. Initial responses were characterized by intense emotional, cognitive, physical and behavioral reactions associated with impaired school performance, strained peer relations, and sleep disturbances. Stress related symptoms were prominent and sustained. Overall, subjects reported a higher sustained degree of distress than adult children following the loss of a parent. Prominent themes are reviewed. Implications and directions for future research are discussed.

Adult affective disorder and early environment

Childhood precursors of symptoms of depression and anxiety were investigated in a national population sample of over 3000 men and women, aged 36 years. Early-life data had been collected prospectively for all subjects. A number of factors, differing for men and women, were found to be significant predictors of adult disorder. Some factors showed strong effects but tended to apply to relatively few individuals, while other more common circumstances had modest influences. Overall, early environment did not seem to hold great significance for adult affective disorder, although multiple disadvantages had a cumulative deleterious effect. There was little evidence of early benefits being protective.

Early childhood bereavement

Acute bereavement responses in preschool children were prospectively assessed. Parentally bereaved subjects (26, 3- to 6-year-olds) were compared with matched, nonbereaved controls (N = 40). Bereaved subjects, particularly boys, were significantly more symptomatic (Child Behavior Checklist--Parent). On a newly standardized affect interview for preschoolers, bereaved children reported feeling more scared and less happy than controls. Bereaved children, especially girls, reported significantly more sadness when thinking about their parents. The ability to report these grieving emotions correlated significantly with improved functioning. Children from families experiencing a drop in income after the death were more symptomatic. Disturbance among subject parents and children was highly correlated. Issues of developmental capacity to grieve and the impact of environmental mediators are discussed.

Early family experiences of women with bulimia and depression

This study characterizes the early family experiences of 30 women with bulimia nervosa and 15 women with major depression, and compares them with 100 women controls, with particular emphasis placed on parental rearing practices, family conflict resolution, sexual mistreatment, problematic childhood indicators, and childhood separation experiences. There is little research on these patient populations in relation to their childhood experiences, and thus, it is difficult to identify markers for women at risk for these disorders. The findings show that there are significant differences between the experiences these women had growing up and those of the control group, and a profile of children at risk based upon the study indicators is presented.

Loss in childhood: anxiety in adulthood

Recent research, especially in Great Britain, has attracted interest by reporting on the relationship between maternal loss and vulnerability to depression among women. Several studies in the United States that included men have not received equal attention. The present study expands on the US work by reporting findings from the Queensbrook Study in New York City, a cross-sectional survey that provides information about the relationships between the family environment of childhood and the prevalence of psychiatric illness in adulthood. The Queensbrook survey was conducted in the mid 1960 as an urban counterpart to the Stirling County Study in rural Atlantic Canada. The data from the urban sample described here were not published earlier, and for this report we used DSM-111 criteria to develop scoring algorithme to identify depression and anxiety. We investigated several types of adverse childhood losses, not solely the death of a mother, and related them to depression and anxiety in both men and women. None of the childhood experience was significant associated with these disorders among women, nor was the death of a parent related to either type of disorder among men. However, boys who left home before 16 years of age, whose parents were divorced or separated, or who were placed in an adopted family had a threefold increase in rates of anxiety as adults. This finding of a positive association between the divorce of parents and later anxiety in men is supported by several of the other population surveys carried out in the United States.

Studies of the affective state in bereaved children

The process of bereavement in children ranges from the absence of grief to symptoms of anxiety and conduct disturbances. Some psychoanalytic opinion holds that the absence of grief, associated with lack of cognitive maturity, leads to the development of psychopathology later in life. Other writers describe a mourning response, taking the form of ambivalence, anxiety, and care giving, which may protect against subsequent depression. This paper describes the affective response in 16 children ages four to 17 years, two to three years following the death of a parent, in order to further characterize developmental aspects of the emotional repertoire of bereavement. Only children aged 12 and over were depressed according to the Poznansky Children's Depression Rating Scale and criteria in the DSM-III. Conduct disturbances were observed in the younger children and some of the older children and were correlated with depression in the group as a whole. This suggests that the expression of depressive affect depends on maturation and that the young child may register grief only through anxiety and negativism. Examples of this spectrum of responses are offered in two case vignettes.

Developmental psychiatry: a perspective

A brief historical introduction to developmental psychology puts twentieth century views into perspective. The ideas of continuity, critical periods and predictability are examined. The case for a developmental perspective of human development is argued, and the tenets underlying such a model are suggested. The utility of the study of human development is discussed.

DSM-III-R and the phenomenology of childhood bereavement: a review

The literature on the phenomenology of childhood bereavement is reviewed. Several authors, particularly in the psychoanalytic literature, have suggested or supported the concept of "absence of grief" in children, based on the postulate that children are unable to tolerate the intense affects of mourning. More recently, systematic studies of nonclinical samples of bereaved children have found "absence of grief" to be uncommon, with most children in fact showing features such as sadness, crying, irritability, and a wide variety of other affective and behavioural symptoms. There does not appear to be a coherent syndrome of childhood bereavement, although tentative associations have been found between some phenomenological features and various child-related, family-related, societal, and circumstantial factors. The level of overall psychological adjustment after parental loss is both variable and controversial. Several tentative predictors of adverse reactions have been described. The possible place of childhood bereavement in current nosology is discussed. Preliminary evidence suggests that the phenomenology of childhood bereavement differs considerably from the DSM-III-R description of "uncomplicated bereavement." Recent evidence suggests that the DSM-III-R concept of uncomplicated bereavement needs to be expanded to include many of the affective and behavioural features of childhood bereavement, although confirmatory controlled research is required. Suggestions for improvement of research designs are made.

Pitfalls of a one-sided image of science: Adolf Grünbaum's Foundations of Psychoanalysis

Adolf Grünbaum's (1984) The Foundations of Psychoanalysis has received extensive attention in psychoanalytic and philosophical circles. Aspects of Grünbaum's argument are reviewed and criticized. While his volume is an important contribution to the epistemological assessment of psychoanalysis, it reflects serious shortcomings in at least four areas: its treatment of the role of suggestion in the analytic enterprise, its scrutiny of the psychoanalytic genetic method, its appreciation of analytic methodology as actually practiced, and, above all, its predication on a unidimensional, positivistic vision of science. Alternative approaches to the philosophy of psychoanalysis are suggested.

Life history factors associated with neurotic symptomatology in a rural community sample of 40-49-year-old women

Associations between a range of life history variables and neurotic pathology (measured by the Crown-Crisp Experiential Index) were examined in a rural community sample of 208 women aged 40-49. Significant childhood associations were a poor maternal relationship, parental discord, nervousness and not liking school. Significant later associations were a poor marital relationship and emotional and behavioural problems in children. There were significant intercorrelations between the significant childhood variables and between the later significant variables but not between the early and later variables. The predictor equations derived from multiple regression analysis fitted significantly a small replication patient sample.

The long-term effects of early parent death: a review

A review of the literature indicates some evidence for an association between early death of the mother and severe forms of depression in adulthood. The relationship of early parent death with later alcoholism, other forms of depression, and milder effects within the general population also is suggested. A number of factors that may mitigate the long-term effects of the loss are discussed. The experience of early parent death is conceptualized as an exceptionally visible representation of the capacity of the child to cope adaptively with developmental crisis.