Research paperThe adolescent grief inventory: Development of a novel grief measurement
Introduction
About half of adolescents experience the death of a significant other such as a family member or a friend over a year (Rheingold et al., 2004), and most adolescents lose a relative or friend before adulthood (Harrison and Harrington, 2001). Experiencing a death potentially affects the bereaved adolescent's short- and long-term quality of life (Balk, 2014, Stroebe et al., 2008). Due to biopsychosocial changes in the transition from childhood to adulthood, bereaved adolescents in particular have increased risks of problems related to physical, and mental health and social functioning (Feigelman et al., 2017). Typical adolescent acute grief reactions include shock, sadness, numbness, yearning, guilt, anger, and distress. They frequently report feeling ill, physical pain, and sleeping problems (Luecken, 2008). Bereaved adolescents often struggle with ‘meaning-making’, forgo the sense of personal invulnerability, and have increased risks of depression, anxiety, post-traumatic stress disorder, and suicidal ideation in the first months after the bereavement (Brent et al., 2009, Stikkelbroek et al., 2016). Bereaved adolescents may commence risky behaviors such as smoking, drinking or fighting, particularly during the first years after the loss (Feigelman et al., 2017, Hamdan et al., 2012). Adolescents losing a parent have higher long-term risks of psychiatric problems, attempted suicide, and violent behaviour (Berg et al., 2016, Jakobsen and Christiansen, 2011, Wilcox et al., 2010).
Conversely, bereaved adolescents may experience long-term positive reactions: increased appreciation of life, maturity, empathy and compassion for others (Andriessen et al., 2017, Andriessen et al., 2018a, Balk, 2014). Whereas a variety of grief reactions are possible, including positive reactions, the pathways of personal growth of bereaved adolescents are yet to be studied (Meyerson et al., 2011). Research with young adults indicates that a minimum level of distress is necessary for personal growth, but there is no linear relationship between the levels of distress and personal growth (Taku et al., 2015). Attachment styles (including the continuing bond with the deceased), coping styles (e.g., self-disclosure), relationships (e.g., social support), and psychological factors (e.g., resilience and meaning making) affect the pathways of personal growth after suicide (Genest et al., 2017). According to a contemporary grief model, the Dual-Process Model of coping with bereavement (Stroebe and Schut, 2010), grieving individuals oscillate between loss-oriented and restoration-oriented stressors, though research with bereaved adolescents is needed.
Several factors may affect the intensity or duration of the grief. However, specifically among adolescents the effect of these factors is inconclusive. The sex and age of the bereaved adolescent, the kinship and psychological closeness of the relationship, the number of deaths experienced, the expectedness of the death, and time since the loss, are inconclusive mainly because of a shortage of research (Balk, 2014). Social support facilitates grief outcomes; however, finding appropriate and sufficient social support is a challenge for bereaved adolescents (Andriessen et al., 2016). Family may be preoccupied with their own grief, friends may lack the necessary skills, and in general, adolescent grief may go unnoticed for others. High self-reliance is common among bereaved adolescents and they may not feel a need to share their grief even if social support (family or friends) is available (Andriessen et al., 2018a).
Bereavement research, including adolescent research, has been criticised for relying on psychiatric rather than grief scales (Neimeyer and Hogan, 2001). Though psychiatric scales may capture common grief feelings, such as depressed mood, they often overlook grief-specific characteristics such as yearning. Also, pathology-focused measurements dismiss grief as a natural reaction to major loss, and overlook positive grief feelings like relief, or outcomes like personal growth. Lastly, research into complicated or prolonged grief, distinct from other disorders, has stimulated development of designated measures such as the Inventory of Prolonged Grief (IPG) for Children and Adolescents (Spuij et al., 2012), derived from the adult version of the IPG. Though such diagnostic instruments provide insight into maladaptive or pathological reactions, arguably no claims regarding complicated grief are valid in the absence of reliable measurements of the variety of “normal” grief reactions (Neimeyer and Hogan, 2001). While the criticism was formulated over 15 years ago, it still holds true for adolescent bereavement research (Stroebe et al., 2013). Over the decades, most progress has been made in adult bereavement studies. Adolescent research is lagging behind, mainly due to a lack of validated measures, a focus on selected relationships (e.g., death of a parent), and reliance on clinical samples (Kaplow et al., 2012). The developmental context of bereaved children and adolescents would be more important than for adults. Hence, empirically derived adolescent grief instruments which have stronger internal validity than expert-based instruments, and mixed-methods approaches combining insights from qualitative research and quantitative data, have been recommended to further adolescent bereavement research (Kaplow et al., 2012, Neimeyer and Harris, 2011).
A review (Neimeyer et al., 2008) of grief instruments identified only one adolescent scale, the Hogan Sibling Inventory of Bereavement (HSIB) (Hogan, 1987, Hogan and DeSantis, 1996, Hogan and Greenfield, 1991), and we could not find any other measure of normal or uncomplicated grief in adolescents. The 46-item Hogan Inventory of Bereavement - Children and Adolescents (HIB) was derived partly empirical, partly expert-based from the 109-item HSIB to apply it to all adolescents, aged 12–18 years. However, apart from Blankemeyer (1993) we could not find a study that used the HIB. Also, though the two HIB factors appear to be valid for bereaved adolescents (Blankemeyer, 1993), it is conceivable that adolescent grief entails more characteristics than the two Grief, and Personal Growth factors. For example, an empirically developed grief instrument for adults consists of six factors (Hogan and Schmidt, 2002). Clearly, adolescent grief requires an empirically developed, contemporary, reliable and comprehensive instrument.
Our aim was to develop empirically a valid grief measurement for adolescents, aged 12–18 years; hereafter “Adolescent Grief Inventory (AGI)”. We hypothesised: i) that the development of the AGI would identify novel items and important characteristics of adolescent grief not captured by the HIB; ii) the AGI scores would correlate strongly with the HIB Grief, a convergent measure; iii) the AGI would not correlate with HIB Personal Growth, a divergent measure; iv) the AGI would correlate positively with distress as measured by the Depression, Anxiety, and Stress Scales (DASS-21) (Lovibond and Lovibond, 1995), and with self-rated severity of impact of the other person's death; v) and no correlation with a divergent measure of social support, the Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet et al., 1988), nor with age and sex of bereaved adolescents, number of deaths experienced, time since death of the significant other, self-rated closeness or expectedness of the other's death. Further, we wanted to investigate if the AGI discriminates between groups based on cause of death of the significant other, kinship with the deceased, and mental health status of participants.
Section snippets
Study design and sampling
First, we undertook a qualitative study to investigate the grief, mental health and help-seeking experiences of adolescents. Participants were eligible i) if a family member or friend died through any cause when participants were 12–18 years old, and ii) participants experienced the death between 6 months and ten years before participation. We conducted semi-structured telephone interviews with 39 participants who were 13–27 years old at the time of the interview. The methodology and results of
Sample
In total, 165 individuals completed all components of the questionnaire. It was predetermined that completing the grief (AGI, HIB), mental health (DASS-21), and social support (MSPSS) measures was essential for study inclusion. Hence, a further 11 individuals who had missed the final questions on mental health diagnosis and suicidal behaviour were also included, resulting in a total sample N = 176. Table 1 summarizes the sociodemographic characteristics. Approximately half of the participants
Discussion
Redressing a gap in the grief research literature, we developed a novel measure of grief in adolescents, the Adolescent Grief Inventory (AGI). Empirical development, using both qualitative and quantitative components, underpinned the internal validity of the AGI. Several items (e.g., related to anger, self-harm, and helplessness) are unique to this grief measure, as shown through comparison with the HIB (Hogan and DeSantis, 1996). Further, the six AGI factors comprehensively cover the variety
Declaration of interest
None.
Contributors
All authors contributed to the design of the study. KA conducted the analyses and drafted the manuscript. All authors contributed to the revision of the manuscript, and agreed with the final version.
Role of the funding source
The study was supported by the Anika Foundation for Adolescent Depression and Suicide. The funding body had no role in the design of the study, the collection, analysis and interpretation of data, the writing of the report, and the decision to submit it for publication.
Acknowledgment
We are grateful to all participants.
Karl Andriessen is a PhD Candidate and a Senior Lecturer (Conjoint) in the School of Psychiatry, UNSW, Sydney, Australia.
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Karl Andriessen is a PhD Candidate and a Senior Lecturer (Conjoint) in the School of Psychiatry, UNSW, Sydney, Australia.
Dusan Hadzi-Pavlovic is a Senior Research Fellow in the School of Psychiatry, UNSW, Sydney, Australia.
Brian Draper is a clinical academic psychiatrist based at Prince of Wales Hospital, Randwick, and a Professor (Conjoint), School of Psychiatry, UNSW, Sydney, Australia.
Michael Dudley is Senior Staff Specialist in Psychiatry at Prince of Wales and Sydney Children’s Hospitals, and a Senior Lecturer (Conjoint) in Psychiatry, UNSW, Sydney, Australia.
Philip Mitchell is a Scientia Professor, School of Psychiatry, UNSW, Sydney, Australia. He is an internationally recognised clinical researcher in depression and bipolar disorder, with a major focus on young people at high genetic risk of bipolar disorder.