Maladaptive coping in adults who have experienced early parental loss and grief counseling

Abstract

This study compares maladaptive coping, measured as substance use, behavioral disengagement, self-blame, and emotional eating, among adults (>18 years) who have experienced early parental loss (N = 1465 women, N = 331 men) with non-bereaved controls (N = 515 women, N = 115 men). We also compared bereaved adults who received grief counseling (N = 822 women, N = 190 men) with bereaved controls who had not (N = 233 women, N = 66 men). Bereaved adults reported significantly more substance use, behavioral disengagement, and emotional eating than non-bereaved adults. Counseling participants reported significantly more substance use and self-blame than non-participants. Our results suggest that early loss may negatively impact the development of adulthood coping.

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Journal of Health Psychology
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DOI: 10.1177/1359105316638550
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The death of a parent in childhood is a painful
experience, with potentially long-term conse-
quences that may impact adult psychological
health (Bowlby, 1980; Haine et al., 2008). Early
parental loss has been linked to increased risks
of depression, anxiety, and substance use in
adulthood (e.g. Appel et al., 2013; Hamdan
et al., 2013), indicating a lowered ability to
cope with the stresses of life (Auerbach et al.,
2010). However, to our knowledge, no study
has investigated the long-term coping behavior
of people who have lost a parent or who have
received grief counseling.
“Coping” refers to the cognitive and behav-
ioral strategies that individuals use to manage
stress (Folkman and Moskowitz, 2004). It is
mobilized by appraisal, a process whereby an
external and/or internal demand is evaluated
against a person’s resources (Lazarus and
Maladaptive coping in adults
who have experienced early
parental loss and grief counseling
Beverley Lim Høeg
1
, Charlotte W Appel
1
,
Annika B von Heymann-Horan
1
,
Kirsten Frederiksen
1
, Christoffer Johansen
1,2
,
Per Bøge
3
, Annemarie Dencker
3
, Atle Dyregrov
4
,
Birgit B Mathiesen
5
and Pernille E Bidstrup
1
Abstract
This study compares maladaptive coping, measured as substance use, behavioral disengagement, self-blame,
and emotional eating, among adults (>18 years) who have experienced early parental loss (N = 1465 women,
N = 331 men) with non-bereaved controls (N = 515 women, N = 115 men). We also compared bereaved
adults who received grief counseling (N = 822 women, N = 190 men) with bereaved controls who had
not (N = 233 women, N = 66 men). Bereaved adults reported significantly more substance use, behavioral
disengagement, and emotional eating than non-bereaved adults. Counseling participants reported significantly
more substance use and self-blame than non-participants. Our results suggest that early loss may negatively
impact the development of adulthood coping.
Keywords
children, coping, counseling, grief, parental loss
1
Danish Cancer Society Research Center, Denmark
2
Copenhagen University Hospital, Rigshospitalet,
Denmark
3
Danish Cancer Society, Denmark
4
Center for Crisis Psychology, Norway
5
University of Copenhagen, Denmark
Corresponding author:
Beverley Lim Høeg, Survivorship Unit, Danish Cancer
Society Research Center, Strandboulevarden 49, 2100
Copenhagen, Denmark.
Email: bevlim@cancer.dk
638550
HPQ0010.1177/1359105316638550Journal of Health PsychologyHøeg et al.
research-article2016
Article
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2 Journal of Health Psychology
Folkman, 1984). Appraisal is influenced by
multiple factors, including experiences across
time (Lazarus, 1999). Within a life-course per-
spective, coping behaviors are seen as driven
by developing systems, such as language and
cognition, and shaped by person–environment
interactions (Zimmer-Gembeck and Skinner,
2011).
Parents play an essential role for adaptive cop-
ing with stress (Gunnar and Cheatham, 2003). A
secure parent–child attachment aids the develop-
ment of emotional regulation (Waters et al.,
2010), while consistent parental support increases
the likelihood of successful coping experiences,
fostering more flexible coping capabilities as the
child matures (Zimmer-Gembeck and Skinner,
2011). The impact of losing a parent may depend
upon the child’s age, which determines the cogni-
tive capability to understand and cope with the
death (Webb, 2010).
Grief counseling aims to facilitate the
bereavement process, that is, to help the
bereaved person adapt to the loss and resolve
grief (Worden, 2009). While most children
adapt without professional help (Akerman and
Statham, 2011), some experience high levels of
impairment warranting professional support
(Worden, 2009). Two meta-analyses have sum-
marized the limited studies on effects of grief
counseling in bereaved children (age range,
5–18 years) (Currier et al., 2007; Rosner et al.,
2010). The first meta-analysis, of 13 controlled
studies, showed an overall average weighted
effect size of Cohen’s d = 0.14 (p = 0.08), indi-
cating no significant treatment effect. The sec-
ond meta-analysis, of 13 controlled and 12
uncontrolled studies, showed overall effect
sizes of Hedges’ g = 0.35 (p < 0.01) and 0.49
(p < 0.001), respectively, indicating small to
moderate treatment effects. None of the studies
considered adult outcomes. A single study, of
the Family Bereavement Program (Sandler
et al., 2003), included positive coping as an out-
come and found effects for girls at the 11-month
follow-up.
In this study, we compared maladaptive coping
strategies (substance use, behavioral disengage-
ment, self-blame, and emotional eating) in
adulthood in relation to early parental loss and
participation in grief counseling. First, we hypoth-
esized that parental loss is associated with disrup-
tion of healthy coping development and that
bereaved adults would report greater use of mala-
daptive coping strategies than non-bereaved
adults. Second, we hypothesized that, by facilitat-
ing the bereavement process, receiving counseling
would be associated with the development of
adaptive coping, and that counseling participants
would thus report less use of maladaptive strate-
gies than non-participants. Additionally, we inves-
tigated whether child gender, which parent was
lost, child’s age at the time of loss, and the per-
ceived presence of family support played moder-
ating roles in this association.
Method
Procedure
Data were drawn from a larger cross-sectional
study of early parental loss and grief counseling,
which combined register-based information with
self-reported questionnaire responses (Appel
et al., submitted). In Denmark, all residents have
been recorded in the Central Population Register
(CPR) since 1 April 1968 (Pedersen et al., 2006)
with unique personal identification numbers,
containing information on sex, date of birth,
family linkage, migration, and death.
Three main nationwide organizations have
offered free telephonic, group, and/or individ-
ual grief counseling to children and young
adults. We identified participants who had
received grief counseling at these centers
between 1999 and 2009 and established a sam-
ple of 1811 participants who met the criteria of
being over 18 years of age at 31 December 2010
and having lost one or both parents before the
age of 30. We identified a second sample of
1803 bereaved participants from the CPR, who
met the same conditions but were not on center
files, and frequency matched them to the first
group on gender, age, and time since parental
death. A third sample of 1853 CPR-based non-
bereaved controls were frequency matched on
gender and age.
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Høeg et al. 3
In all, 5467 participants (4045 females, 1422
males) were identified and invited to complete
the questionnaire by mail. Informed consent is
not required for questionnaire studies in
Denmark; however, information on the project
and the contact details of the primary researcher
were provided. Non-responders were reminded
after 3 weeks and again, by telephone, after a fur-
ther 3 weeks. The study protocol was approved
by the Danish Data Protection Agency (Record
no. 2009-41-3506).
Study sample
A total of 2574 people completed the question-
naire (response rate, 47%). We excluded 12
bereaved respondents who had lost a parent
after the age of 29 years, 67 whose self-
reported parental loss was missing or incon-
gruent with register information, and 36
participants from center files who self-reported
no counseling, obtaining a group of confirmed
recipients of grief counseling (Conf-GC). We
found that 449 (60%) of bereaved participants
in the CPR sample self-reported having
received some kind of counseling (Self-GC),
while 299 (40%) confirmed no counseling
(No-GC). Finally, we excluded 69 respondents
who did not complete the questionnaire and
obtained a final study sample of 2390 partici-
pants, as shown in Figure 1.
Measures
Early parental loss (loss). Loss was defined as
losing one or both parents before the age of 30.
We included individuals up to this age because
previous studies suggest that loss during young
adulthood continues to influence later psycho-
logical functioning (Appel et al., in press; Nick-
erson et al., 2013). Loss was confirmed through
the CPR and cross-checked with the question-
naire items, “Did your father/mother die before
you were 30 years of age?”
Grief counseling (counseling). Participation in
counseling was determined from center files and
checked from replies to the questionnaire item,
“We would like to know if you participated in
professional support at the time your parent died
and if so, how many times did you participate?”
Each support option (“psychologist,” “bereave-
ment group,” “internet-based support,” “support
by phone,” “general practitioner,” “priest,”
“nurse,” or “other”) could have answers ranging
from “Never” to “>40 sessions.” A response of
“Never” for all the categories was considered
self-reported No-GC, while all other responses
were considered Self-GC.
Maladaptive coping. Coping was measured
using the Brief COPE inventory (Carver, 1997),
which was translated into Danish by two
research psychologists and, subsequently, back-
translated into English by a third bilingual psy-
chologist. The back-translation corresponded
semantically to the original version. It consists
of 14 subscales of two items each that are
answered on a 4-point Likert scale, ranging
from 1 (“I haven’t been doing this at all”) to 4
(“I’ve been doing this a lot”). We focused on the
subscales of substance use, behavioral disen-
gagement, and self-blame. The range of scores
for these subscales was 2–8. One additional
item (“I have eaten for comfort”) was added in
the questionnaire, giving a one-item emotional-
eating subscale, with a score range of 1–4. The
Brief COPE scales have good internal consist-
ency, construct validity, and adequate test–
retest reliability (Cooper et al., 2008), although
the Danish version has yet to be validated.
Covariates. Participant’s gender, age at time of
loss (0–5, 6–12, 13–18, ⩾19 years), education
(basic school, high school or vocational, higher
education, unknown), parent lost (father,
mother, both), and perceived family support
(yes, no) were identified as covariates. Gender
and educational level have been related to cop-
ing styles (Christensen et al., 2006; Matud,
2004), and child’s educational level has been
linked to parental educational level (Dubow
et al., 2009), which is in turn associated with
mortality rates (Montez et al., 2012). The parent
lost, participant age at time of loss, and family
support have been shown to affect bereavement
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4 Journal of Health Psychology
outcomes (Raveis et al., 1999; Stroebe et al.,
2006).
Participant gender, birth date, parent lost,
and date of death were obtained by linkage
with the CPR, while participants self-reported
level of education and family support at the
time of the death. Perceived family support
was measured from answers to the item, “What
level of support did you experience from the
persons around you when your parent died?”
Each person option (“parent,” “siblings,”
“grandparents,” and “other family members”)
could be answered with “high,” “moderate,”
“low,” “none,” “don’t know,” or “have none.”
Responses were dichotomized into a Yes/No
perceived family support variable, where high
and moderate reported levels of support were
coded as “Yes” and the remaining responses as
“No.”
Statistical analyses
Descriptive statistics. Descriptive comparisons
of bereaved and non-bereaved participants were
Figure 1. Flowchart of study participants.
Final sample, n = 2426.
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Høeg et al. 5
made according to gender, age, and educational
level. Bereaved participants were further com-
pared by the gender of the deceased parent, age
at time of loss, and perceived family support
according to counseling group (Conf-GC, Self-
GC, and No-GC). Chi-squared tests were used
for categorical variables and t tests for continu-
ous variables.
Parental loss and coping. Multivariable linear
regression models were used to examine the
mean differences in substance use, behavioral
disengagement, self-blame, and emotional eat-
ing according to bereavement status. As histo-
grams indicated that scores on the maladaptive
subscales peaked for the response that the
behavior was not used, we also used logistic
regression to estimate differences in behavior
use (substance use, behavioral disengagement,
self-blame >2; emotional eating >1) according
to bereavement status and expressed as odds
ratios. As log and linear models gave the same
conclusions, linear regression was used for the
remaining analyses to allow possible compari-
sons with the other scales that were more nor-
mally distributed. Analyses were carried out
unadjusted as well as adjusted for age and edu-
cational level.
To investigate whether the differences
between bereaved and non-bereaved partici-
pants were moderated by gender, parent lost,
age at time of loss, and perceived family sup-
port, we added an interaction term between
bereavement status and each of the four modi-
fiers in separate models. The mean changes in
coping scores were estimated, and effect modi-
fication was tested in F tests.
Grief counseling and coping. Multivariable linear
regression models were used to compare differ-
ences in mean coping scores between grief
counseling participants (Conf-GC and Self-
GC) and No-GC. Analyses were unadjusted or
adjusted for participant’s gender, parent lost,
age at time of loss, educational level, and per-
ceived family support, which may be associated
with both receiving counseling and coping
(Holahan and Moos, 1987; Vessey and Howard,
1993). All analyses were carried out using SAS
Enterprise Guide 5.1.
Results
Study sample
Table 1 shows the characteristics of the full
study sample. There were no significant differ-
ences by bereavement status, but there were
significant differences by counseling status.
Those in the Self-GC group tended to be
younger, with correspondingly lower levels of
attained education, and had experienced loss at
a younger age than the Conf-GC and No-GC
groups.
Parental loss and coping
Bereaved participants scored significantly
higher for substance use (adjusted mean dif-
ference (MD) = 0.21, 95% confidence interval
(CI) [0.11, 0.30]), behavioral disengagement
(MD = 0.13, 95% CI [0.02, 0.25]), and emo-
tional eating (MD = 0.15, 95% CI [0.08,
0.23]) but not for self-blame (MD = 0.00,
95% CI [−0.13, 0.14]). The odds ratios with
95 percent CIs gave similar results (Table 2).
Only perceived family support moderated the
association between parental death and
maladaptive coping on all four subscales
(p < 0.0001 for all subscales), while parent
lost and participant’s age at time of loss had a
moderating effect only on substance use
(p = 0.03 and p < 0.0001, respectively; results
not shown).
Grief counseling and coping
Grief counseling recipients and non-recipients
did not differ significantly on the scales of
behavioral disengagement and emotional eat-
ing; however, Conf-GC participants reported
significantly more substance use (adjusted
MD = 0.16, 95% CI [0.01, 0.30], p < 0.05) and
self-blame (MD = 0.32, 95% CI [0.13, 0.52],
p < 0.05) than No-GC participants. The unad-
justed and adjusted results are shown in Table 3.
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6 Journal of Health Psychology
Discussion
Our results underline the important role of paren-
tal loss in coping strategies. In accordance with
our first hypothesis, bereaved adults reported
significantly higher substance use, behavioral
disengagement, and emotional eating than non-
bereaved adults. The finding on substance use
bears out several longitudinal studies that found
higher levels of alcohol and substance abuse
among both youth and adults after parental loss
(Giordano et al., 2014; Hamdan et al., 2013).
Those who lost both parents and those who expe-
rienced death between the ages of 6 and 18 years
appeared most vulnerable to substance use as
adults. For the other subscales, parent lost and
child age at time of loss did not modify our
results, indicating that parental death may have a
long-term detrimental effect regardless of parent
gender and child age.
A new contribution of our study is the finding
that early parental loss is associated with
Table 1. Characteristics of the full sample by bereavement status and of the bereaved sample by grief
counseling status (group percentages in parentheses).
Characteristic Full sample p value
χ
2
Bereaved sample p value
χ
2
Bereaved
(n = 1796)
Non-
bereaved
(n = 630)
Conf-GC
(n = 1012)
Self-GC
(n = 449)
No-GC
(n = 299)
Gender
Male 331 (18) 115 (18) 0.92 190 (19) 67 (15) 66 (22) 0.04
Female 1465 (82) 515 (82) 822 (81) 382 (85) 233 (78)
Age
19–25 years 717 (40) 243 (39) 0.24 396 (39) 211 (47) 100 (33) <0.0001
26–30 years 535 (30) 179 (28) 298 (29) 136 (30) 85 (28)
31–35 years 434 (24) 155 (25) 257 (25) 88 (20) 82 (27)
>36 years 110 (6) 53 (8) 61 (6) 14 (3) 32 (11)
Educational level
Basic school 108 (6) 23 (4) 47 (5) 41 (9) 18 (6)
High school or
vocational
604 (34) 207 (33) 319 (32) 179 (40) 97 (32)
Higher education 1078 (60) 399 (63) 643 (64) 226 (50) 184 (62)
Unknown 6 (0) 1 (0) 0.10 3 (0) 3 (1) 0 <0.0001
Age at time of loss
<5 years 23 (1) n/a 9 (1) 6 (1) 7 (2) 0.0014
6–12 years 239 (13) n/a 133 (13) 70 (16) 30 (10)
13–18 years 574 (32) n/a 312 (31) 166 (37) 82 (27)
>18 years 960 (53) n/a 558 (55) 207 (46) 180 (60)
Perceived family support
Yes 1641 (91) n/a 922 (91) 419 (93) 269 (90) 0.22
No 155 (9) n/a 90 (9) 30 (7) 30 (10)
Parent lost
Father 1003 (56) n/a 499 (49) 271 (60) 209 (70) <0.001
Mother 707 (39) n/a 442 (44) 168 (37) 87 (29)
Both 86 (5) n/a 71 (7) 10 (2) 3 (1)
Conf-GC: confirmed grief counseling; Self-GC: self-reported counseling; No-GC: self-reported no counseling; n/a: not
available.
Some percentages may not add up to 100 due to rounding. Age calculated at 1 March 2012 (mid-point of questionnaire
collection period). Participants identified from the counseling center files who self-reported no counseling (n = 36) were
included in the overall bereaved sample but excluded from the bereaved sample by counseling status.
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Høeg et al. 7
Table 2. Mean score, estimated mean differences, and odds ratio for use of coping behavior with
95 percent confidence intervals by bereavement status.
COPE
subscales
Bereaved Non-bereaved MD
a
[95% CI] OR
a
[95% CI]
Mean
score (SE)
No. with
score
>2 (%)
Mean
score (SE)
No. with
score
>2 (%)
Substance use 2.46 (0.02) 336 (19) 2.24 (0.04) 71 (11) 0.21 [0.11 to 0.30]* 1.79 [1.36 to 2.36]*
Behavioral
disengagement
2.86 (0.03) 740 (41) 2.71 (0.05) 211 (34) 0.13 [0.02 to 0.24]* 1.35 [1.12 to 1.64]*
Self-blame 3.22 (0.04) 968 (54) 3.21 (0.06) 319 (51) 0.00 [−0.13 to 0.14] 1.12 [0.93 to 1.34]
Emotional
eating
1.63 (0.02) 745 (42) 1.47 (0.03) 217 (34) 0.15 [0.08 to 0.23]* 1.34 [1.11 to 1.62]*
SE: standard error; MD: mean difference; OR: odds ratio; CI: confidence interval.
Sample size: n = 1796 bereaved, n = 630 non-bereaved.
a
Adjusted for age and educational level.
*p < 0.05.
Table 3. Mean score and estimated mean differences with 95 percent confidence intervals for maladaptive
coping scales by counseling status: confirmed grief counseling (Conf-GC), self-reported counseling (Self-
GC), or self-reported no counseling (No-GC).
COPE scales Conf-GC
mean
score (SE)
Self-GC
mean
score (SE)
No-GC
mean
score (SE)
Conf-GC versus No-
GC MD [95% CI]
Self-GC versus No-GC
MD [95% CI]
Substance use
Unadjusted 2.50 (0.04) 2.44 (0.05) 2.33 (0.07) 0.17 [0.03 to 0.32]* 0.11 [−0.06 to 2.27]
Fully adjusted
a
3.25 (0.49) 3.16 (0.49) 3.09 (0.49) 0.16 [0.01 to 0.30]* 0.07 [−0.09 to 0.23]
Behavioral disengagement
Unadjusted 2.83 (0.04) 2.92 (0.06) 2.85 (0.07) −0.02 [−0.18 to 0.14] 0.07 [−0.11 to 0.25]
Fully adjusted 3.15 (0.54) 3.19 (0.55) 3.17 (0.55) −0.02 [−0.18 to 0.14] 0.03 [−0.16 to 0.21]
Self-blame
Unadjusted 3.30 (0.05) 3.20 (0.07) 2.98 (0.09) 0.32 [0.13 to 0.51]* 0.22 [0.0081 to 0.44]*
Fully adjusted 4.06 (0.64) 3.92 (0.64) 3.73 (6.65) 0.32 [0.13 to 0.52]* 0.19 [−0.03 to 0.40]
Emotional eating
Unadjusted 1.66 (0.03) 1.61 (0.04) 1.58 (0.05) 0.08 [−0.03 to 0.19] 0.03 [−0.09 to 0.16]
Fully adjusted 1.28 (0.38) 1.20 (0.38) 1.22 (0.38) 0.06 [−0.05 to 0.18] −0.02 [−0.14 to 0.11]
SE: standard error; MD: mean difference; CI: confidence interval.
Sample size: n = 1012 Conf-GC, n = 449 Self-GC, n = 299 No-GC.
a
Adjusted for participant gender, gender of deceased parent, participant age at time of loss, education level, and
perceived family support.
*p < 0.05.
behavioral disengagement and emotional eating
as coping strategies in adulthood. Disengagement
refers to giving up efforts to handle a stressor
and has been linked with low self-efficacy, the
lack of belief in one’s abilities (Bandura, 1977;
Carver et al., 1989). The death of a parent is an
experience of ultimate helplessness for a child
and this vulnerability may interact with the sur-
viving parent’s limited resources to model and
foster subsequent mastery experiences needed
for shaping high self-efficacy (Bandura, 1977;
Fan and Williams, 2009). Our finding on
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8 Journal of Health Psychology
emotional eating backs one previous study that
found an association between parental bereave-
ment and youth obesity (Weinberg et al., 2013).
A possible explanation may be that eating pat-
terns are influenced by family functioning and
quality of parenting (Rhee, 2008), two factors
potentially affected by parental loss. Interestingly,
emotional eating may predict eating disorders
(Stice et al., 2002), which in turn have been
described as ways of coping with problems of
personal control (Polivy and Herman, 2002).
Future research may investigate the possibility
that parental death influences maladaptive cop-
ing through pathways involving efficacy and
control beliefs.
The only factor that modified the association
between loss and all four maladaptive coping
scales in our study was perceived family sup-
port. Significantly lower levels of maladaptive
coping according to bereavement status were
found in adults who reported higher family sup-
port. Emotional support has a positive effect on
bereavement outcomes by lowering psycholog-
ical distress (Raveis et al., 1999) and surviving
parents, who are able to provide higher levels of
emotional support to the grieving child, may
also provide the stable attachment and security
needed in the child’s environment post-loss.
This highlights the need to target the family and
“parenting capacity” of the surviving parent
when intervening in bereaved children.
Contrary to our second hypothesis, we found
no significant differences on behavioral disen-
gagement and emotional eating between those
who received counseling and those who did not.
Furthermore, both groups of participants who
received counseling (Conf-GC and Self-GC)
reported significantly higher usage of substance
use and self-blame than non-recipients, although
the difference between Self-GC and non-recipi-
ents (No-GC) became insignificant in the fully
adjusted model. These findings highlight a num-
ber of methodological and theoretical issues.
First and most important, it is highly proba-
ble that those who had sought and received
grief counseling experienced higher distress
levels compared to those who did not, resulting
in a counseling group with a significantly higher
baseline of maladaptive coping than the non-
counseling group. Second, we had no detailed
information about the structure or content of the
grief counseling, and it is possible that the ser-
vices offered were insufficient for participants
suffering from more severe and complicated
grief reactions. Third, the possibility for grief
counseling to be harmful has been posited by
Jordan and Neimeyer (2003), although the
methodology used in that study has since
proved questionable (Larson and Hoyt, 2007).
However, since children have a “short sadness
span” and a need to focus on non-grief related
activities (Webb, 2010: 17), counseling may
force the child to dwell unnecessarily on aspects
of grief and interfere with the natural oscillation
toward restoration-oriented tasks, as described
in the dual-process model of grief (Stroebe and
Schut, 1999). Screening may therefore be use-
ful as there is evidence that interventions for
symptomatic participants produce better out-
comes than those with no selection criteria
(Rosner et al., 2010).
This study has several strengths. This is the
first study to examine the role of parental loss in
adult coping. Also, our study is the largest on
childhood bereavement and grief counseling. In
the latest meta-analysis on childhood grief
interventions, the largest study had 230 partici-
pants, while the numbers for the rest ranged
from 17 to 87 (Rosner et al., 2010). The identi-
fication of a population-based non-bereaved
control group is also unique, made possible by
national registries that were established years
before this study was hypothesized thereby
avoiding information, recall, and selection bias.
Also, grief counseling was available free of
charge and our sample of counseling recipients
were not recruited in an experimental setting,
hence increasing the ecological validity of the
results and decreasing sample selection bias
(Steele et al., 2012). We also matched our
groups on important confounders such as age,
gender, age at time of parental death, and time
since parental death.
However, the cross-sectional design limits
the understanding of the causal nature of the
association between early parental death, grief
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Høeg et al. 9
counseling, and coping in adulthood. Counseling
participants were heterogeneous with regard to
type and extent of counseling received, thus the
current findings cannot be generalized to spe-
cific counseling practices. We were also unable
to include other factors that influence a child’s
development, such as family functioning, or
adjust for other potentially confounding factors,
such as substance use in the parent(s), which
could be associated with both parental death and
our outcome.
This study underlines the negative role of
early parental loss on coping behaviors in adult-
hood. However, future studies with prospective
design measuring coping behaviors over time
before and after loss and counseling, respec-
tively, are needed. Additional research in cop-
ing using a developmental perspective, and a
further shift in focus to the areas of resilience
and post-traumatic growth after parental death,
may provide additional theoretical and clinical
insights.
Acknowledgements
The authors thank the grief counseling organizations
(The Danish Cancer Society, Children’s Welfare,
and The Danish Counseling and Research Center for
Grieving Children and Youth) for their contribution
to this study. They also thank Visti B. Larsen for his
invaluable assistance in data management.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of inter-
est with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) disclosed receipt of the following
financial support for the research, authorship, and/or
publication of this article: This research was sup-
ported by the Danish foundation TrygFonden (J.nr.
7134-08).
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