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Parental Grief Responses and Personals Growth Following the Death of a Child

Linda P. Rileya; Lynda L. LaMontagneb; Joseph T. Hepworthc; Barbara A. Murphyd a College of Nursing, University of Alabama at Huntsville, Hunstville, Alabama, USA b School of Nursing, Vanderbilt University, Nashville, Tennessee, USA c College of Nursing, University of Arizona, Tuscon, Arizona, USA d School of Medicine, Vanderbilt University, Nashville, Tennessee, USA

To cite this Article Riley, Linda P. , LaMontagne, Lynda L. , Hepworth, Joseph T. and Murphy, Barbara A.(2007) 'Parental

Grief Responses and Personals Growth Following the Death of a Child', Death Studies, 31: 4, 277 299 To link to this Article: DOI: 10.1080/07481180601152591 URL: http://dx.doi.org/10.1080/07481180601152591

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Death Studies, 31: 277299, 2007 Copyright # Taylor & Francis Group, LLC ISSN: 0748-1187 print/1091-7683 online DOI: 10.1080/07481180601152591

PARENTAL GRIEF RESPONSES AND PERSONAL GROWTH FOLLOWING THE DEATH OF A CHILD
LINDA P. RILEY College of Nursing, University of Alabama at Huntsville, Hunstville, Alabama, USA LYNDA L. LAMONTAGNE
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School of Nursing, Vanderbilt University, Nashville, Tennessee, USA JOSEPH T. HEPWORTH College of Nursing, University of Arizona, Tuscon, Arizona, USA BARBARA A. MURPHY School of Medicine, Vanderbilt University, Nashville, Tennessee, USA

Conceptualizing parental grief as a psychosocial transition, this cross-sectional study of bereaved mothers (N 35) examined the relationship of dispositional factors, grief reactions, and personal growth. More optimistic mothers reported less intense grief reactions and less distress indicative of complicated grief. Additionally, mothers who usually coped actively had less intense grief reactions. Mothers who habitually coped using positive reframing had less intense grief reactions and less complicated grief. Personal growth, a positive dimension of grief, was associated with all three coping dispositions; mothers active coping, support seeking, and positive reframing suggesting more personal growth occurred in mothers exhibiting more of these coping dispositions. These findings increase understanding of dispositional factors associated with bereaved mothers grief responses and expand knowledge concerning personal growth as an outcome of bereavement.

Parental grief following the death of a child often is characterized by intense emotional, behavioral, cognitive, and physiological responses that may continue for months or years or may even fail to resolve (Osterweis, Solomon, & Green, 1984; Rando, 1993; Rubin, Malkinson, & Witzum, 2000; Stroebe & Schut, 2001). Intense grief that negatively impacts parents psychological well-being and health
Received 18 August 2005; accepted 1 August 2006. Address correspondence to Linda P. Riley, RN, PhD, Associate Professor, College of Nursing, NB 326, University of Alabama at Huntsville, 301 Sparkman Drive, Huntsville, AL 35899. E-mail: linda.riley@uah.edu

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over time has been labeled complicated grief. The key symptoms of complicated grief include preoccupation with thoughts of the loved one, intense separation distress, prolonged disbelief, and recurrent intrusive images or dreams (Prigerson et al., 1995; Prigerson & Jacobs, 2001). Complicated grief is thought to occur when the adaptive grief process is compounded by individual vulnerabilities or circumstances surrounding the death that impede adjustment to the loss (Attig, 2002). Prior studies of parental bereavement have focused primarily on the negative consequences of parental grief including enduring distress, confusion, depressive symptoms, and social withdrawal (Rando, 1993). Little attention has been given to the identification of individual factors and coping resources that may positively influence parents grief responses and may decrease complicated grief (Calhoun & Tedeschi, 1990, 2001; Gamino, Sewell, & Easterling, 2000; Polatinsky & Esprey, 2000). Research that concentrates on pathological outcomes of grief fails to acknowledge the innate human capacity to cope with adversity and ignores griefs power to act as a catalyst for positive change and growth (Hogan, Greenfield, & Schmidt, 2001; Wortman & Silver, 2001). Research on parental grief has been limited by the lack of a wellarticulated theoretical framework to guide the selection of study variables and to define the relationships of these variables to grief outcomes (Hogan & Schmidt, 2002; Neimeyer & Hogan, 2001; Pine & Bauer, 1986). In a review of the literature, two theoretical perspectives were applicable to the examination of parental grief as conceptualized in this study. The grief to growth model (Hogan & Schmidt, 2002) and Parkes is (1988, 1993) bereavement as a psychosocial transition theory were used to guide the selection of variables in this study. Hogan and colleagues (Hogan et al., 2001) developed a grief scale that measures bereavement multi-dimensionally and included both positive and negative grief reactions. This instrument has been validated in studies of bereaved parents (Hogan & Schmidt, 2002; Hogan, Worden, & Schmidt, 20032004). These researchers substantiated a grief to growth model that describes grief as a process of transition and adjustment characterized by intense emotions of despair, detachment, and avoidance (Hogan & Schmidt, 2002). For some individuals this process also may result in the perception of personal growth, including positive changes in self image, compassion, forgiveness, and tolerance.

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Parkes (1988, l993) conceptualized the grief process as a gradual transition of adjustment to an altered world following the death of a loved one. In this process, bereaved individuals gradually integrate changes secondary to their loss into a new worldview. In bereavement transition, dispositional factors are described as potential vulnerabilities or strengths and are linked to the grief process and to subsequent outcomes (Parkes, 1993; Schaefer & Moos, 2001; Schlossberg, 1981,1984). In grief transition, the bereaved individual is regarded as an active participant engaged in a gradual process of realization, change, and adjustment set within a socio-cultural context containing supportive resources. Bereaved individuals also are recognized as possessing vulnerabilities and strengths that may account for variability in grief transition. Further, positive outcomes are included as potential consequences of transition, making the transition perspective uniquely suitable for bereavement studies that evaluate both negative and positive outcomes of the death of a child (Parkes, 1993; Schaefer & Moos, 2001). The purpose of this study was to investigate the relationships among bereaved mothers dispositional factors and bereavement outcomes. The dispositional factors chosen for study were mothers optimism, coping disposition, and perceived social support. Bereavement outcomes included mothers grief reaction, complicated grief, and personal growth. Dispositional Factors Associated with Parental Grief Optimism Optimism is defined as a dispositional factor characterized by general expectation of future positive outcomes (Carver, 1999). That is, more optimistic persons think that good things will happen and that adversity can be dealt with successfully. Optimism is a stable personal factor thought to influence individuals appraisal of the meaning of a specific stressor and to enhance their ability to cope with the consequences of a stressful situation (Carver, Scheier, & Pozo, 1992; Folkman & Greer, 2000). For example, more optimistic individuals are flexible, better able to alter goals and priorities, and more accepting of unchangeable and uncontrollable life

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events (Scheier, Carver, & Bridges, 2001; Scheier, Weintraub, & Carver, 1986). Dispositional optimism, therefore, may be a personal resource that enables bereaved parents to accept the irreversible death of a child and to reframe the loss experience more positively (Nolen-Hokesema & Larson, 1999). Only a few studies have looked at dispositional optimism in bereaved individuals and its relationship to coping or bereavement outcomes (Davis, Nolen-Hoeksema, & Larson, 1998; Nolen-Hoeksema & Larson, 1999). In one study of hospice deaths, pre-loss optimism was the only significant predictor of family members ability to perceive benefit in the experience of loss (Davis et al., 1998). In a longitudinal study of bereaved parents, more optimistic individuals had fewer symptoms of depression and general distress at 6, 13, and 18 months after the deaths. Optimism also was positively correlated with finding meaning and seeking social support (Nolen-Hoeksema & Larson, 1999). Coping Coping disposition is a stable personal factor that determines how an individual habitually deals with life stressors (Brennan, 2001; Carver, Scheier, & Weintraub, 1989). Conceptualizing coping as a trait emphasizes the components of coping that remain consistent over time (Folkman, Lazarus, Dunkel-Schetter, DeLongis & Gruen, 1986; Park & Folkman, 1997). Active coping, seeking support and positive reframing are three dispositional coping strategies thought to significantly influence an individuals response to adverse life events (Carver et al., 1989). Active coping includes planning, taking direct action, and increasing coping efforts. Coping by seeking social support includes searching for information, advice, sympathy, and assistance from the social network. Coping by positive reframing includes managing distress by positive reinterpretation or construing an event in positive terms (Carver et al., 1989). To date only one study has examined coping disposition in parental grief. In the Netherlands, Hoekstra-Weebers, Littlewood, Boon, Postma, and Humphries (1991) found that younger parents used more active problem solving than older parents and that physical symptoms were positively correlated with parents avoidant coping. These findings suggest that the coping disposition of bereaved parents may significantly influence their overall health.

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Social Support The belief that there is a social support network of concerned individuals who will allow bereaved parents to discuss the experience of losing their child has been associated with improved bereavement outcomes (Hazzard, Weston, & Guiterres, 1992; Leopore et al., 1996; McIntosh, Silver, & Wortman, 1993; Wortman & Silver, 1992). Social support from friends and community sources is uniquely important in parental grief because the quantity and quality of support available from within the family may be compromised due to other family members grief. Available support, however, may not always be helpful and may be colored by unrealistic expectations for prompt recovery (Stylianos & Vachon, 1993). For example, parents may be urged to get over their grief by individuals who feel their grief is too intense and prolonged and who are uncomfortable providing support (Lehman, Ellard, & Wortman, 1986). Bereavement Outcomes Traditionally, descriptions of outcomes of grief transition have emphasized the negative components of grief reactions of bereaved individuals. The affective (e.g., grief misery), physical, cognitive, and interpersonal responses of grief range from mild to severe, and may vary individually or be exhibited in differing patterns over time (Bonanno, 2001). Grief that remains consistently high in intensity and is associated with functional impairment is labeled complicated grief (Keesee, 2001; Ott, 2003; Prigerson et al., 1997; Prigerson & Jacobs, 2001; Rando, 1993; Wolfelt, 1991). Grief reactions can be measured on a continuum from mild to severe with varying degrees of functional impairment. Studies rating complicated grief as a psychological disorder using cut off scores have been validated primarily in samples of bereaved spouses (Prigerson et al., 1997). Further validation of complicated grief disorder in the context of parental grief has been recommended for the determination of accurate diagnostic scores in the context of parental grief (Hogan, Worden, & Schmidt, 2003). In this study a decision was made not to use cut off scores to diagnose mothers complicated grief as a psychological disorder. A sense of personal growth may be perceived by some bereaved individuals after experiencing the death of a child.

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Specifically, they may discuss multiple benefits related to their loss experience and may describe positive changes within their selfidentity and within interpersonal relationships (Davis, NolenHokesema, & Larson, 1998; Tedeschi & Calhoun, 1995, 1996; Wortman & Silver, 1987). Some studies of bereaved parents describe the perception of increased compassion and empathy for others, and the need for adjusted values or reprioritized goals (Helmrath & Steinitz, 1978; Miles & Crandall, 1983). Other studies of bereaved parents have documented growth as the perception of positive changes in parents feelings of competence and strength, and improved interpersonal relationships after the death of a child (Hogan et al., 2001; Hogan & Schmidt, 2002; Polatinsky & Esprey, 2000). In studies of coping with adverse events, positive outcomes have been labeled as posttraumatic growth (Calhoun & Tedeschi, 2001), stress-related growth (Park, Cohen, & Murch, 1996), or personal growth (Frantz, Farrell, & Trolley, 2001; Gamino et al., 2000; Hogan & Schmidt, 2002). Clarifying the factors that are associated with positive grief outcomes has been identified as research priority in order to design interventions that encourage personal growth (Calhoun & Tedeschi, 2001; Schaefer & Moos, 2001). Hypotheses The dispositional factors of optimism, dispositional coping, and perceived social support were hypothesized to be negatively related to bereaved mothers grief responses and complicated grief, and positively related to personal growth. That is, mothers who were more optimistic, who usually coped using active coping, support seeking and positive reframing and who had perceptions of adequate social support would experience less intense grief reactions, less complicated grief responses, and more personal growth. Method Sample This cross-sectional descriptive study recruited 35 bereaved mothers during a six-month period from clients in two community grief centers in the southeastern United States. Bereaved mothers were eligible for this study if their deceased child was under 21

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years of age and died from 2 to 30 months prior to their participation. Mothers participated in individual or group counseling sessions conducted in the community or received the monthly newsletter from the Compassionate Friends. Mothers in this sample were predominantly married (90%), Caucasian (92%), and well educated with 58% reporting college education and 23% holding a professional degree. Mothers mean age was 44 years (SD 8.8), ranging from 25 to 66 years. The most frequent causes of childrens death were accidents (58%) and neonatal infant deaths (12.5%). The mean age of deceased children was 12 years. The mean length of bereavement was 15.7 months (SD 8.4). Procedure Following approval by the Institutional Review Board, participants were recruited from bereaved mothers who attended Compassionate Friends support group meetings or had participated in individual grief counseling in two cities in the southeastern United States. Additional participants were recruited through advertisement of the study in monthly newsletters. The principal investigator described the study by phone or in person to individuals who were interested in participating and scheduled an appointment for a face-to-face interview. After signing an informed consent form, mothers completed a packet of questionnaires in the presence of the principal investigator which took approximately 45 minutes. Instruments Optimism was measured using the Life Orientation Test Revised (LOTR; Scheier, Carver, & Bridges, 1994). Responses are rated using a 5-point Likert scale from 0 (strongly disagree) to 4 (Strongly agree). Possible scores range from 0 to 24 with higher scores indicating more optimism. Scale developers reported internal consistency of .78 and established concurrent validity using measures of self esteem (Rosenberg, 1965) and trait anxiety (Spielberger, Gorsuch, & Lushene, 1974). Additional details concerning the revision of the LOT scale may be found in the article by Scheier et al., (1994). Coping disposition was measured using the dispositional version of the COPE Scale (Carver, et al., 1989). Thirty-six items from the longer original COPE instrument that formed three

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factors in a secondary factor analysis were selected (Carver, et al., 1989). These three factors include active coping (active coping, planning and suppression of competing events), support seeking coping (seeking emotional support and information and a focus on emotions), and positive reframing (restraint coping, positive reinterpretation, and acceptance). Response choices were carefully phrased to indicate usual or habitual coping with life crises. Higher scores indicate more use of that type of habitual coping. Internal consistency was reported for each selected subscale by scale developers as above .62 and validity was confirmed by comparison with measures of trait anxiety, self-esteem, and neuroticism (Carver et al., 1989). Perceived social support was measured using the 5-item Inventory of Social Support (ISS; Hogan & Schmidt, 2002). This scale evaluates the degree a bereaved person believes someone is available to listen non-judgmentally to his or her expression of grief. Items are rated on a Likert scale from 1 (does not describe me at all) to 5 (describes me very well) with higher scores indicating more perceived social support. Cronbach alpha is reported as .76 by the scale developers. Grief responses were measured using the Hogan Grief Reaction Checklist (HGRC; Hogan et al., 2001). This scale contains 61 items and measures negative dimensions of grief using five subscales (49 items). Item responses were rated from 1 (does not describe me at all) to 5 (describes me very well). Higher scores indicate more grief reactions over the past two weeks. The five negative subscales are summed to give an index score of grief misery. This method of scoring the negative aspects of grief was suggested by Gamino et al., (2000). Complicated grief was measured using the 19-item Inventory of Complicated Grief (ICG; Prigerson et al., 1995). Grief symptoms often associated with dysfunction including separation anxiety and intrusive thoughts were evaluated. The scale omits depressive symptoms and anxiety-related responses and focuses on responses indicative of more intense forms of grief. Symptom frequency is rated on a scale from 0 (almost never or less than once a month) to 4 (always or more than once a day). Higher scores indicate more symptoms or greater complicated grief. Alpha coefficients revealed internal consistency of .94 and concurrent validity was determined by comparison to the Beck Depression Inventory

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(Beck, Ward, & Mendelson, 1961) and the present grief subscale of the Texas Revised Grief Inventory (Faschingbauer, Zisook, & DeVaul, 1987). Personal growth was measured using two scales to increase study accuracy and to expand the dimensions of bereaved mothers personal growth evaluated. The 21-item Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) was used to describe the perception of growth or positive change within the self, improved interpersonal relationships, and changes in life priorities or goals compared to pre-crisis. Responses are rated from 1 (I did not experience this change as a result of my crisis) to 6 (I experience this change to a very great degree as a result of my crisis). Higher scores indicate the perception of more positive change or growth. Internal consistency for the total scale was .95 and validity was supported by comparison to the personality traits of optimism and extraversion (Tedeschi & Calhoun, 1996). Personal growth also was measured using the 12-item growth subscale from the Hogan Grief Scale, labeled HGRC-G for this study. This subscale evaluated mothers awareness of a positive sense of self. Items are rated from 1 (does not describe me at all) to 5 (describes me very well) with higher scores indicative of the perception of more personal growth. Internal consistency for the growth subscale was .82 (Hogan et al., 2001).
PARENT INFORMATION

Mothers provided demographic information including age, educational level, ethnicity, occupation, and marital status. The Hollingshead Four Factor Index of Social Status (Hollingshead, 1975) was used to evaluate parents socioeconomic status categorically with higher numbers representing higher social class. Statistical Analysis SPSS version 13 was used for data analysis. The hypothesized bivariate relationships between dispositional factors and parental grief outcomes were assessed using correlations. Although there were no multivariate hypotheses proposed, the data were further explored using multiple regression to assess the unique contributions of each personal factor when all of the other factors were contained in the same multiple regression model. The .05 level of significance was used for all analyses.

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Results Descriptive statistics, including coefficient alpha, for all instruments used in this study are found in Table 1. Internal consistency for all instruments ranged from .80 for positive reframing coping disposition to .96 for the combined misery subscales of the Hogan Grief Reaction Checklist. Correlational Analyses Mothers grief responses were negatively related to all dispositional factors indicating that more optimistic mothers, those who used more active coping, more seeking support, and more positive reframing, and those who had higher levels of perceived social support reported fewer grief responses. For complicated grief, this pattern was identical with one exception: the relationship of complicated grief with active coping was not statistically significant. That is, more optimistic mothers, those who used more seeking support and more positive reframing, and those who had higher levels of perceived social support had less complicated grief. Personal growth as measured by both instruments was positively related to all the dispositional factors except for optimism. Mothers active coping was positively related to personal growth indicating that individuals with a more active coping disposition described more personal growth and positive change. Support seeking coping disposition was positively related to both measures of personal growth, indicating that bereaved mothers who usually seek support from others describe a greater sense of personal growth. Positive reframing coping was positively related to both measures of personal growth indicating that mothers who usually use positive reframing also indicated more personal growth. Perceived social support also was found to have a positive relationship with both measures of personal growth, indicating that greater perceived support was associated with more personal growth. Multiple Regression Analysis When all the personal factors were included in a multiple regression model predicting complicated grief, none were statistically significant. However, in the model predicting grief responses, optimism
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TABLE 1 Summary of Instruments: Descriptive Statistics M (SD) Possible score range Actual score range Cronbach alpha

Instruments (# of items)

15.26 (3.74) 34.97 (6.05) 35.54 (6.67) 35.63 (6.66) 20.80 (3.65) 126.50 (37.9) 49245 525 725 63203 1248 1248 1248 1945 2147 2248

024

522

.83 .87 .87 .87 .80 .96

35.40 (14.26) 88.11 (22.31) 38.93 (10.02)

076 21126 1260

1174 36124 2257

.91 .96 .88

Optimism LotR Total Score (6) Coping Disposition Active Coping (12) Support Seeking (12) Positive Reframing (12) Social Support Inventory of Social Support (5) Grief Symptoms Hogan Grief Reaction Checklist Negative Grief Subscales (Misery) (49) Inventory of Complicated Grief (19) Personal Growth Posttraumatic Growth Inventory (21) Hogan Grief Reaction Checklist Personal Growth Subscale (12)

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288 Dependent variables Negative outcomes Positive outcomes Grief reactions HGRC .583 .424 .423 .596 .455 .488 .326 .381 .457 .383 Complicated grief ICG Personal growth PTGI .301 .428 .413 .512 .453 Personal growth HGRC-G .273 .394 .334 .449 .502

TABLE 2 Correlational Analysis of Relationships of Independent and Dependent Variables

Independent variables

Optimism Active coping disposition Support seeking coping disposition Positive reframing coping disposition Perceived social support

Notes. HGRC Hogan Grief Reaction Checklist; ICG Inventory of Complicated Grief; PTGI Posttraumatic Growth Inventory. p 0.05 level. p 0.01 level (two-tailed).

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remained significant (p .04) and positive reframing was marginally significant (p .05). When only optimism and positive reframing were used to predict grief responses, both were significant (p .03 and .02, respectively). More optimistic mothers and those who used more positive reframing had less intense grief responses. When all the personal factors were included in models predicting the two measures of personal growth, none were statistically significant. When controlling for all the other personal factors, none accounted for a significant amount of variance.
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Discussion This study investigated the relationships among bereaved mothers dispositional factors and bereavement outcomes. First the relationship between bereaved mothers dispositional factors and the grief responses are discussed. This is followed by a discussion of the relationships between their dispositional factors and personal growth. Dispositional Factors and Grief Responses Although optimism is rarely described as an important dispositional factor in bereavement research, in this study the protective properties of optimism were supported by the strong relationship found between optimism and grief responses. Further, when all other dispositional factors were controlled for, optimism was the only variable that had a unique contribution in predicting grief responses. More optimistic mothers experienced less intense grief responses after the death of their child. Additionally, optimism and complicated grief also had a strong negative relationship. That is, more optimistic mothers reported less frequent intrusive images, yearning and searching behaviors, disbelief, and numbness, or responses usually associated with poor health outcomes. There are several possible explanations for these relationships. First, because optimism is characterized by individuals who possess positive future expectations, bereaved mothers search for the positive may reduce the intensity and duration of grief responses as well as improve their ability to find meaning and significance in the death of their child. Second, when adjusting to misfortune, more optimistic individuals have been shown to

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remain persistent in efforts to deal with adverse events even when progress is slow or difficult (e.g., Carver et al., 1989). The expectation of eventual positive outcomes may have sustained coping efforts of the grieving parents in this study as they slowly adapted and coped with changes secondary to the death of their child. Third, research studies dealing with other types of crisis events suggest that more optimistic individuals cope differently. For example, optimistic individuals have been found to be more accepting of unchangeable life events and more flexible in adjusting life goals or priorities (e.g., Carver et al., 1989). These behaviors may have profound influence in the context of parental grief when parents ability to accept the unalterable reality of their childs death may play a key role in alleviating symptoms of complicated grief. Coping disposition in this study was related to bereavement outcomes. Bereaved mothers who usually coped with a crisis actively by taking direct action, planning, and problem solving had less frequent or intense grief responses. This finding is consistent with a study conducted by Murray and Terry (1999) who found that mothers who habitually used problem-focused coping reported less general distress and anxiety 15 months after the death of a child. Although active coping disposition was found to be related to grief responses, no relationship was identified between active coping disposition and complicated grief indicating that bereaved parents with active coping dispositions did not experience less complicated grief. This finding was unexpected. It is possible that action, planning, and problem solving may not be effective coping strategies when parents separation distress is overwhelming and the reality of the death is unalterable. Further, active coping may not reduce the intensity of the yearning for reunion and the presence of intrusive thoughts characteristic of complicated grief. More palliative modes of coping such as distancing and withdrawal may be more effective when parents distress is intense. Significant relationships were found between bereaved mothers support seeking coping disposition, grief reactions, and complicated grief. The desire to share ones loss experience with other people was related to better bereavement outcomes, less grief reaction, and complicated grief for mothers in this study. Social support characterized by empathy and warmth may provide an appropriate outlet for the expression of emotional distress that can be normalized and accepted.

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Bereaved mothers who managed distress by acceptance and reframing of the negative experience in a positive light experienced less intense grief responses and less complicated grief. Positive reframing was marginally significant in predicting grief responses when controlling for the other dispositional factors suggesting that it also may be an important independent factor influencing grief responses. This finding is consistent with other studies of bereaved family members that report less intense grief reactions in individuals who had the ability to see something good resulting from a death and had an opportunity to say goodbye to the deceased (e.g., Gamino et al., 2000). Further, the tragic loss of a child may destroy parents fundamental perceptions of their role as their childs protector and thus damage their self image. This type of world-shaking event may necessitate an extended effort to search for any remnant of the positive in the death. Parents may attempt to reconstruct or reframe the event to maximize positive emotions, to restore their identity and create some degree of stability and predictability in their lives. As hypothesized, mothers who perceived more available social support reported less intense grief responses and less complicated grief. Because intensely distressed parents need to process the details of the traumatizing event in order to accept the death (Simpson, 1997), the availability of confidants who allow the telling and retelling of the circumstances surrounding the death may be useful to facilitate optimal adjustment and gradual acceptance in the core process of grief transition. The opportunity to share the experience of losing a child with someone whose child also died may lessen parents sense of shock and injustice and so lessen complicated grief symptoms. Dispositional Factors and Personal Growth The relationship between optimism and personal growth was positive for bereaved mothers in this study, although not statistically significant. Because other studies in the bereavement literature have identified personality traits as indicators of important coping resources that may influence adjustment to the death of a family member (e.g., Nolen-Hoeksema & Larson, 1999), this relationship needs further study using a larger sample. The possibility that more

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optimistic mothers may possess effective coping reserves or intrinsic resources to draw upon in stressful situations such as the loss of a child needs clarification. Mothers active coping disposition was associated with personal growth. Specifically, individuals who habitually planned and problem solved when faced with life stressors perceived more personal growth than those who do not deal with life events in this manner. Although personal growth has been measured in prior studies of bereaved parents, this study is the first to support the link between personal growth and active coping disposition. Support-seeking coping disposition was associated with personal growth. Bereaved mothers who habitually coped with stressors by seeking instrumental and emotional support reported a sense of greater personal growth after the death of their child. They describe social support as available advice, consolation, and a sense of caring. The findings of this study support similar findings of a parental grief study in Finland conducted by Laakso and Paunonen-Ilmonen (2002). This study found that bereaved mothers reported more personal growth when they relied on social support provided by family members and friends. The opportunity to participate in bereaved parents support groups may have helped the parents in this study to reframe their experience more positively after listening to other parents describe their experiences. Thus, the empathic environment of a mutual support group may serve as a forum for parents search for meaning after the death of their child and may facilitate parents perception of personal growth. Mothers positive reframing of their experience was frequently observed during the 6 months of participant recruitment for this study. Bereaved mothers often discussed positive changes they believed were the result of their bereavement and described their process of grief transition as a process of gradually being able to remember their child with a smile rather than with tears. Mothers appreciation of the frailty of life and of the value of interpersonal relationships have been described as essential components of the concept of personal growth (Tedeschi & Calhoun, 1996). Reframing the experience of loss to include the possibility of positive outcomes is a coping skill that could be nurtured by health care professionals. Perceived social support also was strongly correlated with parents perception of personal growth. Mothers who felt that adequate

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support was available within their social network perceived more personal growth, including positive changes in their self-identity and improved interpersonal relationships. This finding is consistent with other studies that report a direct positive effect of perceived social support on personal growth including parents improved appreciation of individual strengths and events of daily life (e.g., Cadell, Regeher, & Hemsworth, 2003; Tedeschi & Calhoun,1996). These results indicate that bereaved mothers who habitually cope using active coping, support seeking, and positive reframing and who perceived adequate social support described a sense of positive change and personal growth as outcomes of grief transition. Study Limitations and Strengths This study is limited by the cross-sectional nature of the design. One time measurement prohibits any causal inferences in relationships between dispositional factors and parental grief outcomes of grief reaction, complicated grief, and personal growth. The results of this study, however, do provide a basis for the design of future longitudinal research studies of bereaved mothers over a longer period of adjustment to the myriad changes associated with the loss of a child. The relationships of factors identified as strongly related to grief outcomes in this study need to be examined in more detail using multiple measurements across time during bereavement. Another limitation is this studys recruitment from supportseeking bereaved mothers who were predominantly Caucasian. Further, individuals attending support groups may differ in distress levels, ease of emotional expression, and the level of perceived social support from bereaved parents who do not seek support (Allumbaugh, 1999; Caserta & Lund, 1992). A sample of predominantly Caucasian mothers represents only a cross-section of race, ethnicity and gender, therefore, the generalizability of the findings to other bereaved parents is limited. This study also was limited by its small sample size. Although the sample size was sufficient to detect the bivariate relationships hypothesized, in order to adequately address and assess multivariate relationships and longitudinal relationships a larger sample size is needed in future research. A strength of this study is the inclusion of personal growth as a positive outcome of parental grief. Doing so broadens the

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traditional focus on negative outcomes of parental grief and addresses the strength and resilience of bereaved mothers. Conceptualization of parental grief as an active process of adjustment to the changes created by the death of a child depicts bereaved mothers as engaged rather than passive grievers. Examination of the relationship of optimism and grief responses is a valuable contribution to the expanding bereavement literature that relates optimism to improved psychological state, the perception of personal growth, and other positive outcomes of crisis. Measuring parental grief responses using two empirically derived grief instruments rather than using general measures of psychological distress allowed evaluation of normally expected grief reactions as well as parents responses associated with impaired psychological and physical health. Conclusion This study contributes to a growing body of work that emphasizes the need for inclusion of positive in addition to negative outcomes as potential consequences of parental grief. Although this crosssectional study found strong relationships between bereaved mothers optimism, coping disposition, perceived social support, and parental grief outcomes, longitudinal studies of parental bereavement clearly are needed to define causal relationships. Studies over time are needed to accurately test the predicted association of dispositional factors and bereavement outcomes. Future studies using measurements over the grief process will give a more realistic description of how these factors are intertwined and may begin to clarify the influence of possible mediators (e.g., coping) and moderators (e.g., characteristics of the death) that explain or modify the relationships between dispositional factors and bereavement outcomes. Optimally, prospective studies of bereavement will allow detailed exploration of these relationships while controlling for parents stable traits and characteristics as well as pre-existing psychological state before the loss. This study emphasizes the need for the development of a coping scale designed specifically for bereavement studies. Such a scale is necessary to allow more accurate measurement of the complex process of coping with the long-term stressors unique to grief transition. Creation of a coping instrument that better captures the multiple foci of attention and the use of diverse modes of coping

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with loss has been suggested as essential for accurate assessment of the transition of bereavement (Van Heck & DeRidder, 2001). Both theoretical and empirical advances are needed to insure the development of the most appropriate interventions for bereaved parents. Although Hogans grief to growth model and Parkes transition theoretical perspective provided useful frameworks for this study, neither of these approaches alone would adequately capture all the conceptual nuances necessary for an adequate theory. Also, greater knowledge is needed to effectively screen for individuals at risk for complicated grief and to create specific interventions that enhance skills associated with growth and that support individuals at greater risk for poor grief outcomes after the death of a child (Wortman & Silver, 1992). For example, skill-building interventions that emphasize the importance of cognitive flexibility and positive reinterpretation may strengthen a parents ability to adjust to the death of a child. In addition, bereavement interventions that facilitate reframing of the loss and recognizes growth as positive changes within the self and interpersonal relationships may improve outcomes for grieving parents. More study is required to fully understand the key factors that promote optimal personal growth, to determine their mechanism of influence on outcomes of bereavement, and to craft effective programs of intervention. References
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