Direct and indirect effects of bereaved caregivers’ self-compassion on their complicated grief and their child’s mental health

THIS MANUSCRIPT IS CURRENTLY UNDER REVIEWDirect and indirect effects of bereaved caregivers’ self-compassion on their complicated grief and their child’s mental health Na Zhang1, Irwin S

THIS MANUSCRIPT IS CURRENTLY UNDER REVIEW

Direct and indirect effects of bereaved caregivers’ self-compassion on their complicated

grief and their child’s mental health

Na Zhang1, Irwin Sandler2, Jenn-Yun Tein2, Sharlene Wolchik2, and Erin Donohue3

1 Department of Human Development and Family Sciences, University of Connecticut

2 REACH Institute, Department of Psychology, Arizona State University

3 Psychology Department, College of Saint Benedict and Saint John’s University

Author Note:

Correspondence concerning this article should be addressed to Na Zhang, University of

Connecticut, 1 University Place, Stamford, CT 06901 Email: nazhang@uconn.edu

Acknowledgment:

The study was funded by a grant from New York Life Foundation to Irwin Sandler Na Zhang’s work on this paper was supported by a National Research Service Award in Primary Prevention

by the National Institute on Drug Abuse T32DA039772 (PI: Laurie Chassin) through the

REACH Institute, Department of Psychology, at Arizona State University Jenn-Yun Tein’s work was supported by grants from the National Institute on Drug Abuse (2R01DA09757) Jenn-Yun Tein’s and Sharlene Wolchik’s work was also supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD094334) A portion of this work was presented at the 2020 meeting of the Mind and Life Institute Contemplative Research Conference which was held virtually

Self-compassion, which involves mindfulness, self-kindness, and common humanity, has been found to be related to individuals’ mental health Few studies have examined caregivers’ self-compassion in relation to parenting behaviors or child adjustment in addition to its relation their

own mental health Objectives: In the current study we examined caregivers’ self-compassion as

a protective factor related to parentally bereaved children’s internalizing and externalizing problems We further tested whether the relations were mediated by caregivers’ parenting

practices or complicated grief (i.e., persistent severe grief reactions that impair normal

functioning) Methods: The sample consists of caregivers who participated in an intervention

study for bereaved families and reported high levels of complicated grief At T1 (baseline) and T2 (20 weeks later), caregivers completed surveys on demographic information, self-

compassion, complicated grief, parental warmth and consistent discipline, as well as child

internalizing and externalizing problems Results: Findings supported that caregivers’

self-compassion was prospectively related to decreased internalizing and externalizing problems in bereaved children The effect of self-compassion on externalizing problems was mediated by parental warmth and consistent discipline Self-compassion was also prospectively associated with decreased complicated grief and psychological distress, although complicated grief and

psychological distress were not related to child outcomes Conclusions: These findings add to

the knowledge on the psychological benefits of self-compassion for both bereaved children and their caregivers

Key words: self-compassion; parenting; complicated grief; internalizing problem; externalizing

problems

Direct and indirect effects of bereaved caregivers’ self-compassion on their complicated

grief and their child’s mental health

In the United States, over two million children have experienced the death of a parent (Weaver, 2019) Parental death confers risk for multiple short- and long-term mental and

physical health as well as social problems Parental death during childhood is associated with poor psychological outcomes in bereaved children including depression, anxiety, conduct

disorder, low self-esteem, social withdrawal, as well as alcohol and substance abuse (Brent et al.,2009; Hamdan et al., 2012; Kaplow et al., 2010; Worden & Silverman, 1996) About one fifth ofchildren who experience parental health experience serious psychological problems (Dowdney, 2000; Worden & Silverman, 1996) A study based on a nationwide cohort sample from three Nordic countries found that parental death before the age of 18 was associated with a 50% increased all-cause mortality in early adulthood (Li et al., 2014)

Although parental death elevates risk, not all parentally bereaved children experience significant problems Research on risk or protective factors can help identify subgroups who may

be more or less likely to show problem outcomes The extant literature suggests that children who lost a parent at a younger age, whose parent died from external causes (e.g., suicide,

homicide, accident versus illness), who lost a mother (versus a father), and whose family

background is disadvantaged are at higher risk for poor outcomes (Appel et al., 2013; Berg et al.,2016; Brent et al., 2009) In addition, caregivers play a critical role in children’s post-loss

adjustment There is a growing literature that shows that parenting practices predict parentally bereaved children’s adjustment (Haine et al., 2006; Howell et al., 2016; Kwok et al., 2005; Lin etal., 2004; Saldinger et al., 2004; Tein et al., 2006) In addition, some evidence suggests that

caregivers’ mental health problems, such as depression or psychological distress were related to bereaved children’s outcomes (Cerel et al., 2006; Kwok et al., 2005).

In the Family Stress Model (Masarik & Conger, 2017), stressful circumstances are posited to increase parental psychological distress, which influences child adjustment problems through disrupted parenting Jiao et al (2020)’s conceptual framework recognized that bereaved parents face multiple challenges in providing an environment for the healthy development of their bereaved children while dealing with their grief and multiple stressors after the death This framework highlights the role that parent-child relationships play in children’s post-death

outcomes and the interdependence of parent’s and children’s adjustment outcomes

The current study focused on a malleable protective factor, caregivers’ self-compassion Although the concept is understudied in bereaved families, self-compassion may have important implications for parent-child relationships and both the children’s and caregivers’ adjustment outcomes after the death Self-compassion is an inner rather than outer resource that caregivers can rely on while dealing with their challenges It may be difficult for parents to nurture this resource given that caregivers are often advised to take a child-centered approach to parenting after the death (Saldinger et al., 2004) and as a result they may prioritize family care over self-care Below, we discuss the literature and our hypothesized model to test how caregivers’ self-compassion relates to parenting, complicated grief, psychological distress and children’s

outcomes

What is Self-compassion?

Neff (2003a) proposed that self-compassion is a dynamic balance between three

intertwined aspects: mindfulness (versus overidentification), kindness (versus

self-judgment), and common humanity (versus isolation) Specifically, mindfulness refers to the nonjudgmental awareness and acceptance of one’s experience, whereas overidentification refers

to the state of being “fused” with one’s experience which can cause avoidance or rumination Self-kindness involves the caring and responding attitude toward oneself in the face of suffering, whereas self-judgment involves criticizing oneself for having flaws or making mistakes Finally, common humanity points to the understanding that all humans encounter difficulties in life and that one is not alone in their suffering, whereas isolation gives rise to feelings of

disconnectedness and loneliness Self-compassion has been found to be a protective factor in many stressful situations (Leary et al., 2007) A meta-analysis of 14 studies, which included student samples, found large effects of self-compassion on psychological distress, such as

depression, anxiety, and stress (MacBeth & Gumley, 2012) Self-compassion is malleable and can be enhanced through training A meta-analysis of 27 randomized, controlled trials of self-compassion interventions found improvements in a range of psychological outcomes, including stress, depression, and anxiety, negative affect, and rumination (Ferrari et al., 2019)

Self-compassion and Complicated Grief in Adults

The death of a close family member can lead to psychological distress and a wide range

of physical (e.g., dizziness, indigestion, pain) and mental health problems (e.g., depression, traumatic stress symptoms, substance use) (Stroebe, Schut, & Stroebe, 2007) While these responses abate over time for most individuals, about 10% of bereaved adults experience a range

post-of significant emotional and behavioral impairments that either worsen or persist over a

prolonged period of time, which is known as complicated grief (Shear et al., 2011) Normal grief and complicated grief differ by their severity and persistence over time (Holland et al., 2008)

Complicated grief is distinguishable from other bereavement-related mental health problems, such as depression and anxiety (e.g Prigerson et al., 1996)

There are several reasons why self-compassion may reduce complicated grief Wada and Park (2009) discussed how self-compassion may mitigate self-pity or self-criticism that

interferes with adjustment to the death Self-compassion may also be related to adaptive emotion regulation that facilitates adaptive grief and reduces complicated grief (Maccallum & Bryant, 2013) Indeed, self-compassion has been found to be as effective as other adaptive emotion regulation strategies (i.e., cognitive appraisal and acceptance) in reducing depressed mood for adults with major depressive disorder (Diedrich et al., 2014) The elements of self-compassion - mindfulness, self-kindness, and common humanity - may help bereaved people to see their grief-related thoughts and emotions as impermanent mental events rather than parts of their self-identify As a result, the use of maladaptive emotion regulation strategies linked to complicated grief, such as rumination or avoidance, may be reduced (Boelen et al., 2006; Eisma et al., 2014; Maccallum & Bryant, 2013)

Although self-compassion appears to be an antidote to many of the complicated grief symptoms such as avoidance, distress, anger, troubling rumination, and inability to accept the death, little empirical evidence exists on the relation of self-compassion to complicated grief There is one cross-sectional study of family members of missing persons (about one third were parents whose child went missing) that found the self-compassion was significantly related to lower posttraumatic stress symptoms, depression, and complicated grief (Lenferink et al., 2017)

Complicated Grief and Child Adjustment

There is also scant research on the relation of caregivers’ complicated grief to child adjustment after the death Caregivers’ complicated grief could increase children’s internalizing and externalizing problems for several reasons First, parents with complicated grief may reflect underlying neurobiological vulnerabilities (e.g., Schultze-Florey et al., 2012) that could be inherited by their child Second, complicated grief could affect children’s emotion regulation - the processes of “initiating, maintaining, and modulating the occurrence, intensity, and

expression of emotions” (Morris et al., 2007, p 3), which is related to internalizing and

externalizing problems (Eisenberg et al., 2001) In particular, parents with complicated grief mayexhibit negative emotions that are linked to children’s negative emotions through parent-child bio-behavioral synchrony and moment-to-moment dynamics (Morris et al 2014) Finally,

caregivers with complicated grief may unintentionally create a negative emotional climate in the family that can hinder child development (Morris et al., 2007) One qualitative study with

spousally bereaved parents suggested that parents and children shared similar grief reactions and parents struggled to cope with grief in both themselves and their child (Bugge et al., 2014) The current study is the first quantitative examination of the associations between caregivers’

complicated grief and child internalizing and externalizing problems

Self-compassion, Parenting, and Child Adjustment Problems

Self-compassion may be related to parenting practices, as it is related to emotion

regulation, a psychological determinant of parenting (Crandall et al., 2015) Nemati et al (2020) found that parents’ self-compassion was cross-sectionally associated with parental warmth in a sample of mothers of children with developmental disabilities Gouveia et al (2016) found that parental self-compassion was cross-sectionally associated with higher authoritative parenting andlower authoritarian/permissive parenting, and the associations were mediated by mindful

parenting (i.e., bringing awareness and compassion to parent-child interactions) in a community sample of mothers and fathers of school-aged children in Portugal Finally, in a study of parents with a history of depression, Psychogiou et al (2016) found that mothers with higher self-

compassion used less critical comments when describing their preschoolers, and fathers reported less distress and more supportive reactions to their preschoolers who displayed negative

emotions Although the stability of parenting was not controlled for, the study by Psychogiou et

al (2016) represents the first longitudinal study in support of a prospective relation between parental self-compassion and parenting This study also showed that parental self-compassion was negatively associated with preschoolers’ internalizing and externalizing problems, but the associations became non-significant after controlling for the effects of covariates The current study extends this work by examining the prospective relations between caregivers’ self-

compassion and parenting, while controlling for the stability of parenting over time as well as possible confounders

The Current Study

The current study is the first to examine parental self-compassion as a protective factor for parentally bereaved families We used two-wave secondary data from a larger intervention study (for more details, see [MASKED FOR PEER REVIEW], 2021) All bereaved families were receiving services from bereavement agencies and intervention (service type) was

controlled for in the analyses Based on the literature reviewed above, we hypothesized that caregivers’ self-compassion at baseline (T1) would be associated with lower child internalizing and externalizing problems 20 weeks later (T2) We further hypothesized mediation effects such that caregivers’ self-compassion at T1 (independent variable) would be associated with lower complicated grief, lower psychological distress, higher parental warmth, and higher consistent

discipline (mediators) at T2, which in turn would be associated with lower child internalizing and externalizing problems (dependent variables) at T2.

METHOD Participants

A total of 74 caregivers (female = 78.4%) participated in the study They were on average43.8 years (SD = 7.95, Range 26~65) and primarily non-Hispanic (82.4%) and White (64.9%), with 21% being African American, 4.1% Asian American, 2.7% multi-races and 6.8% other races Their education levels were high school (13.5%), some college (9.5%), diploma or

certificate beyond high school (10.8%), associate degree (10.8), Bachelor’s degree (29.7%), Master’s degree (21.6%), or doctorate degree (4.1%) Their children’s age averaged 10.58 years old (SD = 3.67, Range [3~17]);52.7% were female

Relative to the bereaved child, the caregivers were: parent (87.7%), adopted or stepparent(4.1%), grandparent (4.1%), other family relatives (4.1%) The deceased parent was their

husband (45.9%), wife (14.9%), ex-husband (6.8%), ex-wife (2.7%), non-married partner

(14.9%), or other family members (17.5%) The death occurred an average of 20.5 months prior

to the study (SD = 16.4; Range = 3 ~80) The most frequent cause of death was illness (heart disease [21.6%], cancer [24.3%], and other types of illness [24.3%]), followed by accident (10.9%), homicide (8.1%), and suicide (9.5%)

Procedure

Data were drawn from a project that evaluated a community-based program for bereaved families in which caregivers were recruited at four agencies in four states in the United States These agencies regularly provided bereavement support services to either the bereaved children,

caregivers or both Eligibility criteria were: death occurred more than three months prior to the beginning of the study; caregiver had at least one child (<18 years old) who was living at home; and caregiver could complete the assessments in English During the study period, about 40% (n

= 30) of the sample received the services typically provided by the agency, whereas 60% (n = 44) received a group-based program in addition to service-as-usual The group-based

intervention consisted of 10 weekly group meetings led by a staff member of the agency

Because the goal of the current study was not to examine the effects of the group-based

intervention, service type was treated as a covariate in the analyses Caregivers completed

surveys at baseline (T1) and posttest (20 weeks post-baseline; T2) Compensation for their time was $45 at each assessment All participants’ consent was obtained prior to the study All study procedures were approved by the University Institutional Review Board

Measures

Independent variable

Self-compassion was assessed using the 12-item Self-Compassion Scale-Short Form

(Raes et al., 2011), which measures individuals’ self-compassionate responses to their stressful experiences The short form has been found to have the same factor structure as the original scale(Neff, 2003b) and its scores are strongly correlated with those on long form (Raes et al., 2011) The scale has good validity (Neff, 2015) and consists of six subscales: mindfulness (e.g., “when something painful happens I try to take a balanced view of the situation”) versus over-

identification (e.g., “when I fail at something important to me I become consumed by feelings of inadequacy”), self-kindness (e.g., “I try to be understanding and be patient towards those aspects

of my personality I don’t like”) versus self-judgment (e.g., “I’m disapproving and judgmental about my own flaws and inadequacies”), and common humanity (e.g., “when I feel inadequate in

some way, I try to remind myself that feelings of inadequacy are shared by most people”) versus isolation (e.g., “when I’m feeling down, I tend to feel like most other people are probably

happier than I am”) A total score was calculated such that higher scores indicate higher levels ofself-compassion Cronbach’s α was 0.87 in this sample

Mediators

Complicated grief was assessed using the 19-item Inventory of Complicated Grief

(Prigerson, Maciejewski, et al., 1995) Respondents rated their feelings over the past month on a 5-point scale (1 = almost never or not at all in the past month; 5 = always or several times a day).Example items include “you think about [deceased name] so much that it’s hard for you to do things you normally do”, “ever since [deceased name] died, it is hard for you to trust people”, and “you feel that life is empty without [deceased name]).” Scores greater than 25 indicate significant functional impairments in social, mental, and physical health domains (Prigerson et al., 1995) The majority of the current sample (95.9% at T1 and 91.4% at T2) reported ICG scores > 25 The scale has demonstrated good validity (Prigerson, Maciejewski, et al., 1995)

Cronbach’s αs were 0.89/0.90 at T1/T2

Psychological distress was measured using the Demoralization Scale of the Psychiatric

Epidemiology Research Interview (PERI-D; Dohrenwend et al., 1980) which asks about a range

of symptoms over the past month including physiological symptoms, sadness, dread, self-esteem,anxiety, confused thinking, helplessness and hopelessness Research has demonstrated its

validity (Roberts & Vernon, 1981) The scale had a total of 25 items after dropping two items that had low correlations with the overall scale and used time frames other than the past month (“how often in your life have you acted like a coward” and “how often have you done anything

of a sexual nature that society does not approve of”) Items were rated on a 5-point scale ranging

from 1 (never or strongly disagree) to 5 (very often or strongly agree) A composite score was computed, and higher scores indicate higher levels of distress Cronbach’s α was 0.91 for both T1 and T2.

Parental warmth and consistent discipline were assessed using the caregiver-version of

the Children’s Report of Parental Behavior Inventory (Schaefer, 1965) Caregivers rated items that describe parenting behaviors during the previous month on a 3-point scale ranging from 1 (like you) to 3 (not like you) The scale has been used to assess quality of parenting in parentally bereaved families (Kwok et al., 2005) and has demonstrated good validity (Wolchik et al., 2000).For parental warmth, the Acceptance (16 items, e.g., “you were not interested in changing

[child’s name], but liked him/her the way he/she was”) and the Rejection (16 items, e.g., “you made [child’s name] feel he/she was not loved”) subscales were used Cronbach’s αs at T1/T2 were 0.74/0.82 for the Acceptance subscale and 0.78/0.69 for the Rejection subscale The two

subscales were moderately correlated (r = -.48/ -.47 at T1/T2) and were combined such that

higher scores indicated higher acceptance and lower rejection Cronbach’s αs for the combined scale were 0.84/0.85 at T1/T2 For consistent discipline, the Inconsistent Discipline subscale (8 items, e.g., “You punished [child’s name] for doing something one day but you ignored it the next day”) was used Higher scores indicated higher consistent discipline Cronbach’s αs at T1 and T2 were both 0.79

Dependent variables

Child internalizing and externalizing problems were assessed using the two subscales

of the Brief Problem Monitor scale (Achenbach et al., 2011) The scale, which includes items from the Children’s Behavior Checklist, has good validity (Achenbach et al., 2011) Items were rated on a 3-point scale ranging from 1 (Not true) to 3 (Very true) Cronbach’s αs were 0.81 at

T1/T2 for internalizing problems and 0.83/0.75 at T1/T2 for externalizing problem T-scores adjusting for child age and gender were calculated and used in the analyses

Covariates were chosen based on research showing significant relations to bereavement

outcomes: 1) caregiver’s education, as an index of family’s socioeconomic status; 2) caregiver’sgender; 3) child age; 4) child gender; 5) time since death (in months); and 6) sudden death (homicide, suicide, or accident = 1, illness = 0) As mentioned above, service type (0 = service-as-usual; 1 = group-based program plus service-as-usual) was also used as a covariate

Analytic Plan

Missing data was equal to or less than 5.4% on all variables except for externalizing

problems at T2 (n = 5; 6.8%) Little’s MCAR test showed that the assumption of missingness completely at random was not rejected (p > 05) Missing data was handled in the path analyses

with Full Information Maximum Likelihood in Mplus 8 (Muthén & Muthén, 1998-2017) A series of Box’s M Tests (Box, 1949) showed that the multiple variance-covariance matrices were

homogeneous across the two groups of caregivers who received different services (ps > 05),

indicating that the associations of the studied variables were consistent across the two groups

Descriptive statistics and inter-correlations among the key study variables were computed(Table 1) For hypotheses testing, we first applied regression models to examine the relations of self-compassion (T1) to child internalizing (T2) and to externalizing problems (T2), separately, controlling for the stability of internalizing/externalizing problems from T1 to T2 in each model,

as well as covariates We then tested the mediation models separately for each mediator and dependent variable Specifically, each mediation model included a T2 mediator (complicated grief, psychological distress, parental warmth, or consistent discipline) and a T2 dependent

variable (internalizing problems or externalizing problems), while controlling for the stability of the mediator and dependent variable from T1 to T2, as well as the effects of covariates on both the mediator and the dependent variable The a path (independent variable  mediator), b path (mediator  dependent variable), and c’ path (independent variable  dependent variable after controlling for mediation effect) were estimated If both a and b paths were statistically

significant (α = 05), bias-corrected bootstrapped 95% confidence intervals (CI) for the indirect

(mediation) effect (a*b) were computed (MacKinnon et al., 2002) based on 5,000 bootstrap resamples Mediation effects were considered statistically significant if the CI did not include zero The bootstrapped method has better power than several other methods to detect mediation effects (MacKinnon et al., 2002) All models were estimated using the maximum likelihood estimator in Mplus 8 (Muthén & Muthén, 1998-2017) Model fit indices were evaluated using recommended criteria (McDonald & Ho, 2002)

RESULTS

Screening of normality of data distribution for mediators and dependent variables found that skewness and kurtosis were all in the acceptable range (West et al., 1995) Caregivers’ self-compassion was in general moderately to strongly correlated with complicated grief,

psychological distress, child externalizing problems, and parental warmth and consistent

discipline Psychological distress was significantly moderately correlated with child internalizing

or externalizing problems Parental warmth was moderately to strongly correlated with

externalizing problems and discipline was weakly correlated with externalizing problems

[INSERT TABLE 1 HERE]

As hypothesized, results from the regression models (Table 2) showed significant

negative prospective associations of self-compassion to internalizing problems (b = -0.181, SE =

0.074, 95% CI = [-0.327, -0.035], p < 05, β = -.229) and externalizing problems (b = -0.156, SE

= 0.079, 95% CI = [-0.331, -0.001], p < 05, β = -.214), controlling for baseline internalizing or

externalizing problems and covariates Thus, higher caregivers’ self-compassion at baseline was associated with lower internalizing and externalizing problems 20 weeks later

[INSERT TABLE 2 HERE]

A series of mediation models were computed In each model, we controlled for the stability of the mediator and the dependent variable from T1 to T2 as well as the effects of the covariates (i.e., caregiver education and gender, child age and gender, time since death, sudden death, and service type) on the mediator and the dependent variable

As shown in Table 3, some of our hypotheses were supported First, the model that testedparental warmth as the mediator and externalizing problems as the dependent variable (Model 6) found statistically significant a and b paths After including the mediation effect of parental warmth, the association between self-compassion and externalizing problems (c’ path) was no longer significant The model demonstrated a good fit to the data We calculated the bias-

corrected bootstrapped 95% CIs and found that the mediation effect of parental warmth was statistically significant, 95% CI = [-0.166, -0.012] Second, the model that tested consistent discipline as the mediator and externalizing problems as the dependent variable also found statistically significant a and b paths (Model 8) After including the mediation effect of

consistent discipline, the association between self-compassion and externalizing problems (c’ path) was no longer significant The model demonstrated a good fit to the data We calculated thebias-corrected bootstrapped 95% CIs and found that the mediation effect of consistent discipline was statistically significant, 95% CI = [-0.153, -0.006]