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

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PARENTAL GRIEF RESPONSES AND PERSONALGROWTH FOLLOWING THE DEATH OF A CHILD

LINDA P. RILEY

College of Nursing, University of Alabama at Huntsville, Hunstville,Alabama, USA

LYNDA L. LAMONTAGNE

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-sectionalstudy of bereaved mothers (N ¼ 35) examined the relationship of dispositionalfactors, grief reactions, and personal growth. More optimistic mothers reported lessintense grief reactions and less distress indicative of complicated grief. Addition-ally, mothers who usually coped actively had less intense grief reactions. Motherswho habitually coped using positive reframing had less intense grief reactionsand less complicated grief. Personal growth, a positive dimension of grief, wasassociated with all three coping dispositions; mothers’ active coping, support seek-ing, and positive reframing suggesting more personal growth occurred in mothersexhibiting more of these coping dispositions. These findings increase understandingof dispositional factors associated with bereaved mothers’ grief responses andexpand knowledge concerning personal growth as an outcome of bereavement.

Parental grief following the death of a child often is characterizedby intense emotional, behavioral, cognitive, and physiological res-ponses that may continue for months or years or may even fail toresolve (Osterweis, Solomon, & Green, 1984; Rando, 1993; Rubin,Malkinson, & Witzum, 2000; Stroebe & Schut, 2001). Intense griefthat 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, AL35899. E-mail: [email protected]

277

Death Studies, 31: 277–299, 2007Copyright # Taylor & Francis Group, LLCISSN: 0748-1187 print/1091-7683 onlineDOI: 10.1080/07481180601152591

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over time has been labeled complicated grief. The key symptoms ofcomplicated grief include preoccupation with thoughts of the lovedone, intense separation distress, prolonged disbelief, and recurrentintrusive images or dreams (Prigerson et al., 1995; Prigerson &Jacobs, 2001). Complicated grief is thought to occur when the adapt-ive grief process is compounded by individual vulnerabilities or cir-cumstances surrounding the death that impede adjustment to theloss (Attig, 2002).

Prior studies of parental bereavement have focused primarilyon the negative consequences of parental grief including enduringdistress, confusion, depressive symptoms, and social withdrawal(Rando, 1993). Little attention has been given to the identificationof individual factors and coping resources that may positively influ-ence parents’ grief responses and may decrease complicated grief(Calhoun & Tedeschi, 1990, 2001; Gamino, Sewell, & Easterling,2000; Polatinsky & Esprey, 2000). Research that concentrates onpathological outcomes of grief fails to acknowledge the innatehuman capacity to cope with adversity and ignores grief’s powerto act as a catalyst for positive change and growth (Hogan, Green-field, & Schmidt, 2001; Wortman & Silver, 2001).

Research on parental grief has been limited by the lack of a well-articulated theoretical framework to guide the selection of studyvariables and to define the relationships of these variables to grief out-comes (Hogan & Schmidt, 2002; Neimeyer & Hogan, 2001; Pine &Bauer, 1986). In a review of the literature, two theoretical perspectiveswere applicable to the examination of parental grief as conceptualizedin this study. The grief to growth model (Hogan & Schmidt, 2002) andParkes’ is (1988, 1993) bereavement as a psychosocial transitiontheory were used to guide the selection of variables in this study.

Hogan and colleagues (Hogan et al., 2001) developed a griefscale that measures bereavement multi-dimensionally andincluded both positive and negative grief reactions. This instru-ment has been validated in studies of bereaved parents (Hogan& Schmidt, 2002; Hogan, Worden, & Schmidt, 2003–2004). Theseresearchers substantiated a grief to growth model that describesgrief as a process of transition and adjustment characterized byintense emotions of despair, detachment, and avoidance (Hogan& Schmidt, 2002). For some individuals this process also mayresult in the perception of personal growth, including positivechanges in self image, compassion, forgiveness, and tolerance.

278 L. P. Riley et al.


Parkes (1988, l993) conceptualized the grief process as a grad-ual transition of adjustment to an altered world following the deathof a loved one. In this process, bereaved individuals gradually inte-grate changes secondary to their loss into a new worldview. Inbereavement transition, dispositional factors are described aspotential vulnerabilities or strengths and are linked to the grief pro-cess and to subsequent outcomes (Parkes, 1993; Schaefer & Moos,2001; Schlossberg, 1981,1984).

In grief transition, the bereaved individual is regarded as anactive participant engaged in a gradual process of realization,change, and adjustment set within a socio-cultural context contain-ing supportive resources. Bereaved individuals also are recognizedas possessing vulnerabilities and strengths that may account forvariability in grief transition. Further, positive outcomes areincluded as potential consequences of transition, making the tran-sition perspective uniquely suitable for bereavement studies thatevaluate both negative and positive outcomes of the death of achild (Parkes, 1993; Schaefer & Moos, 2001).

The purpose of this study was to investigate the relationshipsamong bereaved mothers’ dispositional factors and bereavementoutcomes. The dispositional factors chosen for study were mothers’optimism, coping disposition, and perceived social support.Bereavement outcomes included mothers’ grief reaction, compli-cated grief, and personal growth.

Dispositional Factors Associated withParental Grief

Optimism

Optimism is defined as a dispositional factor characterized by generalexpectation of future positive outcomes (Carver, 1999). That is,more optimistic persons think that good things will happen and thatadversity can be dealt with successfully. Optimism is a stablepersonal factor thought to influence individuals’ appraisal of themeaning of a specific stressor and to enhance their ability to copewith the consequences of a stressful situation (Carver, Scheier,& Pozo, 1992; Folkman & Greer, 2000). For example, more opti-mistic individuals are flexible, better able to alter goals and priori-ties, and more accepting of unchangeable and uncontrollable life

Parental Grief and Growth 279


events (Scheier, Carver, & Bridges, 2001; Scheier, Weintraub, &Carver, 1986). Dispositional optimism, therefore, may be a personalresource that enables bereaved parents to accept the irreversibledeath of a child and to reframe the loss experience more positively(Nolen-Hokesema & Larson, 1999).

Only a few studies have looked at dispositional optimism inbereaved individuals and its relationship to coping or bereavementoutcomes (Davis, Nolen-Hoeksema, & Larson, 1998; Nolen-Hoek-sema & Larson, 1999). In one study of hospice deaths, pre-lossoptimism 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 optimisticindividuals had fewer symptoms of depression and general distressat 6, 13, and 18 months after the deaths. Optimism also was posi-tively correlated with finding meaning and seeking social support(Nolen-Hoeksema & Larson, 1999).

Coping

Coping disposition is a stable personal factor that determines howan individual habitually deals with life stressors (Brennan, 2001;Carver, Scheier, & Weintraub, 1989). Conceptualizing coping as atrait emphasizes the components of coping that remain consistentover time (Folkman, Lazarus, Dunkel-Schetter, DeLongis & Gruen,1986; Park & Folkman, 1997). Active coping, seeking support andpositive reframing are three dispositional coping strategies thoughtto significantly influence an individual’s response to adverse lifeevents (Carver et al., 1989). Active coping includes planning, takingdirect action, and increasing coping efforts. Coping by seekingsocial support includes searching for information, advice, sym-pathy, and assistance from the social network. Coping by positivereframing includes managing distress by positive reinterpretationor construing an event in positive terms (Carver et al., 1989).

To date only one study has examined coping disposition inparental grief. In the Netherlands, Hoekstra-Weebers, Littlewood,Boon, Postma, and Humphries (1991) found that younger parentsused more active problem solving than older parents andthat physical symptoms were positively correlated with parents’avoidant coping. These findings suggest that the coping dispositionof bereaved parents may significantly influence their overall health.



Social Support

The belief that there is a social support network of concerned indivi-duals who will allow bereaved parents to discuss the experience of los-ing their child has been associated with improved bereavementoutcomes (Hazzard, Weston, & Guiterres, 1992; Leopore et al.,1996; McIntosh, Silver, & Wortman, 1993; Wortman & Silver,1992). Social support from friends and community sources is uniquelyimportant in parental grief because the quantity and quality of supportavailable from within the family may be compromised due to otherfamily member’s grief. Available support, however, may not alwaysbe helpful and may be colored by unrealistic expectations forprompt recovery (Stylianos & Vachon, 1993). For example, parentsmay be urged to get over their grief by individuals who feel their griefis too intense and prolonged and who are uncomfortable providingsupport (Lehman, Ellard, & Wortman, 1986).

Bereavement Outcomes

Traditionally, descriptions of outcomes of grief transition haveemphasized the negative components of grief reactions ofbereaved individuals. The affective (e.g., grief misery), physical,cognitive, and interpersonal responses of grief range from mildto severe, and may vary individually or be exhibited in differingpatterns over time (Bonanno, 2001). Grief that remains consistentlyhigh in intensity and is associated with functional impairment islabeled 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 tosevere with varying degrees of functional impairment. Studies rat-ing complicated grief as a psychological disorder using cut offscores have been validated primarily in samples of bereavedspouses (Prigerson et al., 1997). Further validation of complicatedgrief disorder in the context of parental grief has been recom-mended for the determination of accurate diagnostic scores inthe context of parental grief (Hogan, Worden, & Schmidt, 2003).In this study a decision was made not to use cut off scores to diag-nose mothers’ complicated grief as a psychological disorder.

A sense of personal growth may be perceived by somebereaved individuals after experiencing the death of a child.



Specifically, they may discuss multiple benefits related to their lossexperience and may describe positive changes within their self-identity and within interpersonal relationships (Davis, Nolen-Hokesema, & Larson, 1998; Tedeschi & Calhoun, 1995, 1996;Wortman & Silver, 1987). Some studies of bereaved parents describethe perception of increased compassion and empathy for others, andthe need for adjusted values or reprioritized goals (Helmrath & Steinitz,1978; Miles & Crandall, 1983). Other studies of bereaved parents havedocumented growth as the perception of positive changes in parents’feelings of competence and strength, and improved interpersonal rela-tionships after the death of a child (Hogan et al., 2001; Hogan &Schmidt, 2002; Polatinsky & Esprey, 2000).

In studies of coping with adverse events, positive outcomeshave been labeled as posttraumatic growth (Calhoun & Tedeschi,2001), stress-related growth (Park, Cohen, & Murch, 1996), or per-sonal growth (Frantz, Farrell, & Trolley, 2001; Gamino et al.,2000; Hogan & Schmidt, 2002). Clarifying the factors that are asso-ciated with positive grief outcomes has been identified as researchpriority in order to design interventions that encourage personalgrowth (Calhoun & Tedeschi, 2001; Schaefer & Moos, 2001).

Hypotheses

The dispositional factors of optimism, dispositional coping, andperceived social support were hypothesized to be negativelyrelated to bereaved mothers’ grief responses and complicated grief,and positively related to personal growth. That is, mothers whowere more optimistic, who usually coped using active coping, sup-port seeking and positive reframing and who had perceptions ofadequate social support would experience less intense grief reac-tions, less complicated grief responses, and more personal growth.

Method

Sample

This cross-sectional descriptive study recruited 35 bereavedmothers during a six-month period from clients in two communitygrief centers in the southeastern United States. Bereaved motherswere eligible for this study if their deceased child was under 21



years of age and died from 2 to 30 months prior to their partici-pation. Mothers participated in individual or group counseling ses-sions conducted in the community or received the monthlynewsletter from the Compassionate Friends. Mothers in this sam-ple were predominantly married (90%), Caucasian (92%), andwell educated with 58% reporting college education and 23%holding a professional degree. Mothers’ mean age was 44 years(SD ¼ 8.8), ranging from 25 to 66 years. The most frequent causesof children’s death were accidents (58%) and neonatal infantdeaths (12.5%). The mean age of deceased children was 12 years.The mean length of bereavement was 15.7 months (SD ¼ 8.4).

Procedure

Following approval by the Institutional Review Board, participantswere recruited from bereaved mothers who attended Compassion-ate Friends support group meetings or had participated in individ-ual grief counseling in two cities in the southeastern United States.Additional participants were recruited through advertisement ofthe study in monthly newsletters. The principal investigatordescribed the study by phone or in person to individuals who wereinterested in participating and scheduled an appointment for aface-to-face interview. After signing an informed consent form,mothers completed a packet of questionnaires in the presence ofthe principal investigator which took approximately 45 minutes.

Instruments

Optimism was measured using the Life Orientation Test Revised(LOT–R; Scheier, Carver, & Bridges, 1994). Responses are ratedusing a 5-point Likert scale from 0 (strongly disagree) to 4 (Stronglyagree). Possible scores range from 0 to 24 with higher scores indicat-ing more optimism. Scale developers reported internal consistencyof .78 and established concurrent validity using measures of selfesteem (Rosenberg, 1965) and trait anxiety (Spielberger, Gorsuch,& Lushene, 1974). Additional details concerning the revision of theLOT scale may be found in the article by Scheier et al., (1994).

Coping disposition was measured using the dispositional ver-sion of the COPE Scale (Carver, et al., 1989). Thirty-six itemsfrom the longer original COPE instrument that formed three



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 seekingcoping (seeking emotional support and information and a focuson emotions), and positive reframing (restraint coping, positivereinterpretation, and acceptance). Response choices were care-fully 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 byscale developers as above .62 and validity was confirmed by com-parison with measures of trait anxiety, self-esteem, and neuroticism(Carver et al., 1989).

Perceived social support was measured using the 5-itemInventory of Social Support (ISS; Hogan & Schmidt, 2002). Thisscale evaluates the degree a bereaved person believes someoneis available to listen non-judgmentally to his or her expression ofgrief. Items are rated on a Likert scale from 1 (does not describe meat all) to 5 (describes me very well) with higher scores indicating moreperceived social support. Cronbach alpha is reported as .76 by thescale developers.

Grief responses were measured using the Hogan Grief Reac-tion Checklist (HGRC; Hogan et al., 2001). This scale contains61 items and measures negative dimensions of grief using five sub-scales (49 items). Item responses were rated from 1 (does not describeme at all) to 5 (describes me very well). Higher scores indicate moregrief reactions over the past two weeks. The five negative subscalesare summed to give an index score of grief misery. This method ofscoring the negative aspects of grief was suggested by Gamino et al.,(2000).

Complicated grief was measured using the 19-item Inventoryof Complicated Grief (ICG; Prigerson et al., 1995). Grief symp-toms often associated with dysfunction including separation anxi-ety and intrusive thoughts were evaluated. The scale omitsdepressive symptoms and anxiety-related responses and focuseson responses indicative of more intense forms of grief. Symptomfrequency is rated on a scale from 0 (almost never or less than oncea month) to 4 (always or more than once a day). Higher scores indicatemore symptoms or greater complicated grief. Alpha coefficientsrevealed internal consistency of .94 and concurrent validity wasdetermined by comparison to the Beck Depression Inventory



(Beck, Ward, & Mendelson, 1961) and the present grief subscale ofthe Texas Revised Grief Inventory (Faschingbauer, Zisook, &DeVaul, 1987).

Personal growth was measured using two scales to increasestudy accuracy and to expand the dimensions of bereavedmothers’ personal growth evaluated. The 21-item PosttraumaticGrowth Inventory (PTGI; Tedeschi & Calhoun, 1996) was usedto describe the perception of growth or positive change withinthe self, improved interpersonal relationships, and changes in lifepriorities or goals compared to pre-crisis. Responses are rated from1 (I did not experience this change as a result of my crisis) to 6 (I experiencethis change to a very great degree as a result of my crisis). Higher scoresindicate the perception of more positive change or growth. Internalconsistency for the total scale was .95 and validity was supportedby comparison to the personality traits of optimism and extraversion(Tedeschi & Calhoun, 1996). Personal growth also was measuredusing 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 (doesnot describe me at all) to 5 (describes me very well) with higher scoresindicative of the perception of more personal growth. Internal con-sistency for the growth subscale was .82 (Hogan et al., 2001).

PARENT INFORMATION

Mothers provided demographic information including age, edu-cational level, ethnicity, occupation, and marital status. The Hol-lingshead Four Factor Index of Social Status (Hollingshead, 1975)was used to evaluate parents’ socioeconomic status categoricallywith higher numbers representing higher social class.

Statistical Analysis

SPSS version 13 was used for data analysis. The hypothesizedbivariate relationships between dispositional factors and parentalgrief outcomes were assessed using correlations. Although therewere no multivariate hypotheses proposed, the data were furtherexplored using multiple regression to assess the unique contribu-tions of each personal factor when all of the other factors were con-tained in the same multiple regression model. The .05 level ofsignificance was used for all analyses.



Results

Descriptive statistics, including coefficient alpha, for all instru-ments used in this study are found in Table 1. Internal consistencyfor all instruments ranged from .80 for positive reframing copingdisposition to .96 for the combined misery subscales of the HoganGrief Reaction Checklist.

Correlational Analyses

Mothers’ grief responses were negatively related to all dispositionalfactors indicating that more optimistic mothers, those who usedmore active coping, more seeking support, and more positivereframing, and those who had higher levels of perceived social sup-port reported fewer grief responses. For complicated grief, this pat-tern was identical with one exception: the relationship ofcomplicated grief with active coping was not statistically significant.That is, more optimistic mothers, those who used more seeking sup-port and more positive reframing, and those who had higher levelsof perceived social support had less complicated grief.

Personal growth as measured by both instruments was posi-tively related to all the dispositional factors except for optimism.Mothers’ active coping was positively related to personal growthindicating that individuals with a more active coping dispositiondescribed more personal growth and positive change. Supportseeking coping disposition was positively related to both measuresof personal growth, indicating that bereaved mothers who usuallyseek support from others describe a greater sense of personalgrowth. Positive reframing coping was positively related to bothmeasures of personal growth indicating that mothers who usuallyuse positive reframing also indicated more personal growth. Per-ceived social support also was found to have a positive relationshipwith both measures of personal growth, indicating that greater per-ceived support was associated with more personal growth.

Multiple Regression Analysis

When all the personal factors were included in a multiple regressionmodel predicting complicated grief, none were statistically signifi-cant. However, in the model predicting grief responses, optimism



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remained significant (p¼ .04) and positive reframing was margin-ally significant (p¼ .05). When only optimism and positive refram-ing were used to predict grief responses, both were significant(p¼ .03 and .02, respectively). More optimistic mothers and thosewho used more positive reframing had less intense grief responses.When all the personal factors were included in models predictingthe two measures of personal growth, none were statistically signifi-cant. When controlling for all the other personal factors, noneaccounted for a significant amount of variance.

Discussion

This study investigated the relationships among bereaved mothers’dispositional factors and bereavement outcomes. First the relation-ship between bereaved mothers’ dispositional factors and the griefresponses are discussed. This is followed by a discussion of therelationships between their dispositional factors and personalgrowth.

Dispositional Factors and Grief Responses

Although optimism is rarely described as an important disposi-tional factor in bereavement research, in this study the protectiveproperties of optimism were supported by the strong relationshipfound between optimism and grief responses. Further, when allother dispositional factors were controlled for, optimism was theonly variable that had a unique contribution in predicting griefresponses. More optimistic mothers experienced less intense griefresponses after the death of their child. Additionally, optimism andcomplicated grief also had a strong negative relationship. That is,more optimistic mothers reported less frequent intrusive images,yearning and searching behaviors, disbelief, and numbness, orresponses usually associated with poor health outcomes.

There are several possible explanations for these relation-ships. First, because optimism is characterized by individualswho possess positive future expectations, bereaved mothers’ searchfor the positive may reduce the intensity and duration of griefresponses as well as improve their ability to find meaning andsignificance in the death of their child. Second, when adjustingto misfortune, more optimistic individuals have been shown to



remain persistent in efforts to deal with adverse events even whenprogress is slow or difficult (e.g., Carver et al., 1989). The expec-tation of eventual positive outcomes may have sustained copingefforts of the grieving parents in this study as they slowly adaptedand coped with changes secondary to the death of their child.Third, research studies dealing with other types of crisis events sug-gest that more optimistic individuals cope differently. For example,optimistic individuals have been found to be more accepting ofunchangeable life events and more flexible in adjusting life goalsor priorities (e.g., Carver et al., 1989). These behaviors may haveprofound influence in the context of parental grief when parents’ability to accept the unalterable reality of their child’s death mayplay a key role in alleviating symptoms of complicated grief.

Coping disposition in this study was related to bereavementoutcomes. Bereaved mothers who usually coped with a crisisactively by taking direct action, planning, and problem solvinghad less frequent or intense grief responses. This finding is consis-tent with a study conducted by Murray and Terry (1999) who foundthat mothers who habitually used problem-focused coping reportedless general distress and anxiety 15 months after the death of a child.

Although active coping disposition was found to be related togrief responses, no relationship was identified between active cop-ing disposition and complicated grief indicating that bereaved par-ents with active coping dispositions did not experience lesscomplicated grief. This finding was unexpected. It is possible thataction, planning, and problem solving may not be effective copingstrategies when parent’s separation distress is overwhelming andthe reality of the death is unalterable. Further, active coping maynot reduce the intensity of the yearning for reunion and the pres-ence of intrusive thoughts characteristic of complicated grief. Morepalliative modes of coping such as distancing and withdrawal maybe more effective when parents’ distress is intense.

Significant relationships were found between bereavedmothers’ support seeking coping disposition, grief reactions, andcomplicated grief. The desire to share one’s loss experience withother people was related to better bereavement outcomes, less griefreaction, and complicated grief for mothers in this study. Socialsupport characterized by empathy and warmth may provide anappropriate outlet for the expression of emotional distress thatcan be normalized and accepted.



Bereaved mothers who managed distress by acceptance andreframing of the negative experience in a positive light experi-enced less intense grief responses and less complicated grief. Posi-tive reframing was marginally significant in predicting griefresponses when controlling for the other dispositional factors sug-gesting that it also may be an important independent factor influ-encing grief responses. This finding is consistent with otherstudies of bereaved family members that report less intense griefreactions in individuals who had the ability to see something goodresulting from a death and had an opportunity to say goodbye tothe deceased (e.g., Gamino et al., 2000).

Further, the tragic loss of a child may destroy parents’ funda-mental perceptions of their role as their child’s protector and thusdamage their self image. This type of world-shaking event maynecessitate an extended effort to search for any remnant of thepositive in the death. Parents may attempt to reconstruct orreframe the event to maximize positive emotions, to restore theiridentity and create some degree of stability and predictability intheir lives.

As hypothesized, mothers who perceived more availablesocial support reported less intense grief responses and less compli-cated grief. Because intensely distressed parents need to processthe details of the traumatizing event in order to accept the death(Simpson, 1997), the availability of confidants who allow the tellingand retelling of the circumstances surrounding the death may beuseful to facilitate optimal adjustment and gradual acceptance inthe core process of grief transition. The opportunity to share theexperience of losing a child with someone whose child also diedmay lessen parents’ sense of shock and injustice and so lessen com-plicated grief symptoms.

Dispositional Factors and Personal Growth

The relationship between optimism and personal growth was posi-tive for bereaved mothers in this study, although not statisticallysignificant. Because other studies in the bereavement literaturehave identified personality traits as indicators of important copingresources that may influence adjustment to the death of a familymember (e.g., Nolen-Hoeksema & Larson, 1999), this relationshipneeds further study using a larger sample. The possibility that more



optimistic mothers may possess effective coping reserves or intrin-sic resources to draw upon in stressful situations such as the loss ofa child needs clarification.

Mothers’ active coping disposition was associated with per-sonal growth. Specifically, individuals who habitually plannedand problem solved when faced with life stressors perceived morepersonal growth than those who do not deal with life events in thismanner. Although personal growth has been measured in priorstudies of bereaved parents, this study is the first to support the linkbetween personal growth and active coping disposition.

Support-seeking coping disposition was associated with per-sonal growth. Bereaved mothers who habitually coped with stress-ors by seeking instrumental and emotional support reported asense of greater personal growth after the death of their child. Theydescribe social support as available advice, consolation, and asense of caring. The findings of this study support similar findingsof a parental grief study in Finland conducted by Laakso andPaunonen-Ilmonen (2002). This study found that bereaved mothersreported more personal growth when they relied on social supportprovided by family members and friends. The opportunity to par-ticipate in bereaved parents’ support groups may have helped theparents in this study to reframe their experience more positivelyafter listening to other parents describe their experiences. Thus,the empathic environment of a mutual support group may serveas a forum for parents’ search for meaning after the death of theirchild and may facilitate parents’ perception of personal growth.

Mothers’ positive reframing of their experience was fre-quently observed during the 6 months of participant recruitmentfor this study. Bereaved mothers often discussed positive changesthey believed were the result of their bereavement and describedtheir process of grief transition as a process of gradually being ableto remember their child with a smile rather than with tears.Mothers’ appreciation of the frailty of life and of the value of inter-personal relationships have been described as essential compo-nents of the concept of personal growth (Tedeschi & Calhoun,1996). Reframing the experience of loss to include the possibilityof positive outcomes is a coping skill that could be nurtured byhealth care professionals.

Perceived social support also was strongly correlated with par-ents’ perception of personal growth. Mothers who felt that adequate



support was available within their social network perceived morepersonal growth, including positive changes in their self-identityand improved interpersonal relationships. This finding is consistentwith other studies that report a direct positive effect of perceivedsocial support on personal growth including parents’ improvedappreciation of individual strengths and events of daily life (e.g.,Cadell, Regeher, & Hemsworth, 2003; Tedeschi & Calhoun,1996).

These results indicate that bereaved mothers who habituallycope using active coping, support seeking, and positive reframingand who perceived adequate social support described a sense ofpositive 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 relation-ships between dispositional factors and parental grief outcomes ofgrief reaction, complicated grief, and personal growth. The resultsof this study, however, do provide a basis for the design of futurelongitudinal research studies of bereaved mothers over a longerperiod of adjustment to the myriad changes associated with the lossof a child. The relationships of factors identified as strongly relatedto grief outcomes in this study need to be examined in more detailusing multiple measurements across time during bereavement.

Another limitation is this study’s recruitment from support-seeking bereaved mothers who were predominantly Caucasian.Further, individuals attending support groups may differ in distresslevels, ease of emotional expression, and the level of perceivedsocial support from bereaved parents who do not seek support(Allumbaugh, 1999; Caserta & Lund, 1992). A sample of predomi-nantly Caucasian mothers represents only a cross-section of race,ethnicity and gender, therefore, the generalizability of the findingsto 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 rela-tionships hypothesized, in order to adequately address and assessmultivariate relationships and longitudinal relationships a largersample size is needed in future research.

A strength of this study is the inclusion of personal growth asa positive outcome of parental grief. Doing so broadens the



traditional focus on negative outcomes of parental grief andaddresses the strength and resilience of bereaved mothers. Con-ceptualization of parental grief as an active process of adjustmentto the changes created by the death of a child depicts bereavedmothers as engaged rather than passive grievers. Examination ofthe relationship of optimism and grief responses is a valuable contri-bution to the expanding bereavement literature that relates optimismto improved psychological state, the perception of personal growth,and other positive outcomes of crisis. Measuring parental griefresponses using two empirically derived grief instruments rather thanusing general measures of psychological distress allowed evaluationof normally expected grief reactions as well as parents’ responsesassociated with impaired psychological and physical health.

Conclusion

This study contributes to a growing body of work that emphasizesthe need for inclusion of positive in addition to negative outcomesas potential consequences of parental grief. Although this cross-sectional study found strong relationships between bereavedmothers’ optimism, coping disposition, perceived social support,and parental grief outcomes, longitudinal studies of parentalbereavement clearly are needed to define causal relationships. Stu-dies over time are needed to accurately test the predicted associ-ation of dispositional factors and bereavement outcomes. Futurestudies using measurements over the grief process will give a morerealistic description of how these factors are intertwined and maybegin to clarify the influence of possible mediators (e.g., coping)and moderators (e.g., characteristics of the death) that explain ormodify the relationships between dispositional factors and bereave-ment outcomes. Optimally, prospective studies of bereavement willallow detailed exploration of these relationships while controllingfor parents’ stable traits and characteristics as well as pre-existingpsychological state before the loss.

This study emphasizes the need for the development of a cop-ing scale designed specifically for bereavement studies. Such ascale is necessary to allow more accurate measurement of the com-plex process of coping with the long-term stressors unique to grieftransition. Creation of a coping instrument that better captures themultiple foci of attention and the use of diverse modes of coping



with loss has been suggested as essential for accurate assessment ofthe transition of bereavement (Van Heck & DeRidder, 2001).

Both theoretical and empirical advances are needed to insurethe development of the most appropriate interventions for bereavedparents. Although Hogan’s grief to growth model and Parkes’ tran-sition theoretical perspective provided useful frameworks for thisstudy, neither of these approaches alone would adequately captureall the conceptual nuances necessary for an adequate theory. Also,greater knowledge is needed to effectively screen for individualsat risk for complicated grief and to create specific interventions thatenhance skills associated with growth and that support individualsat greater risk for poor grief outcomes after the death of a child(Wortman & Silver, 1992). For example, skill-building interventionsthat emphasize the importance of cognitive flexibility and positivereinterpretation may strengthen a parent’s ability to adjust to thedeath of a child. In addition, bereavement interventions that facili-tate reframing of the loss and recognizes growth as positive changeswithin the self and interpersonal relationships may improve out-comes for grieving parents. More study is required to fully under-stand the key factors that promote optimal personal growth, todetermine their mechanism of influence on outcomes of bereave-ment, and to craft effective programs of intervention.

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