Communication, self-esteem and prolonged grief in parent-adolescent dyads, 1 – 4 years following the death of a parent to cancer

Purpose: Talking and grieving together may be advantageous for maintaining belief in a meaningful future and can help bereaved adolescents and their parents to cope better with the situation. The aim of this study was to explore communication, self-esteem and prolonged grief in adolescent-parent dyads, following the death of a parent to cancer. Method: This study has a descriptive and comparative design. Twenty family dyads consisting of parentally bereaved adolescents (12 – 19 years) and their widowed parents completed the Parent and Adolescent Communication Scale, Rosenberg Self-Esteem Scale and Prolonged Grief-13, 1 – 4 years following the death of a parent. Results: Twelve family dyads reported normal-high parent-adolescent communication, 11 dyads rated normal-high self-esteem. Two adolescents and three parents scored above the cut-off for possible prolonged grief disorder ( ≥ 35), none of these were in the same dyads. There was a difference ( p < .05) between boys (mean 40.0) and girls (mean 41.9) with regard to open family communication, as assessed by parents. Girls reported lower self-esteem (mean 26.0) than boys (mean 34.1, p < .01). Conclusions: This study provides insights from parentally bereaved families which indicate that despite experiencing the often-traumatic life event of losing a parent or partner, most participants reported normal parent-adolescent communication, normal self-esteem and few symptoms of prolonged grief. The potential usefulness of identifying families who may need professional support in family communication following the death of a parent is discussed.


Introduction
The death of a parent is among the worst things that can happen to an adolescent.The loss of someone loved may affect the individual emotionally, physically, socially, cognitively, and spiritually (Zisook et al., 2014).Previously, adolescents and young adults have reported poor psychosocial wellbeing, anxiety, and depression following the death of a parent to cancer (Lundberg et al., 2018a).If grief reactions persist, the risk of negative outcomes, such as depression, insomnia, and prolonged grief may increase (Bylund-Grenklo et al., 2016).Also, loss of a loved one in adolescence may result in negative life events that make it difficult to cope with losses later in life (Schwartz et al., 2018).
For the widowed parent, losing a partner is not only associated with an elevated risk of psychological health problems, such as depression and anxiety (Blanner Kristiansen et al., 2019;Yopp et al., 2019), which may impact their parental role.The parent also must adjust to substantial secondary consequences of loss, such as changes in household roles and household communication patterns (Stroebe and Schut, 1999;Weber et al., 2019a).A qualitative study, with focus on communication in families with minor children following the death of a parent to cancer, revealed the importance of family communication for coping with the loss (Weber et al., 2019a).Furthermore, studies suggest that communication between the surviving parent and child may be a useful target of clinical intervention to improve psychological health.(Field et al., 2014;Shapiro et al., 2014;Weber et al., 2019b).
Although grief is a natural human reaction and a universal feature of life, form and intensity of its expression can vary considerably.Grief is a complex process, which may affect the development of our identities as it is closely linked to those aspects of life that are most important to us (Archer, 1999).Sometimes yearning becomes persistent, and intense emotional pain and preoccupation with the diseased cause functional impairment.If this impairment lasts for more than six months after the loss it can be referred to as prolonged grief (Prigerson et al., 2009).
Communication is an important factor in determining children's grief reactions.Engaged communication has been reported to be associated with lower levels of grief and depressive symptoms in bereaved children (Shapiro et al., 2014).In a parent-adolescent dyad it is possible that the individuals are at different stages of the grieving process, and consequently have difficulties with communication within the family.Accordingly, as adolescents strive for more autonomy and independence, distress in parent-adolescent relationships is common.Research has shown that the intensity of conflicts is often high and may increase over time in some parent-adolescent dyads, whereas other have lower, more stable levels of conflict intensity across adolescence (Hadiwijaya et al., 2017).
Good family communication has the potential to increase adolescents' life satisfaction and self-esteem (Cava et al., 2014;Levin et al., 2012;Lo Cascio et al., 2013) as well as their psychological health (Weber et al., 2019b).Talking and grieving together with the widowed parent may be advantageous for maintaining belief in a meaningful future and can help bereaved adolescents and young adults to cope better with the situation.In a study by Lundberg et al. (2018a), bereaved young adults reported high levels of a meaningful future when they had good relationships with the widowed parent, shared their grief and received support.Accordingly, poor communication with the widowed parent has been associated with an increased risk of depression and anxiety (Lo Cascio et al., 2013;Raveis et al., 1999).On the other hand, widowed parents have expressed that providing their children with practical and emotional support while at the same time dealing with their own grief can be both difficult and stressful (McClatchey, 2018;Weber et al., 2019a) as they may be struggling with their own identity and feelings of guilt.This struggle may negatively affect their communication with their children (Weber et al., 2019a).Moreover, parental depression has been shown to be associated with poor self-esteem in their children (Krug et al., 2016).
To our knowledge, no previous study has explored communication, self-esteem and prolonged grief in paired adolescent-parent dyads.Considering that both adolescents' and parents' psychological health and self-esteem seem to be dependent on family member's ability to communicate with one another, and that communication may help families to cope with their grief, we found it advantageous to study this further.Thus, the aim of this study was to explore communication, selfesteem and prolonged grief in adolescent-parent dyads, following the death of a parent to cancer.

Design
This study has a descriptive and comparative design, and data was derived from a larger project investigating communication and psychological health in bereaved families with children between 1 and 18 years old at time of parent's death.The study was conducted in accordance with the principles embodied in the Declaration of Helsinki (World Medical Association, 2013).Ethical approval was obtained from the Regional Ethical Review Board in Stockholm, Sweden (Dnr, 2016/1192-31/1).

Participants and procedure
Participants were Swedish-speaking families with children and adolescents living at home.For this paper, we focused on adolescents (12-19 years old) who had lost a parent to cancer 1-4 years earlier and their widowed parents.The families should reside in Stockholm County during data collection and the parents should have lived together at the time of death, to enable examination of the effects of the death on both the adolescent and the widowed parent.
The Swedish National Causes of Death Register and the Multi-Generational Register at Statistics Sweden were used to identify potential participants.Eligible families were identified and sent an informational letter including a link to a website, where they could sign up to register for the study.A link to an online questionnaire was then sent to them by e-mail.Twenty-three adolescents participated in the study, of which three were excluded from the analyses in this paper as their parents did not participate.Data was collected between November and March 2018.

Measures
Study-specific questionnaire.The participants filled out a study and age specific questionnaire, consisting of questions on demographics.
Parent-adolescent communication.The Parent and Adolescent Communication Scale (PAC) was used to measure parent-adolescent communication.Parents completed a parent-proxy form for each of their participating adolescents.Adolescents completed an age adapted adolescent self-report questionnaire.The PAC consists of 20 items answered on a 5-point Likert scale (1 = Strongly disagree, 5 = Strongly agree) with a possible score range between 20 and 100, where scores 20-69 indicate low communication, 70-79 normal communication, and 80-100 high communication.The PAC includes two subscales: open family communication, focusing on the positive aspects of parentadolescent communication, and problems in family communication, focusing on the negative aspects.The items on the problems in family communication subscale are reversed in the analysis, i.e., the higher the score, the milder the problems (Barnes and Olson, 1982).The PAC has been translated and validated previously, where this population was part of the sample (Weber et al., 2019b).The internal consistency for the PAC was high in this sample (total PAC Cronbach's α = 0.92, open family communication Cronbach's α = 0.88, problems in family communication Cronbach's α = 0.85).
Prolonged grief.To assess symptom levels of prolonged grief, the Swedish version of PG-13 was used (Pohlkamp et al., 2018;Prigerson et al., 2009).The PG-13 contains 11 items assessing cognitive, behavioral and emotional symptoms, rated on a 5-point scale (1 = not at all, = several times a day/overwhelmingly), and two items assessing duration and impairment ("yes" or "no").A score of ≥35 indicates probable prolonged grief disorder adults (Pohlkamp et al., 2018).A cut-off score for prolonged grief in adolescents is not available.

Statistical analyses
Descriptive statistics, e.g., means, standard deviations (sd), medians (md), quartiles (q1-q3), frequencies (n) and percentages (%) were used to describe participants' demographic characteristics, as well as parent and adolescent ratings of parent-adolescent communication (PAC), selfesteem (RSE) and prolonged grief (PG-13).Wilcoxon's signed rank test was used to compare parent's reported scores on PAC, RSE and PG-13 with their adolescent's scores on the same instruments, i.e., paired adolescent-parent dyads.The Mann Whitney U test was used to test for differences in PAC, RSE and PG-13 between gender.Spearman's rho (ρ) was used for correlation analyses between the validated instruments.SPSS version 25 was used for statistical analyses.

Family dyad characteristics
In total, 20 family dyads consisting of 20 adolescents (12 girls and eight boys) and 17 parents (11 mothers and six fathers) participated in the study (Table 1).When there was more than one adolescent in the family, the parent answered separate PAC forms for each adolescent.The average age of the adolescents was 15.3 years (sd = 2.0) and that of the parents was 50.5 years (sd 4.9).The families had lost one parent to cancer within the past four and a half years (mean = 3.4 years, sd = 1.0).The adolescents were between 8 and 17 years old at time of death (mean = 12.4 years, sd 2.0).
No statistically significant differences were found between the adolescent and parent reports with regard to parent-adolescent communication (Table 2).Time since death correlated negatively with the adolescents' reports of parent-adolescent communication for PAC total score (ρ = − 0.50, p < .05)and for the open family communication subscale (ρ = − 0.47, p < .05),indicating that the adolescents' ratings of parent-adolescent communication was higher for the adolescents from families with a shorter time since death.This correlation was not found for parent reports.
There was a significant difference (p < .05) between boys and girls with regard to parents' open family communication, indicating that the parents experienced more open communication with their daughters (mean = 41.9, sd = 5.3, md = 44, q1-q3 = 40-45) than their sons (mean = 40.0,sd = 2.3, md = 40, q1-q3 = 38-43).No significant correlation was found between the adolescents' or the parents' age and ratings of parent-adolescent communication.

Self-esteem in the adolescents and their parents
Five adolescents and four parents rated themselves over the cut-off for high self-esteem (≥36), and nine adolescents and nine parents rated their self-esteem as normal (25-36).In total, 11 family dyads rated normal-high self-esteem, whereof high self-esteem was found in both the adolescent and the parent in one dyad (A20/P20).Six adolescents and four parents, including two family dyads (A1/P1 and A7/P7), rated their self-esteem as low (<25) (Fig. 1).

Prolonged grief
Two adolescents and three parents scored ≥35, which is a suggested cut-off for possible prolonged grief disorder in adults.None of these were in the same family dyads.No statistically significant differences were found in prolonged grief between the adolescents and their parents (Table 2).No statistically significant differences in prolonged grief were found between gender.Time since death and age were not significantly correlated with symptoms of prolonged grief.

Correlations between parent-adolescent communication, self-esteem and prolonged grief
For the parents, higher scores on parent-adolescent communication total score correlated statistically significantly with higher scores on self-esteem (ρ = 0.58, p < .01),and the same was seen for open family communication and self-esteem (ρ = 0.59, p < .01).No such correlations were found in the adolescents' reports.
No statistically significant correlations were found between prolonged grief and parent-adolescent communication or between prolonged grief and self-esteem, even though there was a non-significant tendency that high levels of prolonged grief were related to low selfesteem in both groups (adolescents: n = 20, ρ = − 0.40, p = .08,parents: n = 17, ρ = − 0.47, p = .06).

Discussion
This study, focusing on communication, self-esteem and prolonged grief in family dyads consisting of cancer-bereaved adolescents and their widowed parents, mainly reflect normal levels of parent-adolescent communication and self-esteem, and little impact of prolonged grief.The findings reveal that widowed parents reported more positive open communication with their daughters than their sons.Moreover, we found that parentally bereaved girls assessed self-esteem significantly lower than the boys.
Most adolescents, as well as parents, reported scores above the cutoff for normal parent-adolescent communication, and sores indicating high parent-adolescent communication were mutual in five of the twenty family-dyads.However, there were two family dyads in the present study below the cut-off for normal parent-adolescent communication, whereof one family dyad also reported mutual low self-esteem.This may be worth noting already during a parent's illness, to support such   families and enhance their communication as mutual open family communication is central for the democratic functioning in families, leading to satisfaction in both adolescents and parents (Stattin et al., 2011).Bereaved adolescents wanting to improve parent-adolescent communication could be invited to family support programs.In Sweden, a grief and communication support intervention comprised of three sessions has been adapted from the Family Bereavement Program (Ayers et al., 2013;Sandler et al., 2003Sandler et al., , 2018)), and a pilot study suggests that the intervention program could be both feasible and beneficial for families following the death of a parent.
The parents in the current study reported higher open communication, with their daughters than their sons.No studies of parents' reports of parent-adolescent communication were found to either confirm or reject this finding.Adolescents' reports in previous studies are contradictory, and no study was found examining this in the context of bereaved families.A study by Vokáčová et al. (2017), found that boys communication with their fathers easier than girls.Other studies of adolescents' reports of parent-adolescent communication reveal that adolescents have better open communication with their mothers than their fathers (Chen et al., 2018;Heller et al., 2006).It seems that parents perceive a higher quality of communication between themselves and their adolescent when the adolescent shows more openness to communication.Heller et al. (2006) found that girls report higher levels of empathic concern than boys, which was related to open communication with their parents, regardless of parents' gender.
Half of the family dyads in our study reported mutual normal or high self-esteem.This result is consistent with the findings of Lundberg et al. (2018aLundberg et al. ( , 2018b)), who reported normal to high self-esteem in young adults following the death of a parent.What the current study adds, is that girls reported significantly lower self-esteem than boys.This difference has been observed in different cultures across the world (Bleidorn et al., 2016).Overall, boys tend to report higher self-esteem than girls do.Bleidorn et al. (2016) also found that self-esteem increases from adolescence to adulthood, and that this might reflect universal biological processes as well as universal sociocultural influences.According to Pérez-Fuentes et al. (2019), high school students who feel the most affection and communication from their parents were the ones who scored highest on measures of self-esteem.This contrasts with our findings, where the parents reported higher open communication with their daughters, but still the daughters reported lower self-esteem than the sons.
We could not reveal a statistically significant relationship between self-esteem and parent-adolescent communication, yet the family dyad with highest score of self-esteem also scored high on parent-adolescent communication, whereas the family dyad with lowest score of selfesteem reported low parent-adolescent communication.Further, Dellmann (2018) suggests that low self-esteem may be a risk factor in prolonged grief after the death of a partner.In the current study, no significant association was found between symptoms of prolonged grief and self-esteem or between symptoms of prolonged grief and parent-adolescent communication.
The results of this study highlight family communication and selfesteem in bereaved adolescents and their parents.Adolescence is one of the most active phases of human development and physical, psychosocial, emotional or environmental changes during this time may cause health consequences not only in adolescence but over the lifecourse (World Health Organization, 2019).Health care professionals who meet families where a parent is dying or has died, may encourage the adolescent and his or her parents to speak openly and honestly about their feelings, emotional as well as physical, this may also support their grief process (Oates and Maani-Fogelman, 2020).In some families, it may be enough to encourage continuing communication, whereas others may need more professional support to enhance parent-adolescent communication.Evidence-based guidelines for family-centred care within adult palliative care, including care of children and adolescents, would be beneficial for health-professionals to utilise when they meet the ill parent's family.Family-centred care is a way of caring for children and their families within paediatric care, ensuring that the care is planned around the whole family, and that all family members are recognized as care recipients (Shields et al., 2006;Shields 2015).However, to our knowledge no previous studies or evidence-based guidelines for family-centred care within adult palliative care has been found.There is a need for such to enhance the status of children and adolescents in the bereaved family.

Limitations
Our study has both strengths and limitations.Studying communication and self-esteem and prolonged grief in adolescent-parent dyads is a unique approach.Furthermore, both mothers and fathers are represented, as well as their daughters and sons, although the number of participants is sparse.Unfortunately, we have no information of the families who declined participation and their reason to do so.This may have biased our findings.

Conclusion
This study provides insights from parentally bereaved families which indicate that despite experiencing the often-traumatic life event of losing a parent or partner, most participants reported normal parentadolescent communication, normal self-esteem and few symptoms of prolonged grief.It is impossible for us to draw any causal conclusions whether the well functioned communication, and normal level of selfesteem among participating parent adolescent dyads reflect the low symptoms of prolonged grief or not.One can assume that, from previous knowledge that openness in family communication reduce the risk of prolonged grief symptoms.
s signed rank test was used to compare paired adolescent-parent dyads in all outcomes, n = 20.b Parent-Adolescent Communication Scale.Parents answered one form for each adolescent, n = 20.c Rosenberg Self-Esteem Scale.Parents answered one form for themselves, n = 17.d PG-13.Parents answered one form for themselves, n = 17.C. Angelhoff et al.

Table 2
Family communication, self-esteem and grief.