How do the experiences of the early separated and the early bereaved differ and to what extent do such differences affect outcome?

Soc Psychiatry (1984) 19:163-171 Social Psychiatry �9 Springer-Verlag 1984

How do the experiences of the early separated and the early bereaved differ and to what extent do such differences affect outcome?

John Birtchnell and John Kennard

MRC Clinical Psychiatry Unit, Graylingwell Hospital, Chichester, West Sussex, UK

Summary. From a survey of 40- to 49-year-old women from Chichester, West Sussex, 45 were selected whose mothers died before they were aged 11, 38 who were evacuated from their mothers during the 1939-1945 War and 45 who were separated from their mothers for other reasons for at least a year before they were aged 10. A series of 69 non-mother- bereaved or non-mother-separated controls of similar age-range was also collected. Each subject was interviewed at home and asked to complete the Mid- dlesex Hospital Questionnaire, a modified Zung De- pression Scale and the Navran Dependency Scale of the MMPI. There were significant differences between the groups in terms of place of birth, age of the mother at time of the initial break and size of the original sibship. Significantly more evacuees were cared for by foster mothers and significantly more of the "other" separations had a poor relationship with their natural mother. For all groups increased test scores were associated with lower parental social class and poor replacement care. Poor outcome was also associated with being later born for the early bereaved, having a poor relationship with the natural mother for the evacuees and being separated after age 4 for the "other" separations.

No early loss or separation experience can be considered in isolation: it serves more as a focal point around which and following which there exists an in- terplay of circumstances and events, the sum total of which determines the individual's subsequent vul- nerability. In contrast to the more traditional policy of grouping together various types of early parental loss and separation, the present study aims to keep them apart, with the object of examining how the circumstances and consequences of different experiences may vary and of determining whether such variance may affect the long-term outcome. The practice of grouping together different types of expe-

rience has been forced upon many previous investi- gators because they had insufficient numbers to consider them separately. There may have been some justification for believing that what the experiences had in common was more important than ways in which they might differ. Though this may turn out to be true, the correct methodological procedure is first to examine the experiences separately and subsequently to combine those which appear to have similar effects.

In a recent review article Tennant et al. (1980) systematically considered the necessary methodological precautions to be taken in studies of the long- term consequences of early bereavement. Much of what they wrote applies equally to studies of early separation. They dealt at length with the selection of study subjects and appropriate controls and con- cluded that the problems of illness behaviour affect- ing the constitution of clinical samples, and of select- ing controls, could largely be eliminated if studies were carried out on community samples. This is a feature of the present study. Variables to which they referred, which have been included in the present study, are parental age at the subject's birth, sibship size and birth rank, place of birth, parental social class, subject's age at time of loss and the child's experience following the loss. They rightly emphasised that the age of the study subjects is related both to rate of loss experience and illness risk. What they did not consider and what, surprisingly, has not been considered by previous workers is the fact that age represents the time which has elapsed from the mo- ment of loss to the time of the study. It could be argued that the effect of early loss varies according to this time lapse. Both Brown et al. (1977) and Tennant et al. (1981, 1982) have studied samples which range in age from 18 to 65. In the present study all subjects are within the narrow age-range of 40-49.

The study was carried out in Chichester (West Sussex) and in two previously published reports

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(Birtchnell 1980; Kennard and Birtchnell 1982) it was shown that the level of psychiatric caseness in this area is low compared, say, with Camberwell, South London, where the above-mentioned studies were carried out. It was further shown that the incidence of caseness in samples of early mother-bereaved and early mother-separated women was no different from that in a non-early-bereaved and non- early-separated, matched control sample. Scores on the Zung Depression Scale and the Middlesex Hos- pital Questionnaire were also not significantly different in the loss groups and the controls. From Table 1 it will be seen that scores on these tests, and on the MMPI Dependency Scale (for references see Meth- od), in all samples, were significantly lower than those of a sample of Chichester female psychiatric patients. From the outset, therefore, it can be cate- gorically stated that, in Chichester, early bereavement and early separation were shown to have no lasting effect upon the mental health of 40- to 49- year-old women. This finding, although in contrast with the work of Brown et al. (1979), is in general agreement with the recently published work of Ten- nant et al. (1981, 1982).

The aims of the present study are twofold: firstly, to determine whether the circumstances at the time of the event and the subsequent experiences of early mother-bereaved and various categories of early mother-separated women were significantly different, in terms, for example, of the variables specified by Tennant et al. (1980), and secondly, to ascertain whether such differences as may be observed are associated (even within the range of normality) with significant differences in adult test scores. If such differences are observed, and if they are shown to affect outcome, then the case will be made for the selection of more precisely defined study samples.

Method

A detailed account of the collection of the members of the study samples is given in Kennard and Birtch- nell (1982). Briefly, the women aged 40-49 in 14 Chi- chester (West Sussex) general practices were written to and asked about early loss or separation experiences. Those identified in this way were then visited and interviewed in their homes. A control sample of women matched by age at death of father and parental social class with a member of one of the loss groups was also collected. Subsequently, a series of successive psychiatric patients, also aged 40-49, were similarly interviewed. At the time of interview subjects were asked to complete three self-administered tests: a modification of the Zung (1965) De- pression Scale, with a maximum score of 20, the De- pendency Scale of the MMPI (Navran 1954; Birtch-

nell and Kennard 1983), the questions of these two tests being combined in the same questionnaire, and the Middlesex Hospital Questionnaire (MHQ) of neurotic symptomology (Crown and Crisp 1966; Mavissakalian and Michelson 1981) subsequently renamed the Crown Crisp Experiental Index (CCEI). The last test was introduced slightly later than the first two, consequently a small number of subjects did not complete it.

All women written to were asked about their father's occupation and parental social class was graded according to the Registrar General's Classifi- cation of Occupations (OPCS) for 1934. There was no significant difference between the social class distribution of all women written to and that of the control group or of the loss or separation groups.

Subjects were asked to give a detailed account of the actual loss or separation event and to recount the succession of care changes which followed. They were also asked to describe the quality of the relationship between their own parents and of their relationship with each parent and with each caring figure. So far as possible they were encouraged to tell their own story with the minimum of prompting. Each interview was tape recorded and the content of the interview was later organised under appropriate headings. Finally ratings of the quality of the various relationships were made on the basis of the written transcrips.

It must, of course, be acknowledged that there are problems involved in the retrospective assessment of childhood relationships. The impression gained was that parents and parent substitutes were described as they were experienced in childhood and some subjects would volunteer remarks such as, "Of course I've come to see her differently since". Sub- jects were asked to give examples of good or bad behaviour alluded to. Ratings of the quality of the various relationships were made independently by the two authors and, in the small number of instances when there was disagreement, an attempt was made to resolve the difference of opinion by discussion. In the end only relationships which were indisputably good or indisputably bad were counted. It will be noted that the term "poor preseparation maternal relationship" which featured in a previous study (Kennard and Birtchnell 1982) has been dropped. This is because in a high proportion of instances i n which the term was used subjects had later involve- ment with their mothers and it proved difficult to date the stage in the life history when the relationship was poor.

Some reclassification of cases has been made such that the numbers in the various loss groups do not exactly correspond with those in previous reports. The principal study groups now comprise 45 subjects whose mothers died before the age of

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11years, 38 who were evacuated, during the 1939-1945 war, before the age of 10, and 45 separated from their mothers for other reasons, hereafter referred to as the "other" separations. In the last two groups the period of separation was at least a year. The "other" separations can be further subdivided according to the cause of the separation, the largest subgroup being 19 subjects separated as a result of parental discord, separation or divorce, the next being 13 who were illegitimate.

Results

Part 1. Comparison between the loss groups

The circumstances under which the break occurred: An important consideration, and one which affects a number of analyses, is the age at which the initial break from the mother occurred. The evacuees stand apart in this respect in that no one was evacuated before the age of 4. Twenty (52.6%) were evacuated before age 7 and 18 (47.4%) from age 7 onwards. Com- parable proportions of the early bereaved and "other" separations were separated before age 4, from 4 to 6 and from 7 onwards (21, 11 and 13 and 23, 8 and 14). However, of the illegitimate sub-sample 84.6% (11/13) were separated before the age of 4.

There were some striking differences between the groups in respect of place of birth. None of the evacuees, compared with 26.7% of the early bereaved and 28.9% of the "other" separations, was born in West Sussex. In contrast, 52.2% of the controls were born there (2 x 4Z 2 = 32.04, d. f = 3, p < 0.0001). On the other hand, 52.6% of the evacuees and 28.9% of the "other" separations were born in London compared with only 2.2% of the early bereaved and 8.7% of the controls (2 x 4Z 2 = 41.43, d. f = 3 p < 0.0001). A dis- proportionate number of early bereaved came from distant parts of the UK or abroad (37.8% compared with 17.4% of the controls, 17.8% of the "other" separations and 7.9% of the evacuees).

The parental social class was not known for 1 evacuee, 4 of the early bereaved and 11 (24.4%) of the "other" separations, but 10 of these were illegitimate. The known parental social class distribution did not differ significantly between the three main groups, though there was an excess of class III manual among the "other" separations (44.1% compared with 32.4% of evacuees and 29.3% of the early bereaved).

The mean age of mother at the time of the initial break was not known for 7 early bereaved (15.6%) and 1 "other" separation. This mean age was almost the same for the early bereaved and the evacuees, 35.97+7.71 and 35.55+5.00 respectively, but sub-

stantially lower for the "other" separations, 31.05 ___ 8.17 (t = 3.53, p < 0.001, compared with the other two combined). Within the "other" separations group the mean age was markedly lower again for those who were separated before age 4, being 27.14 + 6.81 compared with 35.18 + 7.24 for those separated from age 4 onwards (t=3.86, p <0.001). Thus, the age 4 onwards separations were, in this respect, comparable to the evacuees. It should be pointed out that only half the before age 4 separations were illegitimate.

The difference between the groups in respect of the age of the mother at the subject's birth were less striking. The mothers of the early bereaved were significantly older than those of the two separation groups combined: 30.89+6.12 compared with 28.04_+ 5.69 (t = 2.50, p < 0.02). The mean age of the control subjects' mothers at birth (29.86 +__ 6.47) came between these two figures and was not significantly different from either. The mean age of the "other" separations' mothers was less than that of the evacuees' (27.30_+ 6.65 compared with 28.9_+ 4.27) and that of the before age 4 separations was less than that of the age 4 onwards ones (25.91 _+ 6.63 compared with 28.68 _+ 6.52) but these differences were not statistically significant.

When the subject's sibships were considered the "other" separations again were conspicuously different from the other two groups. No less than 40.0% were only children compared with 17.8% of the early bereaved and 15.8% of the evacuees (Z 2 "other" separations vs other two groups combined-8.33, d. f = 1, p < 0.005). The figure for the controls was 14.3%. The difference was almost, thought not en- tirely, accounted for by the before age 4 separations: 52.2% of the before and 27.3% of the 4 onwards being only children. Similar proportions of all groups came from sibships of 2 and 3, but only 22.2% of the "other" separations compared with 51.1% of the early bereaved and 47.4% of the evacuees came from sibships of 4 or more, the figure of the controls being 48.6%.

It is perhaps surprising that the early bereaved sibships wre comparable in size to those of the evacuees and the controls, for the mothers, had they lived, might have been expected to have had further children. However, no less than 40.0% of the early bereaved women came fourth or more in their sibships, compared with 18.6% of the controls (Z 2 = 6.39, d. f = 1, p < 0.02). Thus, their mothers seem to have died towards the end of the child-bearing period. The birth order distribution of the "other" separations was affected by the high proportion of only children; 57.8% were first-borns and only 11.1% were fourth or more, the equivalent figures of the before age 4 separations being 69.6 and 8.7%. The birth order distribution of the evacuees resem- bled that of the controls.

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The events which followed the break: Though it is self- evident, it is important to bear in mind that the early bereaved differed from the two separation groups in that they had no further contact with their natural mothers and, initially at least, were left in the care of their fathers. Even so, 27 (60.0%) were shortly after- wards separated from their fathers and 16 of these (59.3%, 35.6% of the total) did not return. The proportion of those who left varied with the age at bereavement; 81.0% of those bereaved before age 4 left and 41.7% of those bereaved later did (Z2=7.20, d . f = 1, p < 0.01). Similar proportions of these two groups did not return. Among the separations there were only five instances of the mother leaving the subject in the care of her father. In all other instances the subject was initially separated from both parents. Only one evacuee did not return (2.6%) and 18 (40.0%) of the "other" separations did not return to their natural mothers.

Because the early bereaved did not return to their mothers they were involved in fewer changes of care. Fifteen of them (33.3%) were transferred to a replacement mother with whom they stayed through- out childhood. A further 17 (37.8%) had only two changes of care. Ten of the "other" separations (22.2%) had a single transfer of care and a further 17 (37.8%) had two changes. No evacuee had a single transfer, but exactly half went to one replacement mother with whom they stayed until they returned home. Thus, 40% of the "other" separations and 50% of the evacuees had three or more changes of care. Because of the number of changes of care it is difficult to classify the groups according to who actually was involved in the mothering role. If classified according to the person with whom they spent longest, the evacuees stand out from the other two groups in that 81.6% were cared for by foster mothers, compared with 22.2% of the "other" separations and only 8.9% of the early bereaved 0f2=52.84, d . f =2, p3500.0001). The most frequent care givers for the early bereaved were aunts, step-mothers and grandmothers (20.0, 20.0 and 17.8%) and for the "other" separations were grandmothers, various types of in- stitution and aunts (26.7%, 22.2% and 17.8%).

The subjects' retrospective assessment of the quality of replacement care provided was remark- ably even; just over half of each group considered it to be good and approximately one third of each group considered it to be poor. Step-mothers emerged as the most disliked group, 50.0% being rated by the subjects as poor compared with 27.8% of aunts and 23.8% of grandmothers. Assessment of the subject's relationship with her natural mother was affected by the degree of contact she subsequently had with her. None of the 20 women bereaved before age 4 had any recollection of their mothers and no early bereaved woman spoke unfavourably of her mother.

In contrast, of the 23 women separated before age 4, only 5 (21.7%) had no recollection of their mothers, largely because the remainder had further contact with them. No one was evacuated before age 4. No less than 60.0% of the "other" separations considered the relationship with their mother to have been poor compared with 29.0% of evacuees and only 13.0% of the controls ( 2x3 Z2=28.21, d . f = 2 , p <0.0001). Surprisingly few subjects recalled any serious emotional disturbance in childhood; 4 evacuees (10.5%) recalled being depressed and 6 (13.3%) of the other separations recalled being nervous.

Part 2. The effects of the foregoing upon the test scores

The circumstances under which the break occurred: There is no significant variation in mean test scores between the three loss groups, though all groups scored higher than the controls on the Navran De- pendency Scale (Table 1). This difference was statistically significant for the "other" separations and the early bereaved. When the "other" separations were subdivided into the 19 due to parental discord separation or divorce, the 13 who were primarily illegitimate and the 13 remaining, there were no marked differences between their scores.

The age at the initial break from the mother did not significantly affect the scores of the early bereaved. It will be remembered that no-one was evacuated before the age of 4. From Table 2 it will be seen that the scores tended to be higher, but not significantly so, for those first evacuated from age 7 onwards. On the other hand, the scores were significantly higher for the "other" separations first separated from age 4 onwards on the modified Zung Depression Scale, the Total of the MHQ and the MHQ Somatic and Depression Scales. When the "other" separations were divided into those due to parental discord, separation or divorce and the remainder, the age 4 onwards scores remained higher in both subdivisions, but the scales with significant differences were the Total MHQ and the Phobic Scale for the parental discord group etc. (t = 3.04 and 3.23. p < 0.01 in both instances) and the Zung De- pression, the MHQ Depression and Somatic Scales for the remainder (t = 2.97, p < 0.01, t = 2.16 and 2.22 both p < 0.05).

Place of birth did not affect the scores of the control group. For the early bereaved and the "other" separations the trend was for the mean scores to be higher for those born in West Sussex. For the evacuees, none of whom was born in West Sussex, the London born ones had the higher scores.

Parental social class did not affect the scores of the control group. There was a general tendency for the scores of all three loss groups to be higher for

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Table 1. Mean test scores of early bereaved, evacuees, other early separations, controls and psychiatric patients. Patient data presented for contrast only (ZD = Zung Depression; ND = Navran Dependency; Anx = Anxiety; Pho = Phobic; Obs = Obsession; Som = Somatic; Dep = Depression; Hys = Hysteria; Tot = Total)

ZD ND MHQ Scales

Anx Pho Obs Sore Dep Hys Tot

Early n 43 43 37 37 37 37 37 37 37 bereaved mean 3.93 19.23 a 5.19 4.46 5.84 4.22 3.57 3.14 26.38

SD 3.00 7.09 3.63 2.86 2.86 2.72 2.49 2.88 11.74

Evacuees n 37 37 32 32 32 32 32 32 32 mean 3.57 19.22 5.94 4.91 6.34 4.63 4.84 4.00 30.53 SD 2.99 8.72 4.16 3.39 3.37 3.46 3.17 3.25 15.17

Other early n 45 45 43 43 43 43 43 43 43 separations mean 3.73 20.60 b 5.63 5.35 5.98 4.51 3.60 2.77 27.84

SD 2.67 7.38 3.75 3.20 2.50 3.51 2.75 2.80 11.38

Controls n 67 67 64 64 64 64 64 64 64 mean 3.19 15.94 4.69 4.58 6.58 3.42 3.23 2.91 25.41 SD 3.35 8.65 3.75 2.89 2.99 2.47 2.80 2.90 12.53

Psychiatric n 43 43 43 43 43 43 43 43 43 patients mean 10.52 31,67 10,79 5.88 8.05 7.88 9.02 4.98 46.60

SD 5.03 9.12 3.13 3.36 3.93 3.82 3.45 3.39 15.21

a t =2.09, p <0.05 b t = 2.96, p < 0.005, both compared with the controls. No other comparisons were statistically significant

Table 2. Mean test scores by age at separation from mother (abbreviations see Table 1)

Age at separation ZD ND MHQ Scales from mother (years)

Anx Pho Obs Som Dep Hys Tot

Before age 4 n 23 23 23 23 23 23 23 23 23 (no evacuees) mean 2.60 18.83 4.74 4.61 5.61 3.22 2.57 2.43 23.17

SD 2.29 6.93 3.49 3.06 2.08 2.98 2.37 2.73 10.23

"Other" n 22 22 20 20 20 20 20 20 20 separations mean 4.91 22.45 6.65 6.20 6.40 6.00 4.80 3.15 33.20 age 4 onwards SD 2.56 7.54 3.86 3.22 2.91 3.55 2.73 2.91 10.42

t 3.18 1.68 1.70 1.66 1.04 2.79 2.88 0.83 3.18 p < 0.005 NS NS NS NS p < 0.01 p < 0.01 NS p < 0.005

Evacuees n 19 19 16 16 16 16 16 16 16 age 4-6 mean 3.05 18.89 4.56 4.94 5.25 3.69 4.06 2.88 25.25

SD 2.90 9.25 3.56 2.86 3.36 3.24 2.86 3.36 13.50

Evacuees n 17 17 15 15 15 15 15 15 15 age 7-9 mean 3.71 19.00 7.07 4.87 7.40 5.00 5.33 5.00 34.53

SD 2.62 8.28 4.42 4.09 4.03 2.80 3.27 2.85 14.90

There were no significant difference for the evacuees

those from the lower parental social classes, such that when the loss groups were combined the mean scores for those from class III manual and below were significantly higher on the Phobic Scale (t=2.72, p<0.01), the Somatic Scale (t=2.55, p <0.02) and the Zung Depression Scale (t=2.34, p < 0.025).

There was no significant relationship between the test scores and the age of the mother at the subject's birth or at her death or at the first separation.

Sibship size had no effect upon the scores of the "other" separations and affected the evacuees and the early bereaved differently. For the evacuees, the

scores of those in small sibships ( < 3) were generally higher, and significantly so on the MHQ Anxiety, Obsessional and Hysteria Scales (t=2.29, p<0.05, 3.71, p < 0.001 and 2.37, p < 0.025 respectively) and for the MHQ Total Score (t = 2.46, p < 0.02). For the early bereaved the scores of those in large sibships (> 3) were generally higher, and significantly so on the Navran Dependency Scale (t = 2.66, p < 0.02) the Zung Depression Scale (t = 2.06, p < 0.05) the MHQ Depression Scale (t =2.13, p < 0.05) and the MHQ Total Score (t=2.38, p<0.025). For the controls, scores also tended to be higher for those in large sibships, but not significantly so.

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Table 3. Mean test scores of the early bereaved by birth order (abbreviations see Table 1)

ZD ND MHQ Scales


1st - 3rd

4th or more

t

n 26 26 mean 3.19 17.23 SD 1.92 4.30

n 17 17 mean 5.06 22.29 SD 3.96 9.31

2.07 2.42 p<0.05 p<0.02

23 23 23 23 23 23 4.43 3.91 5.04 3.57 2.70 3.26 2.89 2.78 2.46 2.43 1.96 3.14

14 14 14 14 14 14 6.43 5.36 7.14 5.29 5.00 2.93 4.43 2.87 3.08 2.92 2.66 2.50

1.66 1.51 2.29 1.94 3.02 0.34 NS NS p<0.05 NS p<0.005 NS

23 22.87

8.79

14 32.14 13.91

2.49 p < 0.02

There were no significant difference for the two separation groups

Neither of the separation groups was affected by birth order, but for the early bereaved the scores were significantly higher for those coming fourth or later on the Zung Depression and Navran Depen- dency Scales and the MHQ Obsessional and Depres- sion Scales and the Total MHQ Score (Table 3). Rel- atively few of the controls were fourth or later born, but for those who were the scores were not especially high. What was apparent in the controls was that scores for first-borns, and particularly only children, were significantly lower. This contrasts strikingly with the score of the first-born and only children of the "other" separations.

The events which followed the break. Whether or not the separated women returned to their natural mothers made no appreciable difference to the mean test scores. It did not matter whether they returned to one parent, both parents or neither parent. Whether or not the early bereaved women stayed with or left their fathers also made no difference. However, the scores of those who left heir fathers but subsequently returned were significantly worse on the MHQ De- pression Scale (t=2.58, p<0.02) and the Total MHQ Score (t = 2.29, p < 0.05). This is probably a manifestation of the difficulties experienced by step- children and step-mothers in coming to accept each other.

There was no significant relationship between the mean test scores and number of changes of care either for the individual groups or when the group scores were summated, though there was a tendency for those with more changes of care to have higher scores. The scores of women reared prodominantly by step-mothers were the highest, there being little variation among the scores of women with other types of care. Of the 16 women reared predominant- ly in institutions the only notable feature was a high mean Dependency score (24.50 6.22) which was significantly higher than that of the remainder (19.02 +7.64; t =2.74,p <0.01).

There was a tendency in all three groups for the

scores to be higher for those subjects who considered the quality of replacement care to be poor, such that when the scores were summated (Table 4), the poor replacement care subjects scored significantly higher on the Navran Dependency Scale and the Anxiety and Depression Scales of the MHQ. Considered alone the evacuees with poor care scored significantly higher on the two MHQ Scales (t -- 2.80, p < 0.01 and t = 2.12, p < 0.05) and the early bereaved scored significantly higher on the Depression Scale (t = 2.76, p < 0.01).

Among the "other" separations no association was apparent between the mean test scores and the quality of relationship with the natural mother. Among the evacuees, however, the test scores of those with a poor relationship were significantly higher on the Zung Depression Scale and the Nav- ran Dependency Scale, the Anxiety, Obsessional So- matic and Depression Scale of the MHQ and the To- tal MHQ Score (Table 5). Among the controls too, those who reported poor relationships with their mothers scored significantly higher on the Zung De- pression Scale (t =2.35, p < 0.025), the Anxiety and Depression Scales of the MHQ (t =2.92, p <0.005 and 2.38) and the Total MHQ Score, (t=2.26, p < 0.05). For the early bereaved, fathers assumed great- er importance and consequently the scores of those with a poor relationship with their fathers were generally higher, but only significantly so on the MHQ Obsessional Scale and Total Score (t = 2.04 and 2.22, p < 0.05 in both instances). The scores of those with obvious conflict between principal parent figures tended to be high, but the differences were not significant.

Combining factors was difficult because with each subdivision of the data the numbers in each category were reduced. For the "other" separations, those with bad relationships with both their mothers and their replacement mothers fared no worse than those with good relationships with both; for the evacuees, those with bad relationships with both had significantly higher scores on the Navran Dependen-

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Table4. Mean test scores of those who reported poor and adequante replacement care (scores of the bereaved and the two separation groups combined); (abbreviations see Table 1)

ZD ND MHQ Scales


Poor replacement n 40 40 33 33 33 33 33 33 33 care mean 3.98 21.70 7.00 4.48 6.45 5.00 4.97 2.97 30.88

SD 3.40 10.95 3.67 2.50 3.76 2.95 3.07 2.47 13.49

Adequate n 64 64 59 59 59 59 59 59 59 replacement care mean 3.64 17.95 4.71 4.73 5.64 4.39 3.41 3.34 26.20

SD 2.77 6.42 3.76 3.07 2.62 3.38 2.45 3.22 12.62

t 0.59 2.49 2.75 0.37 1.23 0.84 2.69 0.56 1.71 NS p<0 .02 p<0 .01 NS NS NS p<0 .01 NS NS

Table 5. Mean test scores of evacuees and "other" separations with poor and good relationships with their mothers (abbreviations see Table 1)

ZD ND MHQ Scales


Evacuees Poor n 10 10 10 10 10 10 10 10 10 relationship mean 5.60 23.60 7.80 6.10 8.50 6.60 6.50 4.40 39.70

SD 3.57 10.25 3.85 4.65 3.72 3.06 3.69 3.78 15.68

Good n 24 24 19 19 19 19 19 19 19 relationship mean 2.83 17.21 4.58 4.53 4.89 3.84 3.79 3.79 25.53

SD 2.51 7.67 3.78 2.50 2.96 3.53 2.51 3.19 12.81

2.58 2.00 2.17 1.19 2.85 2.09 2.35 0.46 2.62 p < 0 . 0 2 p<0 .05 p<0 .05 NS p<0 .01 p<0 .05 p<0 .05 NS p < 0 . 0 2

"Other" separations

Poor n 27 27 25 25 25 25 25 25 25 relationship mean 3.48 20.63 6.32 5.72 5.72 4.04 3.68 2.60 28.08

SD 2.50 7.23 3.89 3.00 2.44 3.66 2.82 2.52 11.54

Good n 15 15 15 15 15 15 15 15 15 relationship mean 4.40 21.40 5.13 4.60 6.33 5.33 3.73 3.40 28.47

SD 3.09 8.19 3.46 3.36 2.44 3.42 2.79 3.38 11.68

There were no significant differences for the "other" separations

cy Scale, the MHQ Anxiety and Depression Scale and the MHQ Total Score.

Discussion

In the present study the evacuees stood out as a group not indigenous to West Sussex, born predomi- nantly in larger cities from which war-time evacuation was desirable. Their experience of rural life while evacuated - seven (18.4%) were actually sent to West Sussex - may have influenced their later de- cision to move to Chichester. In this respect they may differ as a group from evacuees who have continued to live in cities. None was separated before age 4 and the majority were cared for by foster mothers. Despite this they had most changes of care, but all but one eventually returned to their natural mother. Even though their separation was imposed upon them by extra-familial circumstances, almost a third recalled considerable discord between their parents and a similar proportion reported a poor relation-

ship with their natural mother. Because they returned to their mother, and because she continued to be their predominant maternal figure, this poor relationship led to detectable and significantly increased psychopathology in adult life.

It is unfortunate that the "other" separations were not a homogeneous group and, in retrospect, it would have been an advantage to have extended the survey so as to include adequate numbers in each of the subgroups. At the time it was not appreciated that those separated before age 4 bore certain distinct characteristics, nor of course that this group carried a more favourable outcome. Their mothers were ap- preciably younger and a high proportion of them were first-born or only children. The outstanding feature of the "other" separations was that so many (60%) had a poor relationship with their natural mother. Yet surprisingly, as it turned out, this proved to have had little effect upon outcome. In retrospect this is presumably because they did not rely upon their mother for care.

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In contrast to the two separation groups, not one member of the early bereaved group spoke unfavourably of her mother. This was due in part to the fact that the 44.4% whose mothers died before they were 4 had no recollection of them at all. Considering that even 13% of the controls disliked their mothers, it is possible that a degree of suppression is present here. Interestingly, the proportion of the early bereaved who spoke disapprovingly of their replacement mothers was no less than that of the two separation groups. The mean age of the mothers of the early bereaved at death was practically the same as that of the evacuees' mothers at separation, and the size of the early bereaved sibships was roughly comparable with that of the evacuees and the controls. However, somewhat more (40.0% compared with 18.6% of the controls) were fourth-born or more.

The one scale which did significantly differen- tiate between the loss groups and the controls was the (Navran) Dependency Scale of the MMPI. Again, the scores were nothing like as high as they were for the psychiatric patients. This finding is of some interest in that it is in accordance with a study comparing early mother-bereaved and non-early-bereaved, female, psychiatric patients (Birtchnel11975). It was recently demonstrated (Birtchnell and Kenn- ard 1983) that this scale has a large depressive com- ponent. However, since no significant differences were apparent on the two depression scales used, this cannot be the whole story. Barry et al. (1965) observed, in young neurotic patients, a high incidence of dependent behaviour (86.7%) in those bereaved before age 4, in contrast to those bereaved between age 11 and 17 (26.7%). In the present study the De- pendency scores of the early bereaved did not vary with age at loss.

It had been anticipated that the study would re- veal that certain types of experiences could meaning- fully be linked with high scores on certain scales. Pedder (1982) proposed reasons, based upon Kleini- an theory, why early separation and early bereavement should give rise to different types of adult psychopathology. The results provide little support from this point of view. The two measures of depression featured most frequently among the significantly high scores for both the early bereaved and the early separated and each of the eight scales used featured at least once.

Two important background variables proved to be parental social class and position in sibship. Par- ental social class had no effect upon the control subjects, but in the bereaved and separated groups the mean scores tended to be significantly higher for those in parental class III manual and below. This suggests that the resources for coping with such family disruption are less adequate in lower social classes. This result is more clear cut than that of a

previous study (Birtchnell 1972) concerned with early bereaved psychiatric patients and general population controls. For the (present) controls it appeared to be an advantage to be first-born or, more particularly, an only child. For the "other" separations, a high proportion of whom fell into this category, no such advantage was apparent. For the evacuees it seemed positively disadvantageous to be from a sibship of one or two. This may conceivably be because children from small sibships rely heavily upon their parents for emotional support and are consequently more vulnerable to separation from them. Children from larger sibships derive some of their support from the other siblings and are less dependent on their parents. Why then did this not also apply to the early bereaved? For them it was worse to come fourth or more in a large sibship, a category well rep- resented in this group. This too is not in accord with previously reported findings on psychiatric patients (Birtchnell 1971). Although over half the early bereaved women were last-born, this result is not the effect of being last-born, for early bereaved last-borns did not have particularly high scores.

A striking difference between the "other" separations and the early bereaved was the significance in the former, but not in the latter, of age at break from mother. Comparing Tables 1 and 2 it will be seen that the scores of the before age 4 separations were if any- thing slightly better than those of the controls, whereas those of the later separations were worse even than those of the early bereaved. There were, however, major differences between the early and later separations, but not between the early and later bereaved. The mothers of the early separations were very much younger at the time of separation; over half the early separations were only children and a much higher proportion of them were illegitimate. The break therefore was not so much from a fully in- tegrated family unit. This may not, however, be the complete explanation, for there was a suggestion too that those who were evacuated at a younger age had lower scores.

The importance of the quality of relationship with the replacement mother was not as great as had been anticipated. Approximately one-third of subjects spoke unfavourably of this replacement mother. Considering the emotional difficulty involved on both sides, this compares reasonably well with the proportion of 13% of control subjects who disap- proved of their natural mother. Although there was a trend in all three study groups for the poor replacement subjects to score high, this only reached statisti- cal significance when the scores of the three groups were summated.

Even though few of the study subjects were seri- ously disturbed, it seems reasonable to have used the data to determine the conditions under which the

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forms of loss and separation considered were the more traumatic. It could be argued that, with rela- tively undisturbed subjects, the retrospective distor- t ion o f early memories, considered sometimes to oc- cur among psychiatric patients as a result of their affective state, is less likely to be present.

Conclusions

differences in the scores o f tests administered during the fifth decade of life.

Acknowledgements. Thanks are due to Mrs. J. Powell of the De- partment of Sociology and Social Administration, University of Southampton, who conducted some of the Chichester interviews, Mr. Dobson of the Family Practitioner Committee and 14 Chi- chester General Practitioners whose patients were used in the community survey. The survey was financed by a donation made to the Friends of Chichester Hospitals and by free monies of the Chichester District.

"I t is highly improbable that simple one-to-one caus- al relationships exist in the field of human develop- ment" (Birtchnell 1980). However unsatisfactory it may be, it seems inevitable to conclude that any specified experience has adverse effects only under certain circumstances. In the present study no single modifying variable had the same effect with any of the three major forms of discontinuity considered or the controls. This points to the necessity for separat- ing out specific types of potentially disturbing experience and perhaps even breaking down each type into smaller sub-categories.

Bearing in mind the considerable variation in the findings of studies of early parental loss and separation, it is perhaps in order cautiously to make some general points on the basis of the present results. It would seem not to be essential to future well-being that a child be reared by her natural mother. Though replacement mothers receive more adverse criticism than natural mothers, the care provided by them would usually seem to be quite adequate. Separation before ties with the family of origin have become well established, i.e. before age 4, is likely to lead to the most satisfactory outcome. Poor parent-child relationships would appear to be more damaging than a break in the continuity of care, so a break from an unsatisfactory relationship may be preferable. When fathers remarry they should be aware that it may not be in their children's best interests to transfer them from a home into which they have settled to an un- familiar step-mother. During periods of reversible separation, such as evacuation, the child's relationship to the natural mother remains the crucial one. During such separations the support of other siblings can be protective.

The present study concerns only those variables which occurred in childhood. It is likely that any de- ficiencies in parenting experiences can, to varying degrees, be compensated for by the establishment of more satisfactory relationships during adolescence and adult life. In this respect it is remarkable that events which occurred before the age o f 11, despite the effects of all subsequent experiences, should still give rise to detectable, and apparently meaningful,

References

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Birtchnell J (1971) Early parent death in relation to sibship size and composition in psychiatric patients and general population controls. Acta Psychiatr Scand 47: 250-270

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Accepted 12 November 1983

J. Birtchnell MRC Social Psychiatry Unit Institute of Psychiatry De Crespigny Park London SE5 8AF England

Documents

How do the experiences of the early separated and the early bereaved differ and to what extent do such differences affect outcome?