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�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������y���jbjbj��4|�{�{Ä�������FF�����������������=0Xi(����lll�/�/�/�/�/�/�/$�1�G4,�/E�(!ll(!(!�/������/�+�+�+(!J�����/�+(!�/�+�+�+�����P��Ƌ������r&d�+x/
00=0�+s5�&�s5�+s5��+�l���+��z�lll�/�/�)�lll=0(!(!(!(!��������������������������������������������������������������������s5lllllllllF%k:Self-assessment of anxiety and depressive symptoms in persons who lost their father during their formative age 

Self-assessment of anxiety and depressive symptoms in persons who grew up without a father 

Ivana Dijani Plaa
 Duga  Home for child and adult victims of family violence, Zagreb 
 HYPERLINK "mailto:ivana.dijanic@zg.t-com.hr" ivana.dijanic@zg.t-com.hr

















The aim of this study is to survey and to emphasis the importance of psychosocial support and expert help to single-parent families in circumstances of sudden death of another parent.
Objective To compare the degree of expressed symptoms of anxiety and depression in persons whose father had died in war and in persons whose father had died a sudden death as a civilian at the time when they were in the formative age.   
Method The study comprised 155 persons of both sexes. The target group consisted of persons whose father had died in the Homeland War and control group of subjects, who have civilian loss of father. 
Results There were proven to be statistically significant differences in the degree of self-assessment of depression and anxiety with regard to the way the study subjects had lost their father. The subjects whose father had died due to civilian causes express more depressive symptoms and more anxiety symptoms in comparison with the subjects whose father had died in war. The age when the subject lost their father has a statistically significant positive correlation with depression and anxiety.
Conclusion The obtained results demonstrate that in anxiety and depression scales significantly more symptoms are exhibited by persons who had lost their father due to civilian causes, unlike those who lost their father to war. It is evident that the loss of father in war circumstances is subject to greater support and care by the society, than is the case with the civilian loss. The results clearly point to the importance of social support received by single mothers after the loss of their husband and their children's father. 

Key words: single-parent family, developmental age, anxiety, depression, father�s death 
Introduction
Single-parent families are families with children aged under 18 in which the parent is widowed or divorced, and has not remarried, or the parent has never been married in the first place (1). A substantial number of studies have shown that on average children who had lived in two-parent families since birth have better cognitive and behavioral results in comparison with children who have lived in a single-parent family (2-3). Compared to children from families with two biological parents, those from single-parent families have more conflicting relationships with their parent, receive less emotional support, cognitive stimulation and supervision, and have a parent who is less involved (3-6). There has been an increasing worldwide trend of families with a single mother since 1950s, and the situation is the same in the countries that had suffered a war, because of an increased male mortality as a result of combat activities, as was the case with Croatia. The existing studies do not differentiate between the types of families with a female parent, hence in this paper the focus is primarily on growing up in single�parent families with the mother, as a consequence of the husband's, i.e. father's death (1). Each single-parent family is different. Children who live with their widowed mother will live in a home which is different from the home of the children of divorced parents or those whose parents never even got married. The children of divorced parents will have a wide range of relationships with their parents and their parents' partners, depending on the custody and the tendency of the parent without the custody to maintain a relationship with their child. It is precisely those differences that render it impossible to generalize the obtained data to all single-parent families in which the care giver is the mother (3, 6). Namely, some hold that the consequences of a parent�s death are usually lesser than the consequences of a divorce or separation. The negative impact of a divorce may be caused by the fact that children whose father leaves of his own accord are more likely to feel abandoned than the children whose father had died (7). Moreover, if the parent�s death occurs at a later age than the divorce, not taking the age of loss into consideration may account for why the children of parents whose spouse had died fare better than the children of divorced parents. Research suggests that even after one takes into consideration the number of years spent away from the father, death and divorce have a similar impact on cognitive abilities, education and earnings. The only significant difference observed was the son's marriage: men were significantly less likely to contract marriage if their father had died (8-9). Fathers provide a unique contribution to a child�s upbringing, including a parenting style different from the mother's, with focus on play, which facilitates a normal emotional development (8, 10). The experience of the loss of father is especially hard in war (11), for it most often occurs as an individual trauma (11). Women are a model for the coping strategy for their children during the war. There is well documented evidence that children's reactions to stress mirror the reactions of the members of their families (12-15), and scientists have also discovered that the mother�s level of anxiety and depression during and after the conflict is the most important predictor of her children�s health (16-18). Each separation is a great trauma and a possible source of psychopathology. Research into these issues is also important from the point of view of transgenerational transfer, as many parents repeat their experiences of primary attachment from the childhood in their relationships with their own children, thus stimulating the transfer of (secure and insecure) attachment through generations (19). There is evidence of a high correlation between the mother's and the children's pain in war situations (20-22), which leads the authors to conclude that the mother�s ability to cope with stress is an important protective mechanism for the children as well. Recent literature suggests that the mental health of a child who has experienced the death of their father primarily depends on the support of the broader family and the child's relationship with the remaining parent (23). Lack of a parent and the age at which the loss took place are key factors on which the negative correlation between the lack of a father and the child's well-being rests (7). Namely, some researchers hold that older children and adolescents have developed more sophisticated capabilities of coping with problems than younger children (24-25). One can assume that younger children are exposed to greater risk, not only because they have not yet mastered cognitive abilities, but also because they ascribe egocentric explanations to events and because they are usually less capable of discussing stressful experiences (24). As for the sex differences, the existing studies on the impact of trauma on mental health demonstrate that girls are more prone to express a greater number of anxiety symptoms than boys (15, 26-27). The importance of family and social support, common ideology, religion and feeling of communion can increase resilience and act as a mechanism for coping with problems (28). 
In this paper we aim to establish the impact of the circumstances of the loss of father on the symptoms in adult age, as some research suggests that circumstances may prevent children and adolescents from getting over the loss, thus increasing the risk of long-term psychological consequences (29-30). For precisely that reason, as well as due to lack of research distinguishing between reasons for which in some families there is only one care giver, our objective is to establish the existence of differences between the two groups depending on the way they lost their father in the formative period of life with regard to long-term consequences, through a self-assessment of the symptoms of anxiety and depression. 

Subjects and methods
Subjects
The study comprised 155 persons of both sexes. One group consisted of persons (N= 98) whose fathers had died in the Homeland War, who had just been born at the time of their father's death, and had since the father's death been growing up in a single-parent family with their mother (Table 1). The second group of subjects (N= 57) did not have any war losses at the target war time from 1991 to 1995 (Table 1). The subjects were equivalent in certain characteristics: age, sex, education, socioeconomic status, civilian loss of father. The subjects were randomly selected from the health care system. Only those subjects were enrolled who did not present any personal psychological disorders. In the overall sample, 50% were women (77% civilian loss and 33% war loss of father) and 50% were men (23% civilian and 56% war loss of father) (Table 1). The majority of them, 63%, were not married at the time of research (27.6% civilian and 72.4% war loss), 51% of subjects were employed (64.8% civilian and 53.2% war loss of father), while 43% were in school (25% civilian and 75% war loss of father), with 51% having completed high school (24.1% civilian and 75.9% war loss of father), and 64.8% with higher education (71.4% civilian and 28.6% war loss of father) (Table 1). The subjects� age ranged between 17 and 37 years, and the age at which they lost their father between one and 30 years on the overall sample, with the age range at which they lost their father to a civilian death between 2 and 30 years, and the age range at which they lost their father due to war activities between 1 and 30 years (Table 1).

 Method
The study was conducted as part of the �Program for the improvement of the quality of life in the families of deceased Croatian defenders, Croatian war military invalids, and the Croatian defenders suffering from PTSD", sponsored by the Ministry of Family, War Veterans and Intergenerational Solidarity of the Republic of Croatia, and participants in the implementation were health institutions that performed systematic examinations, as well as the School of Medicine of the University of Zagreb (11). The data for this research were collected over a period of six months in 2010. The program was implemented in compliance with ethical and professional principles, as well as the principles of data confidentiality. The subjects were selected randomly from their first arrivals to a systematic examination at the Clinic for Tumors in Zagreb.  
The studied variables were as follows: sex, age, civilian or war loss of father, marital status, work status, age at which the subject lost their father, symptoms of anxiety and depression. Only those subjects were involved who did not have personal psychopathological disorders, which was previously assessed by a psychiatry specialist. All participants signed an informed consent form for participation in the study, which, among other things, guaranteed data anonymity. 

Data Collection
A psychologist applied the Structured Interview for Socio-Demographic Data, Zung Self-Rating Anxiety Scale (31), Zung Self-Rating Depression Scale (32), while the Mini International Neuropsychiatric Interview was applied by a psychiatrist in order to eliminate those subjects demonstrating certain psychopathological disorders (6). 
 
Statistical analysis
The measures of descriptive and inferential statistics were used in data processing. 
Qualitative data were presented in absolute and relative frequencies (f, %), while quantitative data were presented by central tendency measures (arithmetic mean) and dispersion measures (standard deviation, range). Distribution normality for the inventories used was verified by the Kolmogorov-Smirnov test. A t-test was used to test the differences between the two groups, while the differences between several groups were tested by an analysis of variance (F-test). The Pearson�s correlation coefficient was used to test the correlation between quantitative variables. The level of statistical significance for this study was set at 5%. Data processing was performed using the SPSS 17.0 program package (33).


Results
It was demonstrated that there were statistically significant differences in the level of self-assessment of depressive symptoms (t= 8.436; p<0.05) and anxiety (t= 5.019; p<0.05) with regard to the way the participants in the study had lost their father (Table 2). The subjects whose father had died a civilian death (44.92�4.79) express more symptoms of depression in comparison with the subjects whose father was killed (35.32�7.65) (Table 2). The subjects whose father had died a natural death (38.35�5.07) express more symptoms of anxiety in comparison with the subjects whose father had died in war (32.97�6.95) (Table 2). Considering the overall sample, it was demonstrated that there was a statistically significant difference in depressive symptoms with regard to the subjects� sex (t=-2.240; p<0.05), whereby female subjects expressed more symptoms of depression than the male subjects (Table 3). When it comes to the comparison between the results of male and female subjects regarding anxiety, there were no statistically significant differences between the two groups (t=-0.892; p>0.05), i.e. men and women equally express anxiety (Table 3). When one takes into account each subject group separately, data shows there are no sex differences within the group of subjects who had lost there father due to a civilian death, in the self-assessment of either anxiety or depression (Table 4), or within the group of subjects with a war loss (Table 5). The results of correlation between the subjects� age, the age at which they lost their father and depression or anxiety, obtained from the entire sample, demonstrate that age has a significant positive correlation both with depression (r=0.233; p<0.01) and anxiety (r=0.196; p<0.05); older subjects express more symptoms of depression and anxiety (Table 6). As for the age at which the subjects lost their father, the results also show that it bears a statistically significant correlation with depression (r=0.435; p<0.01) and anxiety (r=0.196; p<0.05); higher age at which they lost their father also implies increased depression and anxiety (Table 6). There is a statistically significant correlation (r=-0.326; p<0.05) between the age at which the subjects lost their father and the anxiety in the subjects whose father had died a civilian death (Table 7). The subjects who were younger at the time they lost their father display more symptoms of anxiety (Table 7). Age was not proven to be statistically significant either in depression symptoms or in anxiety (Table 7). There is no statistically significant correlation between the self-assessment of symptoms of anxiety and depression, the age at which the subjects lost their father and the current age in the group of subjects whose father had died in war (Table 8).

Discussion
Literature emphasizes the constant presence of the mother as the primary care giver, which could create an implicit presumption that the father-child relationship has little influence on the child�s development, and this popular belief was reinforced by development theoreticians over most of last century. It seems that children who grow up without their father are particularly prone to problems in the area of sexual roles and the development of gender identity, problems in academic performance, psychosocial adjustment and self-control (34). The fathers� biologically and socially reinforced male characteristics predispose them to treat their children differently than mothers. For instance, fathers will more frequently than mothers encourage their children to be competitive and independent and to take risks. However, some refute the universality of the difference in style between mothers and fathers (35). Data obtained in this study confirm the findings existing in literature that women are more prone to depression than men, and that there are no differences between the general population and our sample made up of persons who had grown up without a father, namely who had lost their father in the period before the end of adolescence, i.e. in early adulthood (36-39). Girls openly express their fears, anxiety and other emotions, while boys are usually discouraged from such open displays of emotions and are more likely to hide, deny or suppress difficult feelings and emotions and display more problems in behavior through aggressive patterns (4, 40). Thus some researchers conclude that the father�s absence has a greater negative impact on the boy's psychological state than on the girl's. However, this can be caused by the emphasis placed on aggressive behavior in many studies. When interpreting differences between the sexes, one should bare in mind there is an unequal number of men and women in both groups separately. Nevertheless, the data could be explained by suggesting that the presence of the mother's educational style reduces sex differences in our sample. Namely, the literature frequently mentions the protective factor of the mother as a buffer zone between the traumatic loss of father and the child's well-being, thus the supportive mother-child interaction is considered a particularly important foundation for the development of the child�s self-confidence and independence due to the emotional security and reliability it provides to the child. Hence one can assume that the parent's behavior combining emotional warmth and firm, but fair control is associated with the children's welfare and can protect children from developing behavioral problems (41). The positive correlation between the symptoms of anxiety and depression with the current age, and the age at which the subjects lost their father, is in line with the existing results of research into the symptoms of post-traumatic stress disorder. Those studies compared the results of children with the results of mothers in order to assess if longitudinal effects of psychological trauma are correlated with the development of the situation (29-30), and even though the symptoms of post-traumatic stress disorders increased for children, they remained stable or decreased for mothers (29,42-43). Data suggest that the symptoms of post-traumatic stress disorder in children do not decrease with age (29, 42-43). Symptoms of anxiety and depression that were proven to be more expressed in persons with a civilian loss of father can also be viewed through the prism of transgenerational effect (44). Considering the fact that contemporary research suggests that the mother's anxiety affects parental care (44-45), one should take into account the additional non-genetic means of transferring anxiety to the offspring (44). Such exclusively ecological transfer may be of particular value in the event that offspring is not genetically predisposed to a high level of anxiety (44).  The importance of such research is also evident from the prism of evolutional effect with regard to the natural selection process; individuals genotypically predisposed to react with fear to threats from the environment, i.e. to everyday life, without the care giver that represents a protective factor, a "safe harbor", are more likely to move, survive, and thus transfer their genetic predispositions for anxious and depressive reactions to their offspring (44). The obtained results demonstrate that on anxiety and depression scales significantly more symptoms are expressed by persons with a civilian loss of father, unlike those with a war loss of father. The results evidently point to the importance of social support given to single mothers after they have lost their husband and the father of their children. It is evident that the loss of father in war circumstances is subject to greater support and care by the society, than is the case with the civilian loss. It is as if the children who had lost their father in war had been given a new care giver in the form of the society, and grow up more protected from the consequences for the psychological and mental health than children who had lost their father to civilian causes.  Furthermore, here, too, the age at which the subjects lost their father played a role with regard to the differentiation between the two groups, by demonstrating a significant correlation between the age at which the subjects lost their father to civilian causes and anxiety symptoms. Loss of father at a younger age is associated with more expressed anxiety symptoms. Namely, according to the attachment theory, the function of primary attachment is to serve as a source of security for the child in situations instigating fear or anxiety in it. It is assumed that children develop an inner working model of their affective relationships during the first four years of life, i.e. they construct a mental representation of socioeconomic aspects of the world, other people, themselves and the relationship to other individuals that are important to them (19). The results of studies suggest a causal relationship between the parents' behavior, social support and the support of relatives, and the problems of psychological nature in adolescence and adulthood (41), and the results obtained in this study follow the same direction. 
In conclusion, we can say that living in a single-parent family is on average an important risk factor for the child's development, although it is true that the majority of children who have grown up in a single-parent family do not suffer long-term negative consequences (46). Unfortunately, only longitudinal studies could provide a valid insight into what actually happens in such situations, however, such studies have not been conducted to date, and would also be hard to conduct. Thus the existing results are mostly based on cross-sectional studies, i.e. studies with a time lapse taking into consideration the current state. Namely, a large number of studies provide evidence of a direct correlation between parental behavior and negative family environment, and behavior problems that appear later in life (41). 
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Table 1 Socio-demographic characteristics of the participants (N=155)
CharacteristicParticipants 
    No. (%)War lossCivil lossTotalCause of father�s death    Civil57 (37.0)    War 98 (63.0)Gender    Women34 (43.6)44 (56.4)78 (50.3)     Men64 (83.1)13 (16.9)77 (49.7)AgeMean +/- standard    deviation25.42�5.0129.42�4.0226.90+/-5.05Range (min.-max.)17 - 3720 - 3717 - 37Age when father diedMean +/- standard deviation8.31�4.9819.69�6.9912.48+/-7.0 Range (min.-max.)1- 202 - 301 - 30Education     Primary school15 (93.7) 1 (6.3)16 (10.3)     Secondary school                                                                       60 (75.9)19 (24.1)79 (51.0)     College11 (73.3)4 (26.7)15 (9.7)     University education12 (26.7)33 (73.3)45 (29.0)Marital status     Married21 (52.5)19 (47.5)40 (25.8)     Unmarried71 (72.4)27 (27.6)98 (63.2)     Divorced2 (100)0 2 (1.3)     Unmarried but live together3 (21.4)11 (78.6)14 (9.0)     Widowed1 (100)01 (0.6)Employment status  Employed42 (53.2)37 (46.8)79 (51.0)  Unemployed5 (50)5 (50)10 (6.5)  Still in education 51 (75)15 (25)66 (42.6)
Table 2 Testing for differences between subjects whose father had died a natural death and subjects whose father had died in war, on Zung depression and anxiety scales 

ScalesStatus NMSDT   df    pZung depression scaleCivilian loss of father5744.924.798.436
141
p<0.05War loss of father8635.327.65Zung anxiety scaleCivilian loss of father5738.355.075.019142p<0.05War loss of father8732.976.95

















Table 3 Testing for differences on Zung anxiety and depression scales with regard to the subjects' sex

Scales   Sex NMSDTdfpZung depression scaleMale6837.578.65-2.240141p<0.05Female 7540.587.42Zung anxiety scaleMale 7134.596.86-0.892142p>0.05Female 7335.606.73
















Table 4 Testing for differences on Zung depression and anxiety scales with regard to the sex (civilian loss of father)

ScalesSexNMSDTdfpZung depression scaleMale 1345.843.710.78155p>0.05Female 4444.655.07Zung anxiety scaleMale1337.604.27-0.59155p>0.05Female 4438.505.31
















Table 5 Testing for differences in the total scores on Zung depression and anxiety scales with regard to the subjects' sex (war loss of father)

ScalesSexNMSDTdf    pZung depression scaleMale5535.61  8.330.470
84
p>0.05Female 3134.80  6.34Zung anxiety scaleMale5833.91  7.171.79985p>0.05Female 2931.10  6.21
















Table 6 Coefficient of correlation between the subject�s current age, the age at which they lost their father, and the total scores on Zung anxiety and depression scales 

ScaleAge of loss of fatherAge Zung depressions scale0.435**0.233**Zung anxiety scale0.196*0.196** p<0.05; ** p<0.01


















Table 7 Coefficient of correlation between the subject's current age, the age at which they lost their father, and the�����	�	�	&
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Age of loss of fatherCurrent age
Zung depression scale
0.106-0.061
Zung anxiety scale
-0.326*0.091* p<0.05.














Table 8 Coefficient of correlation between the subject�s current age, the age at which they lost their father, and the total scores on Zung depression and anxiety scales (war loss of father) 

Age of loss of fatherCurrent age 
Zung depression scale
0.0470.049
Zung anxiety scale
0.0360.048



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