CLIMB

Raising survivors of multiple birth loss: What can parents expect?


Raising children is a tough job, even when good advice is easy to find. Parents guiding survivors of a multiple birth loss find themselves navigating uncharted waters without a paddle. To help us steer a bit better, I have brought together medical and psychological facts, parent anecdotes, and recommendations from experienced counselors who work with bereaved parents and survivors.

Introductory cautions
We may never know what may cause medical problems or unusual behaviors in a surviving multiple: inborn genetic traits, pregnancy or birth complications, physical or psychological trauma related to the loss, parenting style, or family grief responses. Psychologists’ opinions vary on the impact of womb experiences on children and adults. Many are skeptical about the significance of losing a wombmate shortly after birth. On the other hand, anecdotes and studies verify the importance of these losses for survivors and their families. Each family needs to draw their own careful conclusions after considering the information that applies to their particular circumstances.

How often do twins vanish or die in the womb, and what happens to them?
In general, monochorionic multiples are at more risk of problems during pregnancy due to shared circulation between the fetuses and a higher risk of malformations. Male multiples, like male singletons, have a slightly higher risk than females of dying during or shortly after pregnancy. In regard to birth order of multiples, the first baby out of the womb has a slightly better chance of survival than the second- or third-born in the same pregnancy, although these differences have become minor because medical care for multiple pregnancies has generally improved since 20-30 years ago.

Roughly 20-50% of pregnancies that start with two or more fetuses result in one fetus vanishing in the first 12 weeks. A vanished twin or triplet in the first trimester may possibly increase cerebral palsy risk very slightly for survivors; but most remaining children will do well.

Death of one multiple after the first trimester occurs in 4-8% of twin pregnancies, and 11-17% of triplets. According to a 2006 review article by Ong et al, after one twin dies in the second to third trimester, surviving identical (monozygotic) twin fetuses who share a placenta (monochorionic) have a 12% risk of also dying before birth, while dichorionic (2-placenta) multiples have a lower, 4% risk of the remaining twin dying. Monochorionic twins who survive pregnancy have an estimated 18% chance of neurologic problems, such as cerebral palsy or developmental delay. In contrast, only 1% of dichorionic survivors have neurologic difficulties. Small studies have documented other rare, but serious, side effects in monochorionic survivors: skin, kidney, gut or lung problems. Fortunately, the outlook is very good for most survivors, but it is worthwhile to inform doctors of surviving multiples about these risks so they watch carefully for any problems in your little ones as they grow. Early intervention with therapy or special education can help affected children.

What is the infant mortality rate? (How many multiples die in their first year?)
2002 U.S. statistics revealed that 3.02% of live-born twins, 6.01% of live-born triplets, and 16.04% of quadruplets died in the first year. Most of these losses occurred soon after birth. Prematurity contributes to many multiple losses. Multiples arrive early much more often than singletons, with half of twins and 9 out of 10 higher order multiples born before 37 weeks of pregnancy. The risk of SIDS in twins is largely explained by prematurity or low birth weight, and is about twice as great for a twin baby as for a singleton. Loss of both twins from SIDS is thankfully a rare event: fewer than 1 in 100 families who lose one twin to SIDS will lose the second twin from the same cause. Cardiorespiratory monitoring does not decrease risk of SIDS in siblings, but it can sometimes reassure parents and detect apnea episodes in preemies. Parents of surviving multiples, especially identical (monozygotic) survivors, will have their living child(ren) carefully examined by a physician after a SIDS death of a co-twin or triplet, and will make decisions about the care of the survivor(s).

What do we know about multiple interactions in the womb?
It is important to keep in mind that even genetically identical twins don’t have an identical environment, even before birth. Differences in placenta circulation, fluid in the amniotic sac, and position in the uterus make each child’s stay in the womb unique. Ultrasound studies can reveal differences in multiples’ temperaments by the fourth month of pregnancy, with clear differences even in monozygous (“identical”) pairs. Traits shown by each baby in the womb tend to persist after delivery, including tendencies to be active or quiet, to have regular or irregular cycles of movement, and to seek or avoid physical contact. Intriguing ultrasound studies done by Alessandra Piontelli showed that at 10-12 weeks, most monochorionic (one-placenta) twins, who are usually separated by a thin membrane, respond to their neighbor’s movements. By 13 weeks, the dizygous (fraternal) multiples start responding to co-twin kicks, and by 15 weeks, all multiples react to stimulation by their wombmates. Patterns of interaction that develop in the womb between multiples tend to remain similar after birth, until about age 2-3 years, when other factors start to influence the twins’ relationship with each other. These findings are summarized in PiontelliÕs chapter in Twin and Triplet Psychology.

Although PiontelliÕs ultrasound observations are meaningful for parents who try to imagine how their children might have interacted, they don’t prove the existence of prenatal social relationships. We know multiple fetuses sense and respond to each other’s movements, but we can’t know if they are aware they have company next door. Detecting emotions such as love, jealousy, or longing for one’s co-twin isn’t possible with ultrasound. Even newborn twins often are surprisingly indifferent to each other. Some cry when they are placed close together, preferring to have their own separate corners of a crib. We do know that most survivors whose twin or triplet “vanished” in the first trimester would not have been physically aware of their co-twin in the womb before the early miscarriage.

Some mothers who have experienced intrauterine loss of a multiple report a period of peculiar, or increased, activity in the womb around the time one baby died. Whether this movement was from the baby who died or from the survivor is unknown, and doctors have not discussed such reports in medical literature.

Are memories from the womb real and reliable?
I have heard of children, starting from about age 4, and many adult surviving multiples who report feeling very lonely after early loss of one or more co-multiples in the womb. Some of these individuals were never told directly that a co-twin or other co-multiples existed, yet as children they might say they felt sad inside their mother, or they may ask where their twin or sibling is. Some sets of two or more surviving multiples have been overheard by their parents talking about memories of their time in the womb, including mention of co-multiples who died. Elizabeth Noble, author of Having Twins, believes she herself is a survivor of the early death of her co-twin in the womb. One mother of surviving multiples is a counselor who uses hypnosis in her practice. She has verified the accuracy of many prenatal or early childhood experiences recalled by her patients. There may be something real in such reports – something that scientific studies cannot easily identify. However, it is important to be skeptical and confirm as many facts as possible in a case report before drawing any conclusions.

Controversial techniques, including primal therapy, hypnotic regression, and Neuro-Emotional Technique (NET) may produce ÒevidenceÓ of a vanished twin. Participants may “relive” prenatal emotional trauma purportedly caused by the death of a co-twin. Prenatal awareness and prenatal memory are ideas as controversial as the techniques used to evoke and explore them. It is important for expectant parents who just learned about the death of a multiple in the womb to put this type of dramatic, untestable account in perspective. Even if there is some truth in tales recalled under hypnotic regression, the experience of support organizations for parents and surviving multiples reveal that most surviving multiples are psychologically well-adjusted, although some have a sense of loneliness or something missing, as further explored below.

Multifetal reduction, conjoined twins, selective termination
Several studies have been done on couples who reduced a high-order multiple pregnancy from three or more fetuses to one or two in hope of a better outcome for the remaining children. These studies show ultimately positive psychological outcome in the parents, although one-fourth to one-third of parents may have some feelings of grief, guilt or mild regret for a couple of years. More importantly, small studies of the children up to four years afterward show no obvious difficulties in early childhood for the live-born children. Several sole surviving conjoined twins whose co-twin died during or after separation surgery have also been reported to have satisfactory psychological adjustment, although questions sometimes arise about their unique birth, surgeries and co-twin’s death. Psychological studies of surviving co-multiples born after selective termination of one abnormal fetus have not been done, but it is reasonable to expect the outcome would be as positive as in the preceding two situations. Careful counseling of parents is imperative in all of these situations before any procedures are performed, so parents can be as knowledgeable as possible about the possible physical and psychological outcomes of any proposed treatments.

How can parental grief reactions affect children? How should parents discuss their deceased children?
Most studies of multiple birth loss have focused on the parents’ grief reactions to loss. These studies reveal that parents grieve just as intensely for loss of a twin as for loss of a singleton. The grief process is, if anything, more complicated than singleton loss. One obvious reason for this is that parents are trying to attach to an infant while simultaneously mourning deeply. Parents also are working through the loss of a special type of parenting, the loss of raising a full set of multiples together, and knowing how it would have been and the relationships the children would have had with each other. They may additionally be adapting to other complications such as prematurity and special medical needs in survivors, sometimes very major ones. In rare situations, parents have been known to reject a surviving child. More commonly, they may become overprotective and fearful that the survivor will suffer illness or death. As with any child, parents raising surviving multiples must strive to protect their children from illness or injury while still allowing them to explore the world, take risks, and learn from their own mistakes.

Parents who have lost a child, those who have been treated for infertility, those raising intact sets of multiples, and those who are raising premature or special needs children are all at greater risk of depression than the average singleton parentÑand so, parents of a surviving multiple(s) may be especially at risk for depression. Marital problems are also more likely in these situations. It is important for parents to take steps to enhance their own psychological health. This will prevent overburdening children with issues beyond their understanding, or saddling them with feelings of inadequacy, failure or guilt. As Jean Kollantai of Center for Loss in Multiple Birth has often remarked, our children cannot, and should not, be our therapists or our support group. Some adult survivors report feeling rejected by their parents because they were not the same gender as the child who died, or they felt inadequate because however hard they tried, as a single individual they could never be “twins” to make up for their parents’ disappointment. Also, it is important that parents not assume that their child shares the feelings of grief and loss for their co-twin that they themselves have. Psychologists, bereavement organizations and adult survivors all emphasize that parents need to seek help for their own grief, for the sake of their children’s mental and physical health.

Adult survivors also encourage newly bereaved parents to openly discuss the loss of co-multiples. Many adult survivors have avoided asking their parents questions because it was obvious that the topic of their co-multiplesÕ perinatal loss is painful. They knew, from hearing about it in their family, that their twin had died, but the matter was never discussed with them, leading them to feel additional guilt. Others only find out in their 30s or 40s that they are survivors of a twin or higher-multiple pregnancy. SurvivorsÕ reluctance to cause their parents pain does not, however, diminish the survivorsÕ curiosity and need to know about a very basic fact of their existence. Joan WoodwardÕs book, ÒThe Lone Twin,Ó and anecdotes from other sources reveal how meaningful it can be to an adult survivor to visit, sometimes for the first time the gravesite of a twin who was stillborn or died in early childhood. Elizabeth Bryan and Carolyn Dawn emphasize the relief that survivors can have when the loss of their co-multiple is openly discussed in the family.

Several authorities, such as Elizabeth Bryan and Jean Kollantai, recommend discussing the deceased co-multiple by name when the survivor is still a baby. To facilitate this discussion, some parents several years after the loss have named a fetus of unknown gender. As children grow, including cemetery visits or informal discussions of deceased multiples in everyday life will help survivors to understand the significance of their co-multiple(s) to their parents, and can gradually form their own opinions as to the importance, if any, of their deceased co-multiple(s) in their own life.

During discussions of the deceased children, it is important to avoid idealizing them, or idealizing what it would have been like to have both twins. In this regard, constant references to a “guardian angel” or “angel twin” could have negative impact on a young surviving twin whose behavior is less than angelic. Dr. Elizabeth Bryan has recommended that parents avoid creating a “shrine” for the child who died, although displaying photos or mementos around the house is a helpful way to maintain awareness of the deceased sibling. Many parents believe their deceased child’s spirit is guiding their survivor, and I myself have referred to my deceased son being “with the angels and God.” However, as children get older and understand our words, we should make sure we’re not unintentionally conveying the message that the deceased child is perfect or better than the child who lived, or that having both children living would have been perfect.

To date, there have not been clear guidelines on how to talk about controversial losses, such as multifetal reduction or selective termination. It is hoped that the survivors would understand that choices were made out of hope and love to give them the best life possible and spare them and others from unreasonable suffering; since we donÕt know the best way to discuss these difficult ethical and moral choices with children, it may be best with younger children and adolescents merely to acknowledge that some fetuses died during pregnancy, without getting into details about the cause. If the fact of reduction was known about other family members, it may be worthwhile to consider discussing details more honestly when children are in their late teen years or early adulthood, so the reduction is not accidentally revealed in the heat of a family argument when the children themselves have become adults.

Finally, it is wise not to burden children with decisions about final disposition of their co-multiple’s remains. Parents who have cremated deceased multiples, or have buried them in a “Babyland” section of a cemetery, wonder whether the surviving child should determine when, or where, to scatter ashes or determine a final resting place for the child who died. Some survivors may want to take part in such decisions as adults, but it is probably best to spare younger children from these choices. This issue hasn’t been explored in professional literature, but parents have wisely pointed out that it could be unhealthy to keep cremated remains in a survivor’s bedroom, or to place them too prominently on a shelf in the home.

How do surviving children react to twin loss as they grow older?
This question has received surprisingly little attention from researchers. Studies of surviving multiples have involved adults who had lost twins at varying ages, and most of them actively responded to researchers’ public calls for surviving multiples who wanted to take part in research projects. Virtually all writings about childhood survivors report on small numbers of children, and none are scientific studies. There are important limitations in such data. For example, it is impossible to know without a systematic survey whether surviving twins have imaginary playmates more often than singleton children. Anecdotal reports might not represent the majority of surviving multiples. Keeping these cautions in mind, the following is a summary of what is known.

Nancy Segal found that adult female survivors who had lost their twin in adulthood seemed to consider their twins’ loss more significant than did surviving twin men. Identical multiples in her studies were more affected by loss than fraternal multiples. Betty Jean Case and Joan Woodward noted the same trends in their interviews with survivors. This question has not been examined in adult survivors of infant loss. Anecdotally, I have known of two triplet bereavement situations in which an identical twin of one of the triplets died before or shortly after birth. In both cases, the identical survivor of the deceased triplet had more significant grief reaction than the fraternal survivor.

Anecdotes shared by a few dozen parents with me over the years, and reported in print by Dr. Elizabeth Bryan, Elizabeth Noble, Eileen Pearlman and others, indicate that some, but not all, surviving children exhibit behaviors that are typical of children affected by other types of loss and grief. A child’s responses will obviously depend on his or her age and ability to understand death and twinship. In children who are older when their twin or co-multiple dies, their grief reaction will be influenced by the nature of the relationship between the twins at the time of the loss, the nature of the loss, and the developmental stage of the surviving child.

As noted above, authorities recommend talking with survivors about the loss from the time of loss, or from birth if the loss occurred before birth. Some survivors who are not told directly about their twin until adolescence or adulthood may feel betrayed by their parents’ withholding of vital information. However, other survivors who are informed later in life are only vaguely curious about their co-multiples, or even proud of their newfound special history. Adults often find revelation of their twin’s death to be a relief, giving them a reason for their lifelong sense of loneliness and incompleteness. When talking to younger children, you can follow Jean KollantaiÕs recommendations to mention the dead child’s name, and that you are sad that he or she died but also quite joyful that your survivor lived.

In infancy, according to Dr. Eileen Pearlman, babies tend to absorb the emotions of people around them. It is therefore important for parents to get support for their own grief and to seek help from others to be sure their surviving children’s emotional and physical needs are met during the time of the parents’ most acute grief.

Consistent, tender loving care is critical for your living multiples in infancy. They depend on you and other adults to meet all their needs, including nourishment, stimulation and affection. This can be hard to provide if you, like some parents, feel distant from your survivor(s), possibly even struggling with feelings of rejection or blame toward them. It is also difficult when you are going through grief for your baby(s) who died, and for Òmy twinsÓ or multiples (and that is in addition to all new parents needing a break, even when they are feeling protective). ItÕs important to have someone reliable who will help care for your infant’s physical and emotional needs while you are taking time to deal with your own grief needs and getting support for yourself. This may help minimize the long-term impact of parental griefÑand parents have noted how much more spontaneously they can enjoy and cherish their living child, without ÒtryingÓ, when they do that. Parents whose own grief needs are not adequately met may contribute unwittingly to the tendency of some survivors to feel lonely or incomplete.

Some survivors have cried in a uniquely distressed way at the moment of their sibling’s death, even if it occurred miles away. Others actually seemed to stabilize when a co-multiple died in NICU. Infant and toddler twins have reportedly been very clingy, sometimes wanting to be held or cuddled more often. A tendency for survivors to seek sleep or cuddling positions that mimic crowding or positioning in the womb have also been noted. Several parents have mentioned that their older infants and toddlers will stand in the crib, staring into space or babbling to the empty room. Mirror fascination starting at an early time in infancy has been noted by many parents, especially those with surviving identical twins. Sleep problems, including night terrors or nightmares, frequent awakening, or wanting to sleep with parents or older siblings has been mentioned by some parents. My son dances with his shadow, as does at least one other survivor I’ve known.

Early childhood (three to five years old) is a time when survivors still react strongly to their parents’ emotions. They are developing their own identity, show “magical thinking,” and cannot understand abstract concepts such as heaven and the permanence of death. Children may think that they caused a death by wishing it, or might think their parents can bring their dead sibling(s) back. They often don’t clearly understand what twins are until age 4, 5 or older.

Many parents of 2 – to 7-year-old survivors have observed their survivors playing with a fantasy playmate of the same age and sex as the child who died, even if they hadn’t been told of the loss. Some children complain of loneliness or sadness. Dreams about the co-sibling by name (even if parents didn’t tell the survivor about the twin who died), and⁄or sightings of an invisible person or child in the bathtub or on the stairs have been noted. Some solo twins may draw two people in a self-portrait, or one person with parts missing. A few children seem particularly drawn to intact sets of twins in preschool or daycare as best friends and playmates. Others become angry at intact sets or at drawings and photos of twins together, or tend to point out toys with broken or missing parts. Children may ask why their twin can’t come visit from heaven to play with them, and they may feel distressed about it if they believe that their twin is right there watching them but wonÕt come down.

Children need explanations about death to be as clear as possible. Avoid confusing euphemisms, such as explaining that their brother is on a long trip or is sleeping. Try to react thoughtfully, with restrained emotions, to your child’s pretend play and questions about death. Avoid overemphasizing your regrets about not being able to raise all your multiples together. A survivor shouldn’t be made to feel she is inadequate because there is only one of her. Playing with puppets or toys, and art activities, may help children express feelings about their loss. Picture books and early childhood books about life cycles may be useful. Introduce the topic of twins or multiples and reassure your child he⁄she is still a multiple, although this should not a major focus in interactions with your young child. Just as being a twin would not be the very most important fact of each childÕs life if both had lived, being a twin and being a surviving twin should not be the most important part of a surviving childÕs identity. Cemetery visits or memorial rituals to honor the deceased twin, can be included in a survivor’s life early on, although he⁄she may not feel sad or understand your own sorrowful feelings, but as he⁄she grows it should be if and when he⁄she wants to go, not because of being expected to go often. Survivors should not be expected to include their twin in prayers, their birthday cake, or anything else because it is what the parent wishes for, but because the child wants and asks for it (and this may change from one time to another).

Middle Childhood (five to nine years old) brings greater understanding of death, although magical thinking is still apparent. School-age children can better understand abstract concepts, and can begin to understand the complicated feelings of parents raising surviving multiples (sadness at loss combined with gladness at having a living child). These years also bring challenges for parents: watching their survivor begin school without his twin, and often, encountering living twins and multiples among their childÕs classmates.

Children at this age sometimes want to discuss the facts behind a sibling’s death in great detail, often repeatedly, sometimes searching for causes. Survivors may feel guilt, wondering why they survived or if they caused their twin to die. Curiosity about what it would have been like to grow up with a twin might be expressed. They might tell perfect strangers either matter-of-factly or excitedly about their siblings who died at birth, or they might only reveal the fact to a few close friends.

Patience, availability, and willingness to answer your survivor’s questions honestly while not blaming him or her for the death are healthy actions. Encourage creative expression of thoughts and feelings in writing or art. Accept your child’s decisions about whether, how and when to reveal their history. At this age, two surviving triplets can make their own choice on whether to refer to themselves as twins or as surviving triplets. They may differ in this choice, even within the same set. Cemetery visits or memorial services offer opportunities for survivors to express feelings by releasing balloons, or leaving toys, drawings or poetry.

Pre-teens and adolescents may have difficulty verbalizing their feelings. They understand that death is not reversible and are both fearful and fascinated about it. They are preoccupied with establishing their identity and very concerned about how they appear to their peers. A tendency toward perfectionism, or feeling one has to “live for two” to prove their worth to their parents, has been described by some survivors in adolescence and early adulthood. When death occurs in older childhood, older multiples may be acutely aware that they remind family and others about the deceased co-multiple. There are some books about death or special needs in a multiple-birth sibling available, many of them out of print but potentially available through used booksellers. Check Dr. PectorÕs website, synspectrum.com⁄articles.html, for a book list. Reading fictional accounts of similar situations may help children of this age explore their complex feelings.

Adult survivors, as earlier noted, sometimes report a deep sense of loneliness or something missing. It is unknown, but reasonable, to think that this might reflect the family situation if there were unmet grief needs of the parents, or difficulties with maternal attachment to the surviving twin. Those who don’t have conscious memories of their twin may find it difficult to verbalize exactly what they feel they’re missing. Many have found it incredibly healing, even in their thirties, to visit their twin’s gravesite, to hear about their parents’ memories of the twin pregnancy and birth, and to be given tangible mementos of their twin. Some survivors who lost a twin later in life have felt liberated by not enduring constant comparisons to their sibling, expressing a sense of freedom to develop as an individual.

Closing thoughts

Many survivors have entered helping professions such as medicine, ministry or teaching. Surviving multiples often show surprising empathy toward others in need. Studies in the 1970s showed surviving twin children, as a group, to be intellectually equal to singletons, while intact sets of twins showed delays relative to their singleton peers. Although surviving multiples may need to be watched for medical or psychological difficulties, the vast majority will prove to be normal, talented and sensitive individuals of whom we can be proud.

References used in preparing this article, and sources for further reading:

1. Blickstein I. and Louis Keith, eds. Multiple Pregnancy: Epidemiology, Gestation and Perinatal Outcome. London: Taylor & Francis, 2005.
2. Brandt R. Twin Loss: A book for survivor twinsÑhigher order multiples – . Twinsworld Publishing Company, Leo IN, 2001.
3. Bryan E, Hallett F. Guidelines for Professionals: Bereavement. Multiple Births Foundation, England, 1997.
4. Bryan EM. Twins, Triplets and More. St. Martin’s Press, New York, 1992.
5. Case BJ. Living Without Your Twin. Tibbutt Publishing, 2001.
6. Dawn CM. The surviving twin: exploring the psychological, emotional, and spiritual impacts of having experienced a death before or at birth. Dissertation, Institute of Transpersonal Psychology, Palo Alto CA, 2003.
7. Getahun D, Demissie K, Lu S-E, Rhoads GG. Sudden infant death syndrome among twin births: United States, 1995-1998. J Perinatol 2004;24:544-551.
8. Haddon L. Surviving co-multiples, twinless twin, lone twin. http:⁄⁄multiplebirthsfamilies.com⁄articles⁄ber_q16.html
9. Haddon L. Articles at multiplebirthsfamilies.com
10. Hayton A. Untwinned: perspectives on the death of a twin before birth. Wren Publications, 2007.
11. Kollantai J Articles at climb-support.org
12. Malloy MH, Freeman DH Jr. Sudden infant death syndrome among twins. Arch Pediatr Adolesc Med 1999; 153(7):736-40.
13. Multiple Birth Bereavement Information Packet, Multiple Births Canada.
14. Newman RB, Luke B. Multifetal Pregnancy: A Handbook for Care of the Pregnant Patient. Philadelphia: Lippincott Williams & Wilkins, 2000.
15. Noble E. Having Twins. Houghton Mifflin Company, Boston, 2003.
16. Ong SS, Zamora J, Khan KS, Kilby MD. Prognosis for co-twin following single-twin demise. BJOG 2006 113(9): 992-8.
17. Pearlman EM and Jill Alison Ganon. Raising Twins : What Parent Want to Know (And What Twins Want to Tell Them). Harper-Collins Publishers, 2000.
18. Raffensperger J. A philosophical approach to conjoined twins. Pediatr Surg Int 1997; 12(4):249-55.
19. Sandbank AC, ed. Twin and Triplet Psychology. Routledge, London, 1999. (especially interesting are PiontelliÕs chapter on ultrasound and Elizabeth BryanÕs chapter on bereavement).
20. Schulz L. The Survivor. Pleasant Word, 2003.
21. Segal NL. Entwined Lives : Twins and What They Tell Us About Human Behavior. E P Dutton, 1999.
22. Smith-Levitin M. Chapter 16, Multifetal Pregnancies: Epidemiology, Clinical Characteristics, and Management, in: Medicine Of The Fetus And Mother. Reece, E Albert and John C. Hobbins, eds. Lippincott-Raven Publishers, 1998.
23. Wilson, LR. Differences between identical twin and singleton adjustment to sibling death in adolescence. Journal of Psychological Practice 1(2):100-104, 1995.
24. Woodward J. The Lone Twin. Free Association Books, London⁄NY, 1998.

Books for children:
The Special Brother, Judy Kidder, Reivers Press, San Diego, CA, 1999.
Always my Twin, Valerie R. Samuels, illustrated by Najah Clemmons, 2005. http:⁄⁄www.synspectrum.com⁄multigriefspecialbooks.doc.

Please visit climb-support.org, synspectrum.com⁄multiplicity.html, multiplebirthsfamilies.com, and twinlesstwins.org for more information about multiple-birth loss and support for parents and survivors.

© Elizabeth A. Pector MD 2001, updated 2007