Grief, bereavement and adjustment disorder in children — formative SAQs

SAQ 1 — Classifying the presentation and choosing first-line care (10 marks)

A nine-year-old boy is brought to clinic fourteen months after his mother died suddenly at home. His father reports that the child still talks about little else, refuses to enter the room where she died, says "I don't know who I am anymore," and has stopped seeing his friends. The father, himself exhausted, asks whether an antidepressant would help his son "move on." [1] [4]

Questions

1. Using the trigger, the clock and the core features, classify this child's presentation. Which diagnosis best fits, and what two features distinguish it from major depressive disorder? (4 marks) [2]
2. Outline the stepped, first-line management, naming the evidence-based psychological therapy and addressing the father's request for an antidepressant. (4 marks) [6]
3. What else must you assess at this consultation, and why? (2 marks) [12]

Model answer

Classification (4). Fourteen months after a bereavement, this child has intense and persistent longing and preoccupation with his mother, avoidance of reminders, identity disruption ("I don't know who I am anymore"), and clear functional impairment (stopped seeing friends) — meeting prolonged grief disorder. The trigger is a death and the clock has run well past the threshold. Two features distinguish it from major depressive disorder: grief is wavelike with preserved positive affect between waves and is centred on the deceased, whereas MDD is pervasive anhedonia with worthlessness and self-loathing; and the PGD core is yearning and identity erosion rather than the anhedonia and psychomotor change of depression. The Geronazzo-Alman work confirms grief, depression and PTSD are empirically distinct in bereaved children. [2] [4]

Stepped management (4). Step 1 assess and triage; Step 2 immediate safety and supportive care with psychoeducation that grief is a normal process and restoration of sleep, routine and school; Step 3 watchful waiting does not apply here because impairment has persisted past the threshold. Step 4 delivers evidence-based psychological therapy — CBT for PGD, the Boelen randomised clinical trial, which targets the avoidance, negative cognitions and insecure bond keeping the grief stuck — with family involvement and active support of the father as the secure base. The antidepressant request should be declined for the grief itself: there is no first-line medication for PGD; an SSRI is reserved for diagnosed comorbid depression or anxiety on its own merits. [6]

What else to assess (2). Suicidality — ideation, intent, plan, means, hopelessness — because distressed and impaired bereaved children are a risk group; and the father's own grief and capacity, because an unsupported caregiver cannot be the secure base the therapy depends on, and caregiver support is part of the child's plan. [1] [12]