Grief, bereavement and adjustment disorder in children

Overview & Definition

An eight-year-old whose grandfather died six weeks ago cries at bedtime, talks about him, and has stopped enjoying football — but plays with friends at school and is eating again. Next door, a thirteen-year-old whose parents separated two months ago is refusing school, snapping at everyone, and wrote in a diary that she "can't see the point." Both are distressed. One is grieving normally; the other may have an adjustment disorder. The skill is telling them apart, and the first principle is that grief is a process, not a disease — most bereaved children adapt without ever needing a diagnosis or a referral. [1] [3]

Bereavement is the objective situation of having lost someone significant. Grief is the natural, multifaceted response — emotional, cognitive, behavioural and physical — to that loss. Normal (uncomplicated) grief in a child shows as waves of sadness and yearning, disturbed sleep and appetite, longing for the deceased, and a gradual return to play, peers and engagement, with overall function preserved. This is the expected trajectory, and the reassurance it offers the family is therapeutic in itself. [1] [3]

Two states cross a disorder threshold and need active treatment. Prolonged grief disorder (PGD) is grief that persists beyond the expected cultural and developmental window — intense yearning or preoccupation with the deceased, with identity disruption, disbelief, avoidance of reminders, and a sense that life has lost meaning — causing marked impairment. Adjustment disorder is a maladaptive reaction to an identifiable psychosocial stressor, developing within about three months, with distress in excess of the stressor or functional impairment, that resolves within about six months of the stressor ending. The gateway that separates them is the trigger: PGD follows a bereavement, whereas adjustment disorder follows any stressor — a parental separation, a serious illness, displacement, or school upheaval. [4] [12]

[4] [6]

Depth on the depressive-syndrome spine lives on the depression leaf, the trauma-response continuum on the PTSD leaf, and acute self-harm risk on the suicide-and-self-harm leaf. This page owns the grief–bereavement–adjustment spine that runs from recognition through stepped care to a closed loop. [2] [12]

References13Show ledgerHide ledger

1. [1]Melhem NM, Moritz G, Walker M, Shear MK, Brent D Phenomenology and correlates of complicated grief in children and adolescents. J Am Acad Child Adolesc Psychiatry, 2007.PMID 17420684
2. [2]Geronazzo-Alman L, Fan B, Duarte CS, Layne CM, Wicks J, Guffanti G, Musa GJ, Hoven CW The Distinctiveness of Grief, Depression, and Posttraumatic Stress: Lessons From Children After 9/11. J Am Acad Child Adolesc Psychiatry, 2019.PMID 30877043
3. [3]Melhem NM, Brent D Editorial: Grief in Children: Phenomenology and Beyond. J Am Acad Child Adolesc Psychiatry, 2019.PMID 30877044
4. [4]Boelen PA, Spuij M, Lenferink LIM Comparison of DSM-5 criteria for persistent complex bereavement disorder and ICD-11 criteria for prolonged grief disorder in help-seeking bereaved children. J Affect Disord, 2019.PMID 30836282
5. [5]Revet A, Suc A, Auriol F, Djelantik AAAMJ, Raynaud JP, Bui E Peritraumatic distress predicts prolonged grief disorder symptom severity after the death of a parent in children and adolescents. Eur J Psychotraumatol, 2021.PMID 34249245
6. [6]Boelen PA, Lenferink LIM, Spuij M CBT for Prolonged Grief in Children and Adolescents: A Randomized Clinical Trial. Am J Psychiatry, 2021.PMID 33472391
7. [7]Cohen JA, Mannarino AP Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Separation. Child Abuse Negl, 2019.PMID 30999167
8. [8]Cohen JA, Mannarino AP, Knudsen K Treating childhood traumatic grief: a pilot study. J Am Acad Child Adolesc Psychiatry, 2004.PMID 15381889
9. [9]Cohen JA, Mannarino AP, Staron VR A pilot study of modified cognitive-behavioral therapy for childhood traumatic grief (CBT-CTG). J Am Acad Child Adolesc Psychiatry, 2006.PMID 17135992
10. [10]Rosner R, Kruse J, Hagl M A meta-analysis of interventions for bereaved children and adolescents. Death Stud, 2010.PMID 24479177
11. [11]Bergman AS, Axberg U, Hanson E When a parent dies - a systematic review of the effects of support programs for parentally bereaved children and their caregivers. BMC Palliat Care, 2017.PMID 28797262
12. [12]Pelkonen M, Marttunen M, Henriksson M, Lönnqvist J Suicidality in adjustment disorder--clinical characteristics of adolescent outpatients. Eur Child Adolesc Psychiatry, 2005.PMID 15959663
13. [13]Chung MS, Chiu HJ, Sun WJ, Lin CN, Kuo CC, Huang WC, Chen YS, Cheng HP, Chou P Association among depressive disorder, adjustment disorder, sleep disturbance, and suicidal ideation in Taiwanese adolescent. Asia Pac Psychiatry, 2014.PMID 24357621