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Identifying Prolonged Grief Reactions in Children: Dimensional and Diagnostic Approaches

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Objective

Children with prolonged grief reactions (PGR) have been found to be at increased risk for depression and functional impairment. Identifying and diagnosing PGR in children is challenging, as there are no available dimensional measures with established thresholds and no diagnostic criteria in the DSM-IV. We examine thresholds for the Inventory for Complicated Grief–Revised for Children (ICG-RC) and compare this dimensional approach to the proposed DSM-5 criteria for Persistent Complex Bereavement–Related Disorder. We also identify a screening tool for PGR.

Method

Parentally bereaved children and adolescents, 8 through 17 years of age, were assessed at 9, 21, and 33 months after parental death. Receiver operating characteristics were used to establish the “best threshold” that would identify youth with PGR and evaluate the proposed DSM-5 criteria cross-sectionally and longitudinally.

Results

A score of 68 or higher on the ICG-RC was found to have high sensitivity (0.942) and specificity (0.965) in differentiating cases of PGR from noncases at 9 months. We also identified a 6-item screening tool that consists of longing and yearning for the deceased, inability to accept the death, shock, disbelief, loneliness, and a changed world view. The proposed DSM-5 criteria correctly identified only 20% to 41.7% of cases with PGR at different time points.

Conclusions

For the identification of youth at risk for PGR, the dimensional approach outperformed the proposed categorical diagnostic criteria. We propose a brief screening scale that, if validated, can help clinicians to identify bereaved children and adolescents at risk for PGR, and guide the development of prevention and intervention strategies.

Section snippets

Sample

We have previously reported on our sample of 182 bereaved children and adolescents, < 18 years of age, who lost a parent to suicide, accident, or sudden natural death.14 In this paper, we address our aims cross-sectionally and longitudinally in 154 of the 182 (84.6%) who had complete data on the ICG-RC at baseline or 9 months (SD = 3.8; range 1–19) after the death. Of these, 129 (83.8%) were followed up at 21 months (SD = 4.1, range 13–31) and 102 (66.2%) at 33 months (SD = 4.5, range 24–43)

ICG-RC Cut-offs

ROC analyses resulted with a score of 68 as the cut-off identifying cases with PGR (class 3) from non-cases (class 1), with high sensitivity (0.942) and specificity (0.965) (Table 2 and Table S1, available online). This cut-off continued to have high sensitivity and specificity at 21 and 33 months. Similar results were obtained when comparing class 3 to classes 1 and 2 combined, although the specificity was lower at 9 months. As ICG-RC scores in classes 1 and 2 declined at 21 and 33 months, and

Discussion

We established cut-offs for the ICG-RC and found that a score of ≥68, 9 months after the loss of a parent, identifies children and adolescents with PGR with high sensitivity and specificity. We derived a 6-item screening tool, which can help clinicians screen for this condition in bereaved children and adolescents. This is the first study to evaluate the performance of the currently proposed DSM-5 criteria for PCBRD in children/adolescents. We found the proposed criteria to have low to moderate

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    • Cited by (0)

    This study was supported by grants R01-MH65368 (D.A.B.) and K01-MH077930 (N.M.M.) from the National Institute of Mental Health (NIMH); and by a Young Investigator Award from the American Foundation for Suicide Prevention (N.M.M.). NIMH and the American Foundation for Suicide Prevention did not participate in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

    Clinical guidance is available at the end of this article.

    Dr. Melhem served as the statistical expert for this research.

    Disclosure: Dr. Brent has received royalties from Guilford Press; has or will receive royalties from the Columbia Suicide Severity Rating Scale (C-SSRS) and the electronic self-rated version of the C-SSRS from ERT, Inc.; and has served as an UpToDate Psychiatry Editor. Dr. Melhem, Ms. Porta, and Ms. Payne report no biomedical financial interests or potential conflicts of interest.

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    Copyright © 2013 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.