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]

SAQ 2 — Adjustment disorder, risk and closed-loop disposition (10 marks)

A fourteen-year-old girl is brought by her mother six weeks after the parents separated. She is refusing school, is irritable and withdrawn, is sleeping badly, and her mother found a note saying "nobody would care if I wasn't here." She has no prior psychiatric history. [12] [13]

Questions

1. Classify this presentation using the trigger and the clock, and explain why it is not prolonged grief disorder or major depressive disorder. (3 marks) [4]
2. Describe your immediate assessment and safety management today. (3 marks) [12]
3. Outline the definitive stepped care and the closed-loop disposition, including the role of medication. (4 marks) [13]

Model answer

Classification (3). This is adjustment disorder: distress in excess of an identifiable stressor (the parental separation), developing within about three months of onset, with functional impairment (school refusal) and a depressed/irritable flavour. It is not prolonged grief disorder because the trigger is a separation, not a death — the two use different triggers and different clocks. It is not yet major depressive disorder because the picture is a maladaptive reaction to a recent stressor rather than pervasive anhedonia and worthlessness meeting MDD criteria, though MDD must be actively screened for and excluded. [4] [12]

Immediate safety (3). The note is a suicidal-ideation disclosure, and adjustment disorder in adolescence carries elevated suicidality (Pelkonen), so this converts the encounter to a safety assessment today: assess ideation, intent, plan and access to means directly and without euphemism; assess hopelessness and any prior self-harm; make a same-day safety plan with the mother including restriction of means, supervision, who to call and where to go; and escalate to crisis mental-health support or emergency services if intent or plan is present. A safeguarding screen for family violence or abuse surrounding the separation runs in parallel. [12] [13]

Definitive care and disposition (4). Step 1 assess and triage; Step 2 immediate safety and supportive care with psychoeducation, restoration of sleep and routine, and a graded return to school with school liaison; Step 3 brief supportive therapy, problem-solving and coping-skills work with watchful resolution expected within about six months of the stressor settling; Step 4 escalate to evidence-based psychological therapy if impairment persists or a comorbid depression emerges. Medication has no first-line role for an adjustment disorder itself; an SSRI is reserved for diagnosed comorbid depression or anxiety under appropriate guidance. Close the loop: name the clinician who owns the plan, the follow-up date, the interim safety strategy and return precautions (re-emergent suicidality, new disclosures, functional decline), and coordinate school, the general practitioner and CAMHS — never an open-loop referral that leaves an at-risk adolescent exposed. [12] [13]