Bereavement and grief is not a mental illness. However, sometimes children who have been bereaved suddenly can develop symptoms that indicate a serious mental health condition.

Mental health disorders that can occur after a challenging bereavement include post-traumatic stress disorder (PTSD), prolonged grief disorder (PGD)[1] and persistent complex bereavement disorder (PCBD)[2].

These conditions require appropriate and expert treatment.

Schools need to be aware of signs and symptoms that a pupil may be developing a mental health condition so they can help families understand how to get their needs assessed and seek appropriate treatment.

Post-traumatic stress disorder (PTSD)

Symptoms of PTSD:

• Avoidance – After a sudden bereavement, a child may seek to avoid any memories or ‘triggers’ that remind them of the circumstances of the death. You may find that a child is unwilling to talk about the death [3]. Triggers can be sensory, including sounds, sights and smells that remind them of the death.
• Flashbacks – After a traumatic event, children may suffer from flashbacks and intrusive recollections of what happened. In younger children, this may be expressed through repetitive play. Traumatically bereaved children may also have frightening dreams that disturb their sleep [4]. 
• Hyperarousal – Children who have been traumatically bereaved may suffer from hyperarousal – symptoms include being easily startled or frightened, and can also cause hypervigilance. Hyperarousal can cause issues with sleeping and concentration, and increased irritability and anger [5].

Other symptoms include an inability to eat, stuttering, sudden outbursts of very strong emotions, or being withdrawn.

When to seek further help:

Schools should be aware that there is an increased likelihood that a child who has experienced a sudden bereavement, may develop a complicated grief disorder – particularly if the child witnessed a violent event such as a homicide or road death.

If you notice that any of the symptoms listed above continue for more than a month after the death, talk to the child’s family and ask them to consult their GP so they can get their needs assessed and obtain appropriate treatment.

If necessary, the GP may also make a referral to the Child and Adolescent Mental Health Service (CAMHS) [6].

Treatment for PTSD:

The UK’s National Institute for Health and Care Excellence (NICE) guidelines for PTSD [7] recommend a course of trauma-focused cognitive behavioural therapy (CBT) interventions for children, where either a diagnosis of PTSD has been made, or clinically important symptoms displayed, more than one month after a traumatic event.

CBT will typically be provided over 6 to 12 sessions, but more if clinically indicated, for example if a child has experienced multiple traumas. Therapy will: be delivered by trained practitioners with ongoing supervision; be adapted to the child’s age and development; and involve parents or carers as appropriate

NICE guidelines advise against the use of drugs for treatment or prevention of PTSD in children under the age of 18. 

Prolonged grief disorder (PGD)

Prolonged grief disorder (PGD) is a “persistent and pervasive” grief response following the death of a person close to the bereaved, such as a parent.

PGD is characterised by a longing for the deceased or a persistent preoccupation with the deceased.

It is also accompanied by intense emotional pain, for example:

• sadness
• guilt
• anger
• denial
• blame
• difficulty accepting the death
• feeling one has lost a part of one’s self
• an inability to experience positive mood
• emotional numbness
• difficulty engaging with social or other activities.

The grief response persists for a long time after the loss (more than six months at a minimum) and grief reactions clearly exceed those that would be expected for the individual.

PGD significantly affects a pupil’s personal, family, social, educational, or other important areas of functioning [8]. 

When to seek further help:

If you notice that any of the symptoms listed above continue for more than six months after the death, talk to the child’s family and ask them to consult their GP so they can get their needs assessed and obtain appropriate treatment.

Treatment for PGD:

Treatment comprises structured sessions of talk-based therapy with a trained practitioner.

Persistent complex bereavement disorder (PCBD) 

PCBD is characterised by “an extreme, disabling yearning for a deceased loved one for a prolonged period of time.” PCBD can affect people of all ages. Symptoms may appear shortly after the death of a close family member or friend, but for children a diagnosis is not made unless symptoms continue for at least 6 months [9].

Common symptoms of PCBD include:

• intense sadness that does not improve over time
• continual yearning for the deceased person
• difficulty trusting other people
• digestive issues
• constantly thinking about the death
• feelings of emptiness
• inability to perform daily activities
• loss of interest in hobbies
• fatigue
• hallucinations of the deceased
• loneliness
• thoughts about suicide.

Although people with normal grief may have similar symptoms, individuals with PCBD experience symptoms for a much longer period of time.

When to seek further help:

If you notice that any of the symptoms listed above continue for more than six months after the death, talk to the child’s family and ask them to consult their GP so they can get their needs assessed and obtain appropriate treatment.

Treatment for PCBD:

Treatment comprises structured sessions of talk-based therapy with a trained practitioner.

References

[1] Cruse. 2019. Childrens’ understanding of death. [Online]. [Accessed on 17/06/2019]. Available from: https://www.cruse.org.uk/get-help/for-parents/childrens-understanding-of-death

[2] Osterweis, M. and Solomon, F. 1984. Institute of Medicine (US) Committee for the Study of Health Consequences of the Stress of Bereavement. Washington DC: National Academies Press (US).

[3] Royal College of Psychiatrists. 2019. Traumatic stress in children: for parents and carers. [Online]. [Accessed 17/06/2019]. Available from: https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/traumatic-stress-in-children-for-parents-and-carers

[4] Marie Curie. 2019. How grief may affect children. [Online]. [Accessed on 17/06/2019]. Available from: https://www.mariecurie.org.uk/help/support/bereaved-family-friends/supporting-grieving-child/grief-affect-child 

[5] World Health Organization. International Classification of Diseases 11th Revision

[6] American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM–5)

[7] Cohen, J. and Scheeringa, M. 2009. Post-traumatic Stress Disorder Diagnosis in Children: Challenges and Promises. Dialogues in Clinical Neuroscience. [Online]. 11 (1), pp. 91-99. [Accessed 17/06/19]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181905/

[8] Royal College of Psychiatrists. 2019. Traumatic stress in children: for parents and carers. [Online]. [Accessed 17/06/2019]. Available from: https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/traumatic-stress-in-children-for-parents-and-carers

[9] NHS. 2018. Symptoms: Post-Traumatic Stress Disorder. [Online]. [Accessed 17/06/2019]. Available from: https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/symptoms/ 

[10] Young Minds. 2019. PTSD – Treating PTSD. [Online]. [Accessed 17/06/2019]. Available from: https://youngminds.org.uk/find-help/conditions/ptsd/ 

[11] National Institute for Health and Care Excellence. 2018. Post-traumatic stress disorder. NICE guideline [NG116]. [Online]. [Accessed 17/06/2019]. Available from: https://www.nice.org.uk/guidance/ng116/chapter/Recommendations#management-of-ptsd-in-children-young-people-and-adults 

[12] World Health Organization. International Classification of Diseases 11th Revision

[13] Depression Alliance (2018) Persistent complex bereavement disorder. [Accessed 29/09/20]. Available from: https://www.depressionalliance.org/persistent-complex-bereavement-disorder/