According to the CDC, to date more than 140,000 children in the United States have a lost a caregiver due to COVID-19.  Some have described this increase in orphanhood as a hidden pandemic in the United States and worldwide.  With 1 in 500 children experiencing loss of a direct caregiver, and likely many more exposed to death of another relative or family friend, pediatricians are more likely to see children exhibiting signs of grief in their offices.  It is imperative for the primary care physician to be able to distinguish the normative grief process from a psychiatric disorder.

The DSM-5 includes Persistent Complex Bereavement Disorder in the section on Conditions for Further Study with an estimated prevalence of 2.4-4.8%.  Colloquially, this is often referred to as prolonged grief.  In children, persistent complex bereavement can be diagnosed after 6 months of symptoms (12 months in adults). Symptoms do not need to be present daily but should be present on more days than not. Symptoms must include at least 1 of the following:

• Persistent yearning for the deceased. In young children, this yearning may be expressed through play and behavior rather than words.
• Intense sorrow and emotional pain in response to the death
• Preoccupation with the deceased
• Preoccupation with the circumstances of death. Again, in young children, this may be expressed through play and extend to preoccupation with fear of other deaths

Additionally, at least 6 of the following must be experienced as well from either category:

Reactive distress to the death:

• Marked difficulty accepting the death. In young children, this should be assessed against what is expected of their developmental stage as very young children do not process death as permanent
• Experiencing disbelief or emotional numbness over the loss
• Difficulty with positive reminiscing about the deceased
• Bitterness or anger related to the loss
• Self-blame or guilt about the death
• Excessive avoidance of reminders of the loss

Social/identity disruption:

• A desire to die to be with the deceased
• Difficulty trusting other individuals since the death
• Feeling alone or detached from other individuals since the death
• Feeling that life is meaningless or empty without the deceased, or the belief that one cannot function without the deceased
• Confusion about one’s role in life (e.g. feeling a part of you died with the deceased)
• Difficulty or reluctance to pursue interests since the loss or to plan for the future

While the symptoms must persist for 6 months to meet criteria for the disorder in children, they can begin at any point after the death and may even be delayed for months or years.  In children, the grief may not be expressed in words but rather in play and behavior, developmental regression, or anxiety including protest behavior at times of separation/reunification with other caregivers.  Younger children are more likely to show signs of separation distress while older children may be more prone to social/identity disruption.

Risk factors for the development of a bereavement disorder include female gender, dependency on the deceased, as would be seen with loss of a caregiver, as well as poor caregiver support after the death.  So, in a situation where one parent dies and the other parent is struggling to cope with that loss, the children may be at increased risk.  Children with a history of a prior loss may be at even increased risk.  Checking in with the remaining caregivers and encouraging them to seek their own support can be an important intervention for the pediatrician to consider and offer.  Prior history of mood disorder may also be a risk factor in the development of persistent complex bereavement disorder.

Substance use disorders are among the most common co-morbidities of persistent complex bereavement disorder after MDD and PTSD.  A CDC report from June 2020 suggested that 13% of Americans had started or increased substance use to cope with the pandemic.  One can only imagine that the numbers have risen since then as we know that both grief and isolation are risk factors for substance use.  This is a consideration of particular importance for loss from COVID-19 as so many of the community rituals we depend on to process grief were stripped away during the pandemic.  Adolescents are also at risk of turning to substances to numb unprocessed pain, and screening tools such as the CRAFFT are important tools to detect misuse.

An important evolution in psychiatry has been the recognition that a depressive episode can begin in the immediate aftermath of loss.  For that reason, DSM-5 eliminated the bereavement exclusion criterion for MDD.  Persistent complex bereavement is distinguished from depression by its singular focus on loss and depression is more likely to be persistent day to day versus the waxing and waning nature of grief. It is important for pediatricians to screen for depression in this population and provide appropriate intervention including referral to psychotherapy and/or starting medication as appropriate.  Consulting with the Project TEACH Child & Adolescent Psychiatrist to present the case for discussion is available and strongly recommended.