Handling traumatic grief reactions in children and adolescents post-9/11

Grief reactions in traumatically bereaved youth, particularly in relation to a shared trauma, constitute a unique aspect of psychological distress. A new study in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) reports that this disorder warrants separate clinical attention.

In the wake of the World Trade Center attack on September 11, 2001 (9/11), researchers from Columbia University Medical Center (CUMC), New York defined the "traumatically bereaved" as those who experienced the loss of a mother, father, sister, brother, grandmother, grandfather, aunt, uncle, other family member, friend, and/or someone else after 9/11 happened.

"Study findings support the potential clinical relevance of a new bereavement disorder during sensitive developmental periods spanning from middle childhood to late-adolescence," said lead author Lupo Geronazzo-Alman, Ph.D., Assistant Professor of Clinical Medical Psychology, Division of Child and Adolescent Psychiatry at the New York State Psychiatric Institute, CUMC. "Grief reactions have added clinical value and merit clinical attention, because they describe maladaptive reactions after 9/11 that are not adequately captured by other disorders such as post traumatic stress and major depression."

The findings, based on The World Trade Center (WTC) Board of Education (WTC-BOE) Study, are comprised of responses taken from a sample of 8,236 youth in grades 4 to 12, who answered a questionnaire six months after 9/11. It is representative of 715,966 New York City (NYC) public school students at the time of assessment.

The 277 youth (3.36 percent of the sample) experienced death of a family member; 576 (6.99 percent) and 1,003 (12.18 percent) youth experienced the death of a friend and of someone else they knew, respectively. In total, 1,696 youth were traumatically bereaved on 9/11, representing 133,446 (18.71 percent) 4th- through 12th-graders attending NYC public schools 6 months after 9/11.

The following five items selected from the UCLA Grief Screening Scale queried bereaved youth about the intensity of grief reactions during the previous month: missing the deceased person; continuing to feel connected to them; avoiding conversations; avoiding activities; and unhelpful rumination about the deceased person.

Symptoms of post traumatic stress disorder (PTSD) and major depressive disorder (MDD) were assessed with the Diagnostic Interview Schedule for Children (DISC-IV) Predictive Scales (DPS), a screening measure derived from the DISC-IV.

To establish whether a new bereavement disorder warrants a place in psychiatric nosology, the researchers provided four types of convergent evidence showing that the (1) predictors (i.e., non-loss-related trauma versus traumatic bereavement); (2) clinical correlates (new health problems since 9/11, functional impairment); (3) factorial structure; and (4) phenomenology of grief reactions are independent of, and distinct from, other common types of post-disaster child and adolescent psychopathology, and capture a unique aspect of bereavement-related distress.

Grief reactions, PTSD, and MDD all have different predictors; traumatic bereavement was associated with grief independently of PTSD and MDD but was not associated with PTSD and MDD after adjusting for grief reactions.

After controlling for PTSD and MDD, grief reactions were significantly associated with functional impairment. Furthermore, a factor analysis showed that grief reactions loaded on one factor, which was distinct from factors underlying PTSD and MDD symptoms. Finally, youth with severe grief reactions could be grouped into two classes characterized by (i) negligible and (ii) only moderate probability of co-occurring PTSD and MDD symptoms, respectively.

"A primary benefit of including a new definition of bereavement disorder into the main text of the DSM-V will fill in a current gap in how clinicians are able to describe and explain reactions to traumatic bereavement, allowing us to better predict and prescribe the most appropriate treatment," concluded Dr. Geronazzo-Alman.