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

Increasing evidence supports the inclusion of a new bereavement-related disorder in future editions of The Diagnostic and Statistical Manual of Mental Disorders (DSM-V)

Increasing evidence supports the inclusion of a new bereavement-related disorder in future editions of The Diagnostic and Statistical Manual of Mental Disorders (DSM-V)



Washington, DC, October 1, 2019

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), published by Elsevier, 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, PhD, 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 posttraumatic 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 posttraumatic 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.

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Notes for editors

The article is "The Distinctiveness of Grief, Depression, and Posttraumatic Stress: Lessons From Children After 9/11” Lupo Geronazzo-Alman, PhD, Bin Fan, MD, Cristiane S. Duarte, PhD, MPH, Christopher M. Layne, PhD, Judith Wicks, BA, Guia Guffanti, PhD, George J. Musa, PhD, Christina W. Hoven, DrPH, MPH (https://doi.org/10.1016/j.jaac.2018.12.012). It currently appears on the JAACAP Articles In Press page and will appear in the Journal of the American Academy of Child and Adolescent Psychiatry, volume 58, issue 10 (October 2019), published by Elsevier.

Dr. Lupo Geronazzo-Alman has a PhD in Psychobiology from the University of Milan (2011) and has been working since 2010 in the Division of Child & Adolescent Psychiatry, New York State Psychiatric Institute.

Copies of this paper are available to credentialed journalists upon request; please contact Mary Billingsley at mbillingsley@aacap.org or +1 202 587 9672. Journalists wishing to interview the authors may contact Lupo Geronazzo-Alman by e-mail at lupo.geronazzo@nyspi.columbia.edu.

About JAACAP

Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) is the official publication of the American Academy of Child and Adolescent Psychiatry. JAACAP is the leading journal focusing exclusively on today's psychiatric research and treatment of the child and adolescent. Published twelve times per year, each issue is committed to its mission of advancing the science of pediatric mental health and promoting the care of youth and their families.

The Journal's purpose is to advance research, clinical practice, and theory in child and adolescent psychiatry. It is interested in manuscripts from diverse viewpoints, including genetic, epidemiological, neurobiological, cognitive, behavioral, psychodynamic, social, cultural, and economic. Studies of diagnostic reliability and validity, psychotherapeutic and psychopharmacological treatment efficacy, and mental health services effectiveness are encouraged. The Journal also seeks to promote the well-being of children and families by publishing scholarly papers on such subjects as health policy, legislation, advocacy, culture and society, and service provision as they pertain to the mental health of children and families. www.jaacap.org