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Fast Facts

A brief refresher with useful tables, figures, and research summaries

Attachment, Trauma, and Other Stressor-Related Disorders

In this section, we address the diagnosis and management of the following stress-related disorders in children:

Disorders of Attachment
- Reactive Attachment Disorder
- Disinhibited Social Engagement Disorder
Trauma and Other Stressor-Related Disorders

Disorders of Attachment

Attachment is the organization of behaviors in the young child that are designed to achieve physical proximity to a preferred caregiver at times when the child seeks comfort, support, nurturance, or protection. This develops during the first year of life but can be disrupted under various circumstances and have long-term consequences. Lack of attachment to a specific attachment figure is exceedingly rare in reasonably responsive caregiving environments, and signs of reactive attachment disorder have never been reported in the absence of serious neglect. Insecure attachment is a risk factor and secure attachment is a protective factor for developing mental illness in the future.

Two disorders described in Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) are associated with disruption in attachment and other social behaviors in the setting of extreme neglect: reactive attachment disorder and disinhibited social engagement disorder.

Reactive attachment disorder (RAD): The essential feature is the early onset of abnormal social relatedness across contexts in the absence of other core symptoms of pervasive developmental disorders. RAD has not been reported in children without a history of neglect. Therefore, neglect is a required diagnostic criterion for a RAD diagnosis. In the presence of history of neglect, children with RAD present with social behaviors that are consistently avoidant and withdrawn. Mood and behavioral dysregulation are also common.
Disinhibited social engagement disorder (DSED): Alternatively, children with a history of extremely insufficient care who display patterns of excessive and indiscriminate friendliness may meet criteria for DSED.

Diagnosis

The diagnostic criteria for RAD and DSED are outlined in the following two tables:

Summary of DSM-5-TR Diagnostic Criteria for Reactive Attachment Disorder
The child shows a consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, including both rarely seeking comfort when distressed and minimally responding to such comfort when it is provided. The child displays a persistent social and emotional disturbance characterized by at least two of the following: minimal social and emotional responsiveness limited positive affect unexplained irritability, sadness, or fearfulness that are present even during nonthreatening interactions with caregivers The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults repeated changes of primary caregivers that limit opportunities to form stable attachments rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutional rearing) The behavioral disturbances in Criterion A began following the lack of care in Criterion C, and the lack of care is presumed to be responsible for the behavioral disturbance. The child does not have an autism spectrum disorder. Symptoms were present before age 5. The child has a developmental age of at least 9 months.

Summary of DSM-5-TR Diagnostic Criteria for Reactive Attachment Disorder

The child shows a consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, including both rarely seeking comfort when distressed and minimally responding to such comfort when it is provided.
The child displays a persistent social and emotional disturbance characterized by at least two of the following:
- minimal social and emotional responsiveness
- limited positive affect
- unexplained irritability, sadness, or fearfulness that are present even during nonthreatening interactions with caregivers
The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
- social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults
- repeated changes of primary caregivers that limit opportunities to form stable attachments
- rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutional rearing)
The behavioral disturbances in Criterion A began following the lack of care in Criterion C, and the lack of care is presumed to be responsible for the behavioral disturbance.
The child does not have an autism spectrum disorder.
Symptoms were present before age 5.
The child has a developmental age of at least 9 months.

Summary of DSM-5-TR Diagnostic Criteria for Disinhibited Social Engagement Disorder
A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults including at least two of the following: reduced or absent reticence with regards to approaching or interacting with unfamiliar adults overly familiar verbal or physical behavior that is not consistent with cultural norms for the child’s age diminished or absent checking back with adult caregivers, even in unfamiliar settings willingness to go off with an unfamiliar adult with minimal or no hesitation The behaviors in Criterion A are not limited to impulsivity (as in attention deficit-hyperactivity disorder) but include socially disinhibited behavior. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults repeated changes of primary caregivers that limit opportunities to form stable attachments rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutional rearing) The behavioral disturbances in Criterion A began following the lack of care in Criterion C, and the lack of care is presumed to be responsible for the behavioral disturbance. The child has a developmental age of at least 9 months.

Summary of DSM-5-TR Diagnostic Criteria for Disinhibited Social Engagement Disorder

A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults including at least two of the following:
- reduced or absent reticence with regards to approaching or interacting with unfamiliar adults
- overly familiar verbal or physical behavior that is not consistent with cultural norms for the child’s age
- diminished or absent checking back with adult caregivers, even in unfamiliar settings
- willingness to go off with an unfamiliar adult with minimal or no hesitation
The behaviors in Criterion A are not limited to impulsivity (as in attention deficit-hyperactivity disorder) but include socially disinhibited behavior.
The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
- social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults
- repeated changes of primary caregivers that limit opportunities to form stable attachments
- rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutional rearing)
The behavioral disturbances in Criterion A began following the lack of care in Criterion C, and the lack of care is presumed to be responsible for the behavioral disturbance.
The child has a developmental age of at least 9 months.

Management

Treatment of attachment disorders is complex and typically involves a multidisciplinary team. The primary and most essential intervention for children with disorders of attachment is ensuring that the child is in an adequate caregiving situation. No evidence supports pharmacologic treatment for the primary symptoms of either RAD or DSED. However, children with attachment disorders experience high rates of comorbidity with other mental health conditions, and medication management may be indicated for some co-occurring symptoms and disorders.

Prognosis

The clinical picture in patients with RAD or DSED often improves to the point of remission in children who are subsequently cared for in supportive and invested environments, even if the quality of attachments is still disrupted. Notably, research has largely been limited to children aged 5 and younger. Little is known about the long-term implications of the disorder in older children. Involvement of a specialist is always recommended in children with attachment-related disorders.

Trauma and Other Stressor-Related Disorders

The significance of adverse childhood experiences (ACEs), including both abuse (physical, sexual, or psychological) and dysfunction in the child’s environment (parental substance use, exposure to violence, neglect, etc.) cannot be overstated. Such experiences affect both mental and physical health. A seminal retrospective cross-sectional study published in 1998 demonstrated significant long-term health risks in adults exposed to ACEs, with a dose-response relation between exposure to ACEs and health-related risk factors for diseases in adulthood. These findings continue to be supported in ongoing studies. In a national study, untreated child abuse and neglect alone accounted for more years lost to disability than all mental health disorders combined. The following trauma- and other stressor-related disorders are covered in this section:

Acute Stress Disorder and PTSD
Adjustment Disorders
Prolonged Grief Disorder

Acute Stress Disorder and PTSD

Diagnosis: Trauma is a great mimicker in mental health, meaning that trauma-related syndromes can present with myriad symptoms that mimic attentional, anxiety, mood, and even psychotic disorders. Traumatized children are particularly overrepresented in the child welfare and justice systems. The effects of childhood physical and sexual abuse are significant, as are the effects of childhood neglect.

The diagnosis of post-traumatic stress disorder (PTSD) requires that the duration of associated symptoms is more than one month, whereas symptoms with shorter duration may represent acute stress disorder. The diagnostic criteria for acute stress disorder and PTSD are outlined in the following two tables:

Summary of DSM-5-TR Diagnostic Criteria for Acute Stress Disorder
Patient has been exposed to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: direct experience witnessing an event learning of a traumatic event that happened to a close family member or friend that was violent or accidental repeated or extreme exposure to adverse details of traumatic events Nine or more of the following symptoms (from any combination of categories), began or worsened following the traumatic event: *Intrusion symptoms:* recurrent, involuntary, and intrusive distressing memories, or in children, repetitive play expressing themes or aspects of the event recurrent distressing dreams related to the event (although the content might not be recognizable as directly related to the event in children) dissociative reactions (flashbacks) where the individual feels or acts as if the trauma were recurring, or reenactment in play intense or prolonged psychological distress or marked physiological reactions to internal or external cues that symbolize or resemble the event Negative mood symptoms: persistent inability to experience positive emotions Dissociative symptoms: an altered sense of the reality of the self or surroundings inability to remember an important aspect of the event Avoidance symptoms: efforts to avoid distressing memories, thoughts, or feelings related to the event avoidance of external reminders that arouse distressing memories, thoughts, or feelings related to the event *Arousal symptoms:* sleep disturbance irritable behavior or angry outbursts with little or no provocation hypervigilance problems with concentration exaggerated startle response Duration of symptoms is at least 3 days and up to one month following the trauma exposure. The disturbance causes clinically significant distress or impairment in functioning. The disturbance is not better attributed to something else (a medical condition, substance use, brief psychotic disorder).

Summary of DSM-5-TR Diagnostic Criteria for Acute Stress Disorder

Patient has been exposed to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
- direct experience
- witnessing an event
- learning of a traumatic event that happened to a close family member or friend that was violent or accidental
- repeated or extreme exposure to adverse details of traumatic events
Nine or more of the following symptoms (from any combination of categories), began or worsened following the traumatic event:
- Intrusion symptoms:
  - recurrent, involuntary, and intrusive distressing memories, or in children, repetitive play expressing themes or aspects of the event
  - recurrent distressing dreams related to the event (although the content might not be recognizable as directly related to the event in children)
  - dissociative reactions (flashbacks) where the individual feels or acts as if the trauma were recurring, or reenactment in play
  - intense or prolonged psychological distress or marked physiological reactions to internal or external cues that symbolize or resemble the event
- Negative mood symptoms:
  - persistent inability to experience positive emotions
- Dissociative symptoms:
  - an altered sense of the reality of the self or surroundings
  - inability to remember an important aspect of the event
- Avoidance symptoms:
  - efforts to avoid distressing memories, thoughts, or feelings related to the event
  - avoidance of external reminders that arouse distressing memories, thoughts, or feelings related to the event
- Arousal symptoms:
  - sleep disturbance
  - irritable behavior or angry outbursts with little or no provocation
  - hypervigilance
  - problems with concentration
  - exaggerated startle response
Duration of symptoms is at least 3 days and up to one month following the trauma exposure.
The disturbance causes clinically significant distress or impairment in functioning.
The disturbance is not better attributed to something else (a medical condition, substance use, brief psychotic disorder).

Summary of DSM-5-TR Diagnostic Criteria for Post-Traumatic Stress Disorder (PTSD)
Criteria for children older than 6 years: Patient has been exposed to actual or threatened death, serious injury, or sexual violence in one or more of the following ways: direct experience witnessing a traumatic event in person* learning of a traumatic event that happened to a close family member or friend repeated or extreme exposure to adverse details of traumatic events The presence of one or more of the following intrusion symptoms associated with the traumatic event and beginning after the event occurred: recurrent, involuntary and intrusive distressing memories, or in children, repetitive play expressing themes or aspects of the event recurrent distressing dreams related to the event (although the content might not be recognizable as directly related to the event in young children) dissociative reactions (flashbacks) where the individual feels or acts as if the trauma were recurring, or reenactment in play intense or prolonged psychological distress to internal or external cues that symbolize or resemble the event marked physiological reactions to above cues Patient exhibits persistent avoidance of stimuli associated with the traumatic event as evidenced by at least one of the following: avoidance (or efforts to avoid) distressing memories, thoughts, or feelings related to the event avoidance of external reminders that arouse the above (memories, thoughts, feelings) Patient has negative alterations in cognitions or mood associated with the traumatic event, which began after the traumatic event occurred and are manifest by two or more of the following: inability to remember an important aspect of the traumatic event (not related to head injury or substance use at the time of the event) persistent and exaggerated negative beliefs or expectations about oneself, others, or the world persistent distorted cognitions about the cause or consequences of the traumatic event that lead individuals to blame themselves or others persistent negative emotional state markedly diminished interest or participation in significant activities feelings of detachment or estrangement from others persistent inability to experience positive emotions Patient shows marked alterations in arousal and reactivity associated with the traumatic event, beginning or worsening after the event, and evidenced by two or more of the following: irritable behavior and angry outbursts reckless or self-destructive behavior hypervigilance exaggerated startle response problems with concentration sleep disturbance Criteria outlined in A, B, C, and D have a duration of more than one month. The disturbance causes clinically significant distress or impairment in functioning. The disturbance is not better attributed to something else (a medical condition, substance use). Criteria for children younger than 6 years: The criteria are similar except for the following key differences: Criterion A: This can be met via learning that a traumatic event happened to a parent or caregiver. Criterion B: Reexperiencing and reenactment may not be associated with obvious distress. Criterion D: Young children may experience diminished interest or participation in significant activities, including constriction of play, socially withdrawn behavior, and persistent reduction in expression of positive emotion. *Witnessing a traumatic event does not include events that are witnessed only in electronic media, television, movies, or pictures, unless that exposure is occupational (as in social media content screening).

Summary of DSM-5-TR Diagnostic Criteria for Post-Traumatic Stress Disorder (PTSD)

Criteria for children older than 6 years:

Patient has been exposed to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
- direct experience
- witnessing a traumatic event in person*
- learning of a traumatic event that happened to a close family member or friend
- repeated or extreme exposure to adverse details of traumatic events
The presence of one or more of the following intrusion symptoms associated with the traumatic event and beginning after the event occurred:
- recurrent, involuntary and intrusive distressing memories, or in children, repetitive play expressing themes or aspects of the event
- recurrent distressing dreams related to the event (although the content might not be recognizable as directly related to the event in young children)
- dissociative reactions (flashbacks) where the individual feels or acts as if the trauma were recurring, or reenactment in play
- intense or prolonged psychological distress to internal or external cues that symbolize or resemble the event
- marked physiological reactions to above cues
Patient exhibits persistent avoidance of stimuli associated with the traumatic event as evidenced by at least one of the following:
- avoidance (or efforts to avoid) distressing memories, thoughts, or feelings related to the event
- avoidance of external reminders that arouse the above (memories, thoughts, feelings)
Patient has negative alterations in cognitions or mood associated with the traumatic event, which began after the traumatic event occurred and are manifest by two or more of the following:
- inability to remember an important aspect of the traumatic event (not related to head injury or substance use at the time of the event)
- persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
- persistent distorted cognitions about the cause or consequences of the traumatic event that lead individuals to blame themselves or others
- persistent negative emotional state
- markedly diminished interest or participation in significant activities
- feelings of detachment or estrangement from others
- persistent inability to experience positive emotions
Patient shows marked alterations in arousal and reactivity associated with the traumatic event, beginning or worsening after the event, and evidenced by two or more of the following:
- irritable behavior and angry outbursts
- reckless or self-destructive behavior
- hypervigilance
- exaggerated startle response
- problems with concentration
- sleep disturbance
Criteria outlined in A, B, C, and D have a duration of more than one month.
The disturbance causes clinically significant distress or impairment in functioning.
The disturbance is not better attributed to something else (a medical condition, substance use).

Criteria for children younger than 6 years:
The criteria are similar except for the following key differences:

Criterion A: This can be met via learning that a traumatic event happened to a parent or caregiver.
Criterion B: Reexperiencing and reenactment may not be associated with obvious distress.
Criterion D: Young children may experience diminished interest or participation in significant activities, including constriction of play, socially withdrawn behavior, and persistent reduction in expression of positive emotion.

*Witnessing a traumatic event does not include events that are witnessed only in electronic media, television, movies, or pictures, unless that exposure is occupational (as in social media content screening).

Management

Acute stress disorder: Cognitive behavioral therapy (CBT) is often effective in children with acute stress disorder. CBT helps children learn to manage their emotions and develop coping skills. Benzodiazepines are generally contraindicated based on adult studies and have been associated with adverse outcomes in children with acute stress.

PTSD: Trauma-focused psychotherapy is currently first-line treatment for children and adolescents with PTSD and includes individual and family-based treatment. This modality requires specific training and should be performed by certified pediatric mental health clinicians. A trauma-informed approach aims to support patients and avoid unintentional retraumatization through an appreciation of how traumatic experiences impact patients and families, creation of a safe and nonjudgmental environment, respect for boundaries, and collaborating with and empowering patients and families.

Medication management in PTSD is generally symptom focused (e.g., mood complaints may be managed with an antidepressant or mood stabilizer and sleeping difficulties may be managed with a sleep aid). Care should be taken to avoid polypharmacy; if a medication does not provide significant benefit to a patient, it should be discontinued before additional medications are added to the regimen.

Prognosis: Evidence suggests that early intervention and treatment improve outcomes in patients with trauma-related conditions. Therefore, it is important to consider the possibility of trauma early, especially in cases of complex psychiatric symptoms; untreated trauma can result in significant morbidity and impaired functioning. Involvement of a specialist is always indicated for acute stress disorder and PTSD.

Adjustment Disorder

Adjustment is the process of adapting to changes and stressors in one’s environment. Although individuals are expected to experience some distress or difficulties as the process unfolds, adjustment disorders represent disruptions or severe manifestations of this process.

Diagnosis: Adjustment disorders are considered trauma- and stressor-related disorders akin to acute stress disorder and PTSD. However, the severity of the inciting trigger and specific trauma-associated symptoms (e.g., flashbacks or dissociation) are not diagnostic criteria. Instead, adjustment disorders reflect the presence of emotional or behavioral symptoms in response to a stressor that are out of proportion to the severity or intensity of the stressor, leads to functional impairment, or both. Decline in school, work, and relational engagement are common manifestations. In individuals with medical conditions, adjustment disorders can manifest as lack of appropriate engagement in care. Demographic factors (e.g., culture, age) are important to consider in the diagnosis because they can influence what is considered an inappropriate or disproportionate response to a stressor.

Note that the patient’s symptoms should not reflect normal grief, exacerbation of an existing mental health diagnosis, or meet the criteria for another diagnosis (e.g., prolonged grief disorder). The DSM-5-TR diagnostic criteria for adjustment disorder are outlined in the following

DSM-5-TR Diagnostic Criteria for Adjustment Disorder
The development of emotional or behavioral symptoms in response to (an) identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). These symptoms or behaviors are clinically significant, as evidenced by one or both of the following: marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation significant impairment in social, occupational, or other important areas of functioning The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder. The symptoms do not represent normal bereavement and are not better explained by prolonged grief disorder. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months. Specify whether: With depressed mood: Low mood, tearfulness, or feelings of hopelessness are predominant. With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant. With mixed anxiety and depressed mood: A combination of depression and anxiety is predominant. With disturbance of conduct: Disturbance of conduct is predominant. With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant. Unspecified: For maladaptive reactions that are not classifiable as one of the specific subtypes of adjustment disorder. Specify if: Acute: This specifier can be used to indicate persistence of symptoms for less than 6 months. Persistent (chronic): This specifier can be used to indicate persistence of symptoms for 6 months or longer. By definition, symptoms cannot persist for more than 6 months after the termination of the stressor or its consequences. The persistent specifier applies when the duration of the disturbance is longer than 6 months in response to a chronic stressor or to a stressor that has enduring consequences.

DSM-5-TR Diagnostic Criteria for Adjustment Disorder

The development of emotional or behavioral symptoms in response to (an) identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:
- marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation
- significant impairment in social, occupational, or other important areas of functioning
The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.
The symptoms do not represent normal bereavement and are not better explained by prolonged grief disorder.
Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

Specify whether:

With depressed mood: Low mood, tearfulness, or feelings of hopelessness are predominant.
With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant.
With mixed anxiety and depressed mood: A combination of depression and anxiety is predominant.
With disturbance of conduct: Disturbance of conduct is predominant.
With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant.
Unspecified: For maladaptive reactions that are not classifiable as one of the specific subtypes of adjustment disorder.

Specify if:

Acute: This specifier can be used to indicate persistence of symptoms for less than 6 months.
Persistent (chronic): This specifier can be used to indicate persistence of symptoms for 6 months or longer. By definition, symptoms cannot persist for more than 6 months after the termination of the stressor or its consequences. The persistent specifier applies when the duration of the disturbance is longer than 6 months in response to a chronic stressor or to a stressor that has enduring consequences.

Management: Treatment of individuals with adjustment disorder can be as simple as addressing the stressor. However, removal of the stressor is not always feasible. Pediatric providers can provide support by encouraging resilience through identification of coping skills and problem-solving and engaging support systems (e.g., parents, mentors, and educators) to help the patient and attenuate the stressor. Adjustment disorder does not always require a mental health specialist, unless the patient is suffering significant impairment, does not show improvement with supportive treatment, or there are acute safety concerns.

Patients diagnosed with adjustment disorder are at increased risk for both suicide attempts and completed suicide. Therefore, all patients experiencing adjustment disorder, including those who do not require specialist care, should be assessed for suicidality. Medication is not indicated in this condition given that symptoms are due to a psychosocial stressor and no evidence indicates that medication leads to improvement in individuals with adjustment disorder.

Prognosis: Patients with adjustment disorders who receive appropriate interventions typically have a good prognosis and symptoms can resolve in some cases with the removal of the stressor. However, adjustment disorder symptoms can persist for longer than 6 months if the identified stressor, or the consequences of the stressor, continue to persist. Delayed identification and treatment can result in negative academic, social, and health outcomes due to functional impairment and may lead to the development of more significant mood and behavioral disorders over time.

Prolonged Grief Disorder

Prolonged grief disorder is the newest diagnosis to be added to the DSM-5-TR and refers to maladaptive coping and difficulty adjusting to the loss of a loved one. Prolonged grief disorder must be distinguished from the normal level of functional impairment and distress associated with bereavement. The reaction in patients with prolonged grief disorder is out of proportion to the experience of normal grief and is marked by disproportional distress, functional impairment, or both. Prolonged grief is distinct from adjustment and other trauma- and stressor-related disorders in that it reflects a distortion of the natural grieving process and adjustment to a significant emotional stressor. The presenting distress and functional impairment must be carefully assessed in the context of the patient’s cultural, religious, and social background and variability in grief manifestations across those domains. Patients with prolonged grief disorder that results in significant impairment or emergence of self-harm, suicidal ideation, or other safety concerns should be referred to a mental health provider.

Summary of DSM-5-TR Diagnostic Criteria for Prolonged Grief Disorder
The death of a person who was close to the bereaved individual, at least 12 months prior (for children and adolescents, death must have occurred at least 6 months prior). Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree. In addition, the symptom(s) has occurred nearly every day for at least the last month: intense yearning/longing for the deceased person preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death) Since the death, at least three of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month: identity disruption (e.g., feeling as though part of oneself has died) since the death marked sense of disbelief about the death avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders) intense emotional pain (e.g., anger, bitterness, sorrow) related to the death difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future) emotional numbness (absence or marked reduction of emotional experience) as a result of the death feeling that life is meaningless as a result of the death intense loneliness as a result of the death The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The duration and severity of the bereavement reaction clearly exceed expected social, cultural, or religious norms for the individual’s culture and context. The symptoms are not better explained by another mental disorder, such as major depressive disorder or post-traumatic stress disorder and are not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Summary of DSM-5-TR Diagnostic Criteria for Prolonged Grief Disorder

The death of a person who was close to the bereaved individual, at least 12 months prior (for children and adolescents, death must have occurred at least 6 months prior).
Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree. In addition, the symptom(s) has occurred nearly every day for at least the last month:
- intense yearning/longing for the deceased person
- preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death)
Since the death, at least three of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month:
- identity disruption (e.g., feeling as though part of oneself has died) since the death
- marked sense of disbelief about the death
- avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders)
- intense emotional pain (e.g., anger, bitterness, sorrow) related to the death
- difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future)
- emotional numbness (absence or marked reduction of emotional experience) as a result of the death
- feeling that life is meaningless as a result of the death
- intense loneliness as a result of the death
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The duration and severity of the bereavement reaction clearly exceed expected social, cultural, or religious norms for the individual’s culture and context.
The symptoms are not better explained by another mental disorder, such as major depressive disorder or post-traumatic stress disorder and are not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Management: Specific therapeutic interventions, such as complicated grief therapy, have been developed for treatment of individuals experiencing prolonged grief. CBT also has been shown to be beneficial, including CBT interventions that target specific symptoms (e.g., CBT for insomnia) as well as CBT protocols developed specifically to address prolonged grief disorder. The use of selective serotonin-reuptake inhibitors (SSRIs) for management of prolonged grief has been shown to improve depressive symptoms in adults, although grief-specific symptoms persisted. The evidence for pharmacologic interventions is limited, and no specific medications are indicated for children or adolescents with prolonged grief disorder.

Prognosis: Prolonged grief disorder can persist without treatment and is associated with increased risk for substance use, depression, and suicide as well as poor health outcomes. Treatment can lead to improved outcomes and remission or reduction of symptoms. Patients with prolonged grief disorder that results in significant impairment or emergence of self-harm, suicidal ideation, or other safety concerns should be referred to a mental health provider.

Research

Landmark clinical trials and other important studies

Research

Reactive Attachment Disorder and Disinhibited Social Engagement Disorder in Adolescence: Co-occurring Psychopathology and Psychosocial Problems

Seim AR et al. Eur Child Adolesc Psychiatry 2022.

Most adolescents with a reactive attachment disorder and disinhibited social engagement disorder diagnosis had several cooccurring psychiatric disorders and psychosocial problems.

Midazolam Exposure in the Paediatric Intensive Care Unit Predicts Acute Post-Traumatic Stress Symptoms in Children

Long D et al. Aust Crit Care 2022.

One quarter of children had post-traumatic stress symptoms (PTSS) during the 12 months after PICU discharge. One month after discharge, elevated PTSS were most likely to occur in children who had received midazolam therapy.

Validation of the New DSM-5-TR Criteria for Prolonged Grief Disorder and the PG-13-Revised (PG-13-R) Scale

Prigerson HG et al. World Psychiatry 2021.

The DSM-5-TR criteria for prolonged grief disorder were reliable and valid measures for the classification of bereaved individuals with maladaptive grief responses.

CBT for Prolonged Grief in Children and Adolescents: A Randomized Clinical Trial

Boelen PA et al. Am J Psychiatry 2021.

Prolonged grief disorder and its symptoms in bereaved children and adolescents can be effectively treated by cognitive behavioral therapy interventions.

Read the NEJM Journal Watch Summary

Predictors and Moderators of Treatment Outcome for Single Incident Paediatric PTSD: A Multi-Centre Randomized Clinical Trial

de Roos C et al. Eur J Psychotraumatol 2021.

Parental psychopathology predicted poorer outcomes for the child in both treatments.

Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults

Felitti VJ et al. Am J Prev Med 1998.

This seminal retrospective cross-sectional study demonstrated significant long-term health risks in adults exposed to adverse childhood experiences (ACEs), with a dose-response relation between exposure to ACEs and health-related risk factors and diseases in adults.