There are few epidemiological studies on rates of bereavement in childhood and adolescence. Among a nationally representative sample of children and adolescents in Great Britain, 3.5% had experienced the death of a parent or sibling and 6.3% had experienced the death of a close friend [27]. However, the real figures are likely higher, given that many of the children in this study were young. Another study reported that an estimated 4% of children and adolescents in the United Kingdom have faced the death of a parent, with 77.6% of young people reporting the loss of at least one relative or close friend [28]. Similarly, in the United States, an estimated 4% of children and adolescents experience the death of a parent before the age of 18 [29]. In a sample of Dutch primary school-aged children (N = 1770, mean age = 10.24 years), 5% of children had experienced the sudden death or serious injury of a loved one, such as a best friend who died suddenly or a sibling who had committed suicide [1]. Recent studies confirmed these numbers in different populations [27, 30].

Although there has been increasing recognition of a disorder characterized by patterns of difficult or disturbed grief, there is not yet a clear consensus on the terminology researchers and clinicians should use to identify the same pattern of emotional and behavioral disturbances (see Chap. 14). Over the years, the most commonly used terminologies for this constellation of symptoms have been complicated grief, prolonged grief disorder, pathological grief, and traumatic grief. In the latest version of the Diagnostic and Statistical Manual (DSM), the American Psychiatric Association [9] introduced Persistent Complex Bereavement Disorder (PCBD), in the section on conditions for further studies, which contains emerging measures and models that require future research, but also as a possible diagnosis as “other specified trauma and stressor-related disorder”.

In accordance with these criteria, a diagnosis of PCBD requires that a child experience the loss of someone whom they were close to. At least one of the following core symptoms must be experienced intensely by a child:

In addition, at least six of the following 12 associated symptoms, which fall under one of two symptom clusters (distress related to the death or loss of social and identity reference), must also be experienced intensely by a child:

Lastly, a diagnosis should not be made until at least 6 months have elapsed since the death; this timeframe diagnostic criterion differs from the adults’one (12 months). These symptoms must lead to significant clinical or social consequences and disturbances and must deviate from the normal and expected reactions to loss according to a bereaved child’s culture, religious beliefs, and age.

While grief, mourning, and bereavement are universal human experiences, individual reactions to death may vary considerably, especially in children, and can be influenced by a multitude of factors, including personality, culture, religious beliefs, the nature of the relationship with the deceased, and the conditions of the death. Concepts of grieving style and trajectories of grief emphasize this variability [31].

Grieving styles are individual cognitive, behavioral, and affective strategies used to adapt to loss and are highly influenced by personal and cultural factors. Doughty [32] described two types of grievers: intuitive grievers, who do not express their grief and keep secret about it, and instrumental grievers, who openly share their feelings and emotions about their experience. These grieving styles are important to take into account, as difficulties may arise when an individual uses a grieving style that does not match his or her natural style [31].

To address the concept of grief trajectories in children, some authors have suggested that the mourning journey occurs concomitantly to the child’s developmental journey [33]. This highlights the importance of taking developmental phases into account to understand and clinically describe grief reactions. Table 4.2 describes these developmental phases as they relate to understanding death, as well as the most frequently associated grief reactions by age. Six developmental stages are described: infants (0- to 2-year-olds), toddlers (2- to 4-year-olds), preschoolers/early elementary schoolers (4- to 6-year-olds), primary schoolers (6- to 8-year-olds), middle schoolers/preadolescents (8- to 12-year-olds), and high schoolers/adolescents (12- to 18-year-olds). The inability to perceive and clearly understand death may lead to grief reactions in which general distress, regression, separation anxiety, or sleep disturbances are frequently encountered. In contrast, adolescents, who have a clear perception of death, will be more prone to express their suffering through existential questions, anxiety, difficulty studying, feelings of isolation, or risky behaviors.

It is important to keep in mind that the grieving process in children and adolescents is not linear and is often marked by periods of regression during which the child may begin to re-experience symptoms of grief and have recurrent memories of the deceased. Alternatively, an increased understanding of death may allow the child to attribute a different meaning to the loss in his or her personal life. Thus, it is essential to insist on thorough and careful clinical assessment of a child’s difficulties and situation to clearly perceive his or her own journey of bereavement. The two following clinical vignettes (Vignette 1 and Vignette 2) illustrate various reactions and demonstrate that these reactions can include many symptoms that do not necessarily strictly belong to the grief spectrum, including, for instance, behavioral and somatic symptoms.