dren, the distress may be expressed in play and behavior, developmental regressions, and
anxious or protest behavior at times of separation and reunion. Separation distress may be
predominant in younger children, and social/i dentity distress and risk for comorbid de-
pression can increasingly manifest in older children and adolescents.
Risk and Prognostic Factors 
Environmental. Risk for persistent complex bereavem ent disorder is heightened by in-
creased dependency on the deceased person pr ior to the death and by the death of a child.
Disturbances in caregiver support increase the risk for bereaved children. 
Genetic and physiological. Risk for the disorder is height ened by the bereaved individ-
ual being female.
Culture-Related Diagnostic Issues 
The symptoms of persistent complex bereav ement disorder are observed across cultural
settings, but grief responses may manifest in cu lturally specific ways. Diagnosis of the dis-
order requires that the persistent and severe responses go beyond cultural norms of grief
responses and not be better explained by culturally specific mourning rituals. 
Suicide Risk
Individuals with persistent complex bereavement disorder frequently report suicidal
ideation.