Exploring the Association of Time‐After‐Death on Psychological Distress in Parents Who Lost a Child to Cancer

Pediatric Blood & Cancer BRIEF REPORT Exploring the Association of Time-After-Death on Psychological Distress in Parents Who Lost a Child to Cancer Peter Francis Raguindin1Jerina Deda1Anna Katharina Vokinger1Eva De Clercq1Katrin Scheinemann1,2 Andre Oscar von Bueren3,4Eva Maria Tinner5,6Eva Bergstraesser6Eddy Carolina Pedraza1 Gisela Michel1 1Faculty of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland 2Division Oncology/ Hematology, Children’s Hospital of Eastern Switzerland, St Gallen, Switzerland 3Department of Pediatrics, Division of General Pediatrics, Gynecology and Obstetrics, Pediatric Hematology and Oncology Unit, University Hospitals of Geneva, Geneva, Switzerland 4Faculty of Medicine, Department of Pediatrics, CANSEARCH Research Platform for Pediatric Oncology and Hematology, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland 5Department of Pediatrics, Division of Hematology/Oncology, Inselspital Bern, University of Bern, Bern, Switzerland 6Pediatric Palliative Care and Children’s Research Centre, University Children’s Hospital Zurich, Zurich, Switzerland Correspondence: Gisela Michel ([email protected]) Received: 6 August 2025 Revised: 2 September 2025 Accepted: 8 September 2025 Funding: This study was funded by the Swiss Cancer Research (Grant No. KFS-4995-02-2020) and Cancer League Central Switzerland. Keywords: anxiety | bereavement | childhood cancer | depression | parents | psychological distress ABSTRACT We conducted a cross-sectional survey of 101 bereaved parents in Switzerland to determine the association between timeafter-death and psychological distress. Eligible deceased children were identified via the national registry and forwarded to former treating pediatric oncology centers, which then contacted the parents. Psychological distress was measured using the Brief Symptom Inventory (BSI-18). Time-after-death ranged from 2 to 24 years (mean =11.3, SD =5.6). Linear regression and spline models showed no significant association between time-after-death and psychological distress. Our findings suggest that time-after-death alone does not predict parental psychological distress. 1 Introduction The death of a child is recognized as one of the most traumatic events in a parent’s life [1]. Although many bereaved parents eventually find ways to adapt to their loss, some continue to experience intense and prolonged psychological distress [2–4]. In childhood cancer, this emotional burden is aggravated by prolonged caregiving, enduring hope for a cure, and repeated exposure to medical trauma during the child’s treatment. Despite extensive research on the negative outcomes of parental bereavement following childhood cancer, significant gaps remain in understanding long-term psychological outcomes beyond 5–10 years post-bereavement [1–3]. Previous research on the association of time and psychological distress has primarily used linear modeling approaches, which may overlook potential non-linear associations. We aimed to explore if the time after a child’s death has an influence on psychological distress in parents, whether it decreases, remains stable, or increases, and explore if there is a non-linear association. 2 Methods This is a cross-sectional study in Switzerland that aimed to examine the psychosocial outcomes among bereaved parents whose child died from cancer. Study procedures are described in our previous publication [4, 5]. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2025 The Author(s). Pediatric Blood & Cancer published by Wiley Periodicals LLC. Pediatric Blood & Cancer,2025;0:e32060 https://doi.org/10.1002/pbc.32060 1of6 2.1 Setting and Population Eligible participants were parents of children who: (a) were diagnosed with cancer, (b) were aged ≤18 years at diagnosis, (c) received treatment in Switzerland, and (d) died from cancer ≥1 year before study participation. The Swiss Childhood Cancer Registry (ChCR) provided a list of eligible cases to three participating pediatric oncology units in the country. Hospital staff confirmed the contact information using clinical records and excluded families considered unsuitable for contact due to clinical or personal reasons. The unit staff sent invitation packages to eligible parents, including an information sheet, an informed consent form, a questionnaire per parent, and prepaid return envelopes. Parents were asked to complete the questionnaires on paper or online (Qualtrics). The collaborating clinical centers placed reminder phone calls to non-responders starting 5 weeks after the initial mailing. Parent support organizations also shared study information through their networks, and interested parents contacted the study team directly. Data collection was conducted between July 2022 and 2023. 2.2 Measure The questionnaire covered psychological health, overall wellbeing, end-of-life and bereavement experiences, and support needs and preferences. It contained 192 items and required approximately 60–90 min to complete. The questionnaire also underwent face and expert validation prior to implementation. Specifically for this study, psychological distress was assessed using the Brief Symptom Inventory-18 (BSI-18) [6–8]. The tool assesses somatization, depression, and anxiety, and a Global Severity Index (GSI), representing overall psychological distress. The BSI-18 has been validated in Switzerland [8]andshowed high internal consistency (Cronbach’s αsomatization: 0.77, depression: 0.92, anxiety: 0.90, and GSI: 0.94). Raw sum scores were converted into standardized T-scores (mean =50, standard deviation =10) based on German normative data [6]. Clinical distress was defined as a T-score ≥63 on the GSI or on at least two symptom scales. 2.3 Data Analysis We explored three methods to determine the association of time after the child’s death and parental psychological distress. First, we fitted a linear regression using GSI as the dependent variable and time-after-death as the independent variable, both treated as continuous variables. Second, we divided the population into three groups according to time-after-death: recent (1–5 years), intermediate (6–10 years), and long-term (>10 years). We fitted another linear regression with GSI as a continuous dependent variable and bereavement length (recent, intermediate, longterm) as the independent categorical variable. Crude and adjusted models (accounting for sociodemographic differences) were fitted, and marginal means were predicted to demonstrate the difference in GSI among the three groups. Third, we explored the non-linear pattern of the association of time-after-death and GSI by fitting a restricted cubic spline. We used a model using continuous GSI as the dependent variable and the time-after-death (with four randomly assigned knots) as the independent variable. The mkspline2 package was used, and plots were done using the smoothing parameters according to the adjustrcspline package. All analyses were done using Stata 19.5 (StataCorp, TX). All tests were two-tailed, with pvalues <0.05 considered statistically significant. 2.4 Ethical Considerations The study was approved by the Ethics Committee of Northwest and Central Switzerland (EKNZ 2021-00906, August 4, 2021). All participants provided written informed consent. Data were deidentified before analysis and stored on secure university servers with access limited to study investigators. The information sheet emphasized the sensitivity of the topic and explained that the study aimed to improve psychosocial support services to encourage participation. Contact details of investigators were provided for questions or in case there was a need for support. 3Results The ChCR identified 388 deceased children, of which 262 were contacted by the three participating oncology units. A total of 96 parents of 77 deceased children participated (response rate: 29.8%). Seven additional parents of four cases contacted the study team independently. The final sample comprised 101 parents of 80 cases (21 parent couples, 59 individual parent respondents (46 mothers and 13 fathers; Table 1). Time-after-death ranged from 2 to 24 years (mean =11.3, SD =5.6). Mean scores for GSI (mean =50.4, SD =9.3), somatization (49.7 ±8.5), depression (47.8 ±9.4), and anxiety (52.2 ±9.5) were all within normative ranges compared with population norms [8]. No statistically significant differences were observed among bereaved parents with recent, intermediate, and long-term timeafter-death in crude or adjusted analyses. Neither linear nor spline regression demonstrated a statistically significant association (Figure 1). Clinical distress was identified in 11 participants (10.9%), with no difference among recent, intermediate, and long-term bereaved parents (Table 1). 4 Discussion Our findings show that psychological distress remains stable over time [9, 10] and within norms of the general population. The stable pattern of psychological distress can be interpreted in several ways. First, grief reaction, coping strategies, and resilience are critical factors to consider when examining longterm psychological consequences after loss. Changes in these adaptive mechanisms over time, seen in longitudinal studies [11], may have moderated the association between psychological distress and time-after-death. An alternative interpretation suggests that bereaved parents, similar to the general population, may experience psychological distress at any time for reasons not related to their child’s death [12, 13]. Psychological symptoms 2of6 Pediatric Blood & Cancer,2025 15455017, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pbc.32060 by ZHB Luzern, Wiley Online Library on [17/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TABLE 1 Sociodemographic, child, cancer-related characteristics, and psychological distress of bereaved parents divided according to length of bereavement. Total Recent Intermediate Long-term pvalue N101 (100.0%) 20 (19.8%) 26 (25.7%) 55 (54.5%) Time-after-death (years) 11.3 (5.6) 2–24 years 4.1 (1.1) 1–5 years 7.7 (1.5) 6 to 10 years 15.5 (3.5) >10 years Sociodemographic characteristics Age (years) 53.8 (8.1) 47.5 (5.9) 53.3 (7.8) 56.5 (7.7) <0.001a Age category <50 years 29 (29.3%) 10 (50.0%) 8 (30.8%) 11 (20.8%) 0.014a 50–60 years 44 (44.4%) 10 (50.0%) 12 (46.2%) 22 (41.5%) >60 years 26 (26.3%) 0 (0.0%) 6 (23.1%) 20 (37.7%) Sex Male 35 (34.7%) 8 (40.0%) 8 (30.8%) 19 (34.5%) 0.808 Female 66 (65.3%) 12 (60.0%) 18 (69.2%) 36 (65.5%) Education Compulsory schooling 5 (5.0%) 1 (5.0%) 1 (3.8%) 3 (5.6%) 0.612 Vocational training 64 (64.0%) 11 (55.0%) 15 (57.7%) 38 (70.4%) University 31 (31.0%) 8 (40.0%) 10 (38.5%) 13 (24.1%) Employment Unemployed 25 (25.0%) 4 (20.0%) 8 (30.8%) 13 (24.1%) 0.686 Employed 75 (75.0%) 16 (80.0%) 18 (69.2%) 41 (75.9%) Household income <6000 CHF / month 13 (14.8%) 3 (15.8%) 3 (12.5%) 7 (15.6%) 0.934 >/=6000 CHF / month 75 (85.2%) 16 (84.2%) 21 (87.5%) 38 (84.4%) Migration background No migration background 60 (81.1%) 13 (86.7%) 13 (68.4%) 34 (85.0%) 0.260 Migration background 14 (18.9%) 2 (13.3%) 6 (31.6%) 6 (15.0%) Practicing religion No 66 (69.5%) 12 (60.0%) 17 (68.0%) 37 (74.0%) 0.508 Yes 29 (30.5%) 8 (40.0%) 8 (32.0%) 13 (26.0%) Civil status Single/divorced 17 (17.2%) 3 (15.0%) 3 (12.0%) 11 (20.4%) 0.630 Married 82 (82.8%) 17 (85.0%) 22 (88.0%) 43 (79.6%) Childor cancer-related characteristics Location of death Healthcare facility 34 (43.0%) 8 (47.1%) 6 (30.0%) 20 (47.6%) 0.395 Home 45 (57.0%) 9 (52.9%) 14 (70.0%) 45 (57.0%) Diagnosis Leukemia/lymphoma 21 (26.6%) 5 (29.4%) 5 (25.0%) 11 (26.2%) 0.341 CNS tumor 36 (45.6%) 9 (52.9%) 6 (30.0%) 21 (50.0%) Others 22 (27.8%) 3 (17.6%) 9 (45.0%) 10 (23.8%) Sex of the child Male 44 (55.7%) 11 (64.7%) 15 (75.0%) 18 (42.9%) 0.041a Female 35 (44.3%) 6 (35.3%) 5 (25.0%) 35 (57.1%) (Continues) 3of6 15455017, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pbc.32060 by ZHB Luzern, Wiley Online Library on [17/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TABLE 1 (Continued) Total Recent Intermediate Long-term pvalue Child’s age at diagnosis Infant <1 year 6 (7.6%) 2 (11.8%) 1 (5.0%) 3 (7.1%) 0.948 Early child 1–5 years 24 (30.4%) 5 (29.4%) 5 (25.0%) 14 (33.3%) Late child 6–10 years 22 (27.8%) 5 (29.4%) 7 (35.0%) 10 (23.8%) Adolescent >10 years 27 (34.2%) 5 (29.4%) 7 (35.0%) 15 (35.7%) Child’s age at death Infant <1 year 3 (3.8%) 1 (5.9%) 0 (0.0%) 2 (4.8%) 0.729 Early child 1–5 years 14 (17.7%) 2 (11.8%) 3 (15.0%) 9 (21.4%) Late child 6–10 years 23 (29.1%) 7 (41.2%) 5 (25.0%) 11 (26.2%) Adolescent >10 years 39 (49.4%) 7 (41.2%) 12 (60.0%) 20 (47.6%) Psychological distress (BSI-18) Global Severity Index 50.4 (9.3) 52.2 (11.5) 49.9 (6.8) 50.0 (9.7) 0.636 GSI (adjusted)a50.8 (10.1) 49.4 (9.8) 50.9 (10.0) 0.335 Somatization 49.7 (8.5) 50.5 (9.3) 48.7 (7.4) 49.9 (8.7) 0.753 Somatization (adjusted)b49.9 (9.3) 48.8 (9.1) 50.2 (9.2) 0.870 Anxiety 47.8 (9.4) 48.4 (11.3) 47.8 (7.5) 47.6 (9.6) 0.957 Anxiety (adjusted)b46.5 (10.1) 47.7 (9.9) 48.5 (10.1) 0.312 Depression 52.2 (9.5) 55.6 (11.5) 51.2 (6.7) 51.4 (9.8) 0.205 Depression (adjusted)b54.9 (10.2) 50.5 (9.9) 52.1 (10.1) 0.257 Caseness No 90 (89.1%) 16 (80.0%) 25 (96.2%) 49 (89.1%) 0.219 Yes 11 (10.9%) 4 (20.0%) 1 (3.8%) 6 (10.9%) Abbreviations: CHF, Swiss Francs; CNS, central nervous system; GSI, Global Severity Index. apvalue <0.05, statistically significantly different among bereaved parents with recent, intermediate, and long-term time-after-death. bMarginal means from the regression model adjusting for age and sex of the child, which were shown to be different among bereaved parents with recent, intermediate, and long-term time-after-death. may thus reflect concurrent life stressors rather than exclusively grief-related pathology. Unfortunately, our findings remain exploratory, and further analyses are still needed to test each hypothesis. Most studies have investigated negative outcomes (prolonged grief and psychological distress) and time-after-death, using linear models. However, human responses often show non-linear patterns [14]. Our study applied a more comprehensive approach by modeling the association of psychological distress and timeafter-death both linearly and non-linearly using categorical predictors and splines. Also, most studies on childhood cancer bereaved parents focused on 5–10 years after child loss [9, 10, 15]. Our study included parents up to 24 years after their loss. A limitation is the relatively low participation rate, which is common in studies involving bereaved parents due to the emotional burden of revisiting painful experiences [16, 17]. To mitigate the impact of a limited sample size, a comprehensive case identification was conducted using the nationwide registry (ChCR), and reminder calls were made to improve recruitment. Second, gatekeeping bias may have occurred during hospital screening, where individuals with unstable psychological status may have been excluded, potentially leading to an overrepresentation of participants with better psychological outcomes. Third, self-selection bias is possible, as individuals with more favorable mental health are more likely to participate than those with adverse outcomes [16]. However, some bereaved parents may participate to help others by sharing their experiences, which partly offsets this bias [16]. Our sample closely resembled non-participants in the ChCR data, further supporting the representativeness of the study population. Finally, our findings are based on cross-sectional analysis, such that contextual changes may affect psychological distress more than child loss. For example, because parents are more likely to engage in support groups during the early bereavement phase and less likely in later phases, our results may underestimate distress in the initial period and overestimate it in later stages. Support for bereaved parents often declines, yet some experience long-term psychological distress [18]. Our findings underline the need for long-term follow-up rather than limiting care to the immediate bereavement phase. Routine screening for psychological outcomes should be embedded in pediatric oncology 4of6 Pediatric Blood & Cancer,2025 15455017, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pbc.32060 by ZHB Luzern, Wiley Online Library on [17/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License FIGURE 1 Psychological distress (GSI, y-axis) as a function of time-after-death (x-axis). The linear and spline models strongly suggest that psychological distress is not associated with time-after-death (LR =1.16, pvalue =0.559, linear vs. spline model). Red line shows the fitted linear model. Blue line shows the fitted spline model with 95% confidence interval, with overlapping intervals indicated by shading. Box marks the observed range of BSI scores. follow-up, with clear referral pathways to specialized care [18, 19]. Implementing transitional bereavement care models can link hospital services, primary care, and community resources, ensuring continuity and tailored support [20]. This approach can help reduce enduring long-term psychosocial hardship among bereaved families. 5 Conclusion Our finding suggests that time-after-death is not associated with psychological distress in parents whose child died from cancer. Contextual factors such as grief reactions, resilience, and socioeconomic conditions should be further examined to understand their role in long-term psychological distress. Author Contributions P.F.R. and G.M. conceptualized the study. P.F.R. and J.D. performed the analysis. P.F.R., J.D., A.K.V., E.D.C., E.C.P., and G.M. wrote the first draft of the manuscript. K.S., A.O.V.B., E.M.T., and E.B. recruited participants, reviewed the draft, and provided expert feedback. E.M.T., E.B., and G.M. secured funding. G.M. supervised the data collection and analysis. All authors approved the manuscript. Acknowledgments We thank the participating hospitals and the parents who participated in our survey. We also acknowledge and appreciate the help of our interns, Katja Rueesch, Simone Walde-Foehn, Kathleen Ostheim, Laura Haxhosaj, and Sebastian Thackwell, and Dr. Manya Hendriks. Open access publishing facilitated by Universitat Luzern, as part of the Wiley - Universitat Luzern agreement via the Consortium Of Swiss Academic Libraries. Ethics Statement Ethical approval was granted through the Ethics Committee of Northwest and Central Switzerland (EKNZ 2021-00906; 04 August 2021). The research was conducted in accordance with the principles of the Declaration of Helsinki. The study is compliant with the Swiss Human Research Act (810.30 Federal Act of September 30, 2011 on Research involving Human Beings) and Federal Regulations on Data Protection (235.1 Federal Act on Data Protection of September 25, 2020). Written informed consent was obtained from all study participants. Conflicts of Interest The authors declare no conflicts of interest. 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