Living with grief and thriving after loss: a qualitative study of Chinese parents whose only child has died

ABSTRACT

Introduction: Chinese bereaved parents over the age of 49 who have lost their only child are known as shidu parents. This study aimed to explore their symptoms of prolonged grief disorder (PGD) and post-traumatic growth (PTG).

Methods: Shidu parents who experienced the loss of their only child at least six months prior and had no biological or adopted children at the time of the study were recruited. Eleven shidu parents participated in individual interviews conducted in Mandarin via WeChat video or voice calls. The interview guide was developed by the first researcher and refined through discussions with doctoral students and a professor specializing in bereavement. Reflexive thematic analysis was used to analyse the data from the semi-structured interviews.

Results: The interviewees (3 men and 8 women) were aged between 53 and 72 years, and the time since their child’s loss ranged from 2.25 to 24 years. Four themes of PGD symptoms were identified: Separation distress, Cognitive, emotional, and behavioural symptoms, Somatic responses and Changes in grief responses. Subtheme of ‘feelings of inferiority or shame’ and ‘somatic responses’ were prominent among this group, potentially representing culturally relevant grief reactions. They also experienced genuine PTG that helped them adapt to life without the child: changes in self-perception, changes in interpersonal relationships, and a changed philosophy of life. The subtheme of ‘living for self’ emerged as a potentially unique PTG among shidu parents.

Conclusion: Shidu parents share some important similarities with bereaved individuals across cultures, but also exhibit some unique characteristics. Considering their persistent intense grief, regular screening for grief severity, physical issues, and suicidal ideation is essential. Culturally sensitive interventions that acknowledge and validate their sense of inferiority or shame may be beneficial. Additionally, fostering PTG may support shidu parents in coping with their loss and adapting to life.

HIGHLIGHTS

• Shidu parents exhibited culturally specific grief reactions, such as feelings of inferiority or shame and somatic responses.

• Shidu parents may experience genuine PTG, which could help them adapt to life without their child.

• ‘Living for self’ seemed to be a unique positive change for shidu parents.

1. Introduction

Grief is a natural and common reaction to bereavement. For about 90% of adults who experience natural bereavement, they can gradually recover from their grief (Lundorff et al., 2017). However, a minority of bereaved individuals may experience severe and persistent grief, thus developing prolonged grief disorder (PGD; Prigerson, Kakarala, et al., 2021). PGD was included as a new diagnosis in the International Classification of Diseases (ICD-11; World Health Organization, 2018) and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR; American Psychiatric Association, 2022). Its core symptoms consist of strong longing for and/or persistent preoccupation with the deceased, accompanied by accessory symptoms such as emotional pain, sense of disbelief about the death (Prigerson, Boelen, et al., 2021). Although substantial evidence supports the inclusion of this bereavement-related distress in diagnostic manuals, the debate regarding a PGD diagnosis remains ongoing (Eisma, 2023; Prigerson et al., 2024). A significant concern is that the guidelines for PGD in both ICD-11 and DSM-5-TR are mainly based on research conducted in Europe and North America (Killikelly et al., 2023), so the cross-cultural knowledge of PGD is still lacking (Hilberdink et al., 2023). Existing evidence suggests considerable variation in the experience, interpretation and reporting of prolonged grief symptoms across cultures (Eisma, 2023). This indicates that culturally relevant grief symptoms in certain bereaved populations may not be included in the PGD criteria (Stelzer et al., 2020). For example, a qualitative study found that somatic symptoms were prominent among bereaved individuals in Japan, which were missing from the current PGD criteria (Killikelly et al., 2023). Consequently, further research is required to enhance the understanding of this new condition, particularly regarding the culture-specific grief experiences in non-Western contexts.

Child loss is often considered as one of the most painful bereavement experience (Reynolds et al., 2020), which is associated with a higher prevalence of PGD (Buur et al., 2024). Coping with the death of a child can be more complicated for Chinese parents who have lost their only child, often referred to as shidu parents. Shidu parents are typically defined as bereaved parents over the age of 49 who have lost their only child and do not have any biological or adopted children (Xu, Xie, et al., 2022). In China, adult children bear primary responsibility for providing care, emotional support, and financial assistance for their aging parents. Children also fulfil parents’ social roles and contribute to their sense of meaning in life (Wu & Penning, 2019). Moreover, influenced by Chinese Confucian culture, having a child to continue ancestral line is almost a sociocultural norm (Xu, Wen, et al., 2022; Zhou, Wu, et al., 2022). Childlessness is often perceived as unfilial to one’s ancestors and a failure to meet society’s expectations (Shi et al., 2019). Additionally, death of a child is a taboo topic in China, which may be unfairly stigmatized as unlucky. This cultural context may compel bereaved individuals to suppress their feelings and experience increased social isolation (Yuan et al., 2024). Therefore, shidu parents face a series of psychosocial stressors and are vulnerable to PGD (Yuan et al., 2022). Compared to other types of loss, the loss of an only child may result in the highest risk for PGD (Buur et al., 2024; Yuan et al., 2024). A meta-analysis study found that 75% of the shidu parents had PGD symptoms and 20.9% of the shidu parents met the diagnostic criteria for PGD (Yuan et al., 2022). According to ICD-11 criteria, the prevalence of PGD was as high as 35.5% among parents who have lost their only child nearly a decade ago (Zhou et al., 2020). Moreover, they may also suffer from posttraumatic stress disorder, depression, anxiety, insomnia and various physical health issues (Eli et al., 2021; Fang, 2022; Wang et al., 2021; Xu, Xie, et al., 2022; Zhou et al., 2018). Alarmingly, it is estimated that there were one million shidu parents in 2018, with numbers expected to remain high until at least 2030 (Lin et al., 2023). The experience of losing the only child is a unique form of child loss and shidu parents are deeply influenced by the Chinese traditional culture, thereby their grief reactions may manifest differently. It cannot be assumed that the current PGD criteria derived from samples from Western countries are fully applicable to shidu parents. Given the large number of shidu parents and high prevalence of PGD among them, there is an urgent need for further research on their bereavement outcomes and the development of culturally sensitive interventions tailored to their needs.

Post-traumatic growth (PTG) is a common phenomenon which has been found in a variety of trauma populations, including in shidu parents (Xu et al., 2021; Zhang et al., 2016). It is defined as positive psychological change as a result of coping with traumatic events or high-stress experiences (Tedeschi & Calhoun, 1996). After losing the only child, shidu parents may develop a new philosophy of life. For instance, their priorities about life have changed. They may also exhibit personal changes, such as developing new goals or interests. Positive changes can also manifest in relationships, including an increased sense of closeness and compassion towards others (Xu et al., 2021). However, there are significant controversies related to the construct of perceived PTG. The famous one is the Janus-Face model, which suggests that PTG is not only constructive, but also contains illusory and self-deceptive components (Zoellner & Maercker, 2006). Additionally, there are challenges in measuring PTG. Posttraumatic Growth Inventory (PTGI) is the most widely used instrument to evaluate perceived positive changes (Infurna & Jayawickreme, 2019). However, the retrospective measure of PTG may not reflect actual pre- to post-trauma change (Gangel et al., 2024). Furthermore, the manifestation of PTG is likely to exhibit cross-cultural differences (McDiarmid & Taku, 2017). For example, religious/spiritual growth was frequently mentioned in American samples, whereas it was rarely emphasized outside the America (Waugh et al., 2018). Thus, conducting in-depth interviews with shidu parents can facilitate a more comprehensive understanding of their PTG following the loss of the only child.

Overall, shidu parents experienced the unique kind of child-death and their grieving process is affected by Chinese traditional culture. Only using the instruments developed in Western context may not be sufficient to capture their grief symptoms and positive changes. Qualitative methods, such as in-depth interviews, are an effective way to explore the range, depth and meaning of possible responses in a population (Hollifield et al., 2002). Therefore, the current study aimed to use in-depth interviews to gain insight into the PGD symptoms and PTG among Chinese shidu parents, thereby enhancing understanding of cross-cultural differences in bereavement adjustment.

2. Method

2.1. Participants and recruitment

The current study was a part of a larger project titled ‘Constructing a psychological help system for Chinese shidu parents’, which was approved by the Ethics Committee of Beijing Normal University. The inclusion criteria for qualitative interview were as follows: (1) parents who experienced the death of their only child at least six months prior, consistent with the proposed criteria for PGD in ICD-11; (2) currently without any biological or adopted children; (3) parents aged 49 years or older; and (4) the ability to engage in in-depth conversations.

Initially, the purposive sampling method with maximum variation sampling was employed to obtain rich information (Etikan et al., 2016). Therefore, shidu parents demonstrating severe grief (total score of Prolonged Grief Scale-Revised [PG-13-R] ≥ 30) (Prigerson, Boelen, et al., 2021) or significant PTG (total score of Short Form of Posttraumatic Growth Inventory for Chinese Shidu Parents [PTGI-CS-SF] ≥ 36) (Xu et al., 2021) were selected from the whole project. Specifically, three individuals (ID1, ID2, ID3) scoring 43, 41, and 39 on the PG-13-R, respectively, and two individuals (ID6, ID7) scoring 44 and 39 on the PTGI-CS-SF participated voluntarily in the interviews. Subsequently, snowball sampling was utilized to recruit additional participants based on referrals from these interviewees. They were invited to refer other shidu parents who might be willing to participate in the study, and also helped by sharing the recruitment advertisement within their online and offline groups. Moreover, participants encompassed diverse demographic characteristics (e.g. age, education, marital status) and loss-related details (e.g. cause of death, duration since loss). Specifically, two respondents (ID4 and ID8) proactively contacted the researcher after viewing the advertisement and expressed interest in participating. Respondent ID6 referred ID5, who subsequently referred ID9. To further enrich the sample and ensure collection of rich information, two leaders of shidu parent groups (ID10 and ID11) were also invited. These two leaders have been actively involved in WeChat groups (a popular social media platform in China) for over two years and have frequent communication with other shidu parents.

The sample size of (10 + 3) serves as a reasonably effective guideline for interview studies (Francis et al., 2010). Given that coding and in-depth analysis do not necessarily reach a fixed end point, decisions regarding the cessation of coding and recruitment were made based on data quality and adequacy (e.g. richness, complexity) in addressing the research question (Braun & Clarke, 2021).

During the recruitment phase, shidu parents were clearly informed of the purpose of the study, the content of the interview guide, potential risks and benefits, and the principle of confidentiality. Thirteen shidu parents were interested and electronic written informed consents were signed prior to interviews. One participant withdrew before the scheduled interview due to discomfort discussing the child-death. Another participant experienced high emotional arousal during the interview, prompting the interviewer to offer immediate emotional support and terminate the interview. Finally, 11 shidu parents (3 men and 8 women) were successfully interviewed by the first author between April and June 2022. At the time of interview, participants’ ages ranged from 53 to 72 years, and the length of time since their child loss ranged from 2.25 to 24 years, with most frequent being 4–5 years. Detailed characteristics of the interviewees are provided in Table 1, where each participant was anonymized and identified by a numerical code to ensure confidentiality.

Table 1.

Characteristics of the interviewees.

	Gender	Age	Education level	Marital status	Child’s gender	Child’s age	Time since loss (years)	Cause of death
ID1	Male	60	High school	Widowed	Daughter	28	5.75	Chronic illness
ID2	Female	59	Middle school	Widowed	Son	28	5.67	Sudden illness
ID3	Female	64	High school	Married	Son	37	2.25	Lung cancer
ID4	Male	72	College	Married	Son	36	4.42	Suicide
ID5	Female	54	College	Married	Son	20	4.50	Heart attack
ID6	Female	68	College	Married	Son	37	3.75	Chronic illness
ID7	Female	68	Middle school	Widowed	Son	40	5.17	Heart attack
ID8	Female	59	High school	Divorced and remarried	Daughter	27	5.50	Suicide
ID9	Female	67	Middle school	Divorced and remarried	Son	18	24.00	Accident
ID10	Male	65	Post-graduate	Married	Son	16	14.00	Accident
ID11	Female	53	High school	Married	Daughter	25	4.25	Cancer

2.2. Study material: interview guide

An initial interview guide was developed by the first author, informed by a comprehensive review of the literature and study objectives. Subsequent refinements were made following consultations with two doctoral students and a professor specializing in bereavement and grief. The final version of the interview guide underwent review and approval from both the research team and a shidu father to ensure linguistic appropriateness. The guidelines included open-ended questions designed to explore shidu parents’ grief reactions, changes over time, and PTG. Examples of questions included: ‘What were your initial thoughts, feelings, or reactions upon learning about your child’s death?’, ‘How have your thoughts or feelings changed over time?’, ‘What are your current thoughts or feelings regarding your loss?’, ‘How long did it take for your intense grief/ mood to improve (a little)?’ and ‘Have you experienced any positive changes since the loss? If so, please provide some examples.’ At the end of each interview, participants were invited to share any additional thoughts they wished to convey.

2.3. Interviewer

The interviewer (the first author) had over five years of experience as a researcher specializing in bereavement and grief. She was undertaking her PhD project in clinical psychology, focusing on grief and PTG among Chinese shidu parents. Before this study, she completed a two-year training program in Cognitive Behavioural Therapy and interned for one year at an outpatient psychological counselling department. Furthermore, she received specialized training in prolonged grief therapy at the Center for Prolonged Grief for one year. With extensive experience in working with shidu parents and a strong rapport-building ability, she established relationships quickly with the interviewees.

2.4. Procedure

Due to the impact of the COVID-19 pandemic, face-to-face interviews were impractical for this study. Instead, nine participants were interviewed via WeChat video, while two others participated through voice calls. The semi-structured interviews were administered by the first author in Mandarin, and audio-recorded with participants’ consent.

Given the sensitive nature of the interview topics and differences among participants, the interview length varied. Some participants experienced significant emotional fluctuations during the interviews, breaking down in tears multiple times. In these cases, the interviewer consistently expressed empathy and provided emotional support, which extended the duration of the interviews. Additionally, interviews were longer for participants who had difficulty articulating their thoughts and feelings clearly, as the interviewer needed to ask more questions to guide them to provide more detailed information. Conversely, participants who were able to focus on the questions and express their thoughts and experiences fluently tended to have shorter interview length.

2.5. Data analysis

The interview length ranged from 55 to 134 min, with an average of 1.57 h. Audio data were transcribed into Chinese text using iFlytek’s transcription service (https://www.iflyrec.com), followed by meticulous verbatim proofreading by the interviewer through repeated listening to recordings. A total of 17.28 h of audio yielded 224,340 words in transcription.

Reflexive thematic analysis (TA), emphasizing the researcher’s reflective engagement with the data and analytic process, was applied to analyse the qualitative data (Braun & Clarke, 2019). The analysis followed six phases: familiarizing the data, generating codes, initial theme generation, reviewing and refining themes, defining and naming themes, and producing the report. Themes were developed using latent and/or semantic coding, following an inductive and/or deductive approach. To ensure coding quality, the first two authors independently coded three sets of textual data. Subsequently, the first three authors deeply engaged with and reflectively interpreted the data. After resolving discrepancies and ambiguities through discussion, the first author completed coding the remaining interview transcripts.

All qualitative data were analysed by software MAXQDA 2022.

3. Results

3.1. Prolonged grief symptoms of shidu parents

Four themes of prolonged grief symptoms were identified among shidu parents: (1) Separation distress (2) Cognitive, emotional, and behavioural symptoms, (3) Somatic responses and (4) Changes in grief responses. Themes, codes and illustrative examples are presented in Table 2.

Table 2.

Themes of prolonged grief symptoms and illustrative examples.

Themes	Codes	n	Illustrative examples
Separation distress	Intense yearning/ longing for the child	9	I miss my son every minute and I just wonder where I can find him again. (ID2) How could you not miss your child? A mother never forgets her child. I miss him every day. (ID6)
	Persistent preoccupation with the child	10	Things about my child frequently recurred in my mind, like a movie. (ID2) I shop online every day now. Because my mind is full of my child. I can’t do anything else. (ID3)
Cognitive, emotional, and behavioural symptoms	Identity disruption	3	It feels like you are a walking zombie, as if a part of your own life has disappeared. (ID10) I often don’t know who I am now. When I went up the stairs two days ago, I was thinking, who am I? I'm a human being. What’s a human being? (ID11)
	Disbelief or difficulty accepting death	9	When the doctor told me (the child had died), I didn't believe it. I didn’t allow the doctor to cover the body with a white cloth, because I thought a miracle would happen. Even now, I find it difficult to accept this reality. (ID3)
	Avoidance of reminders	10	I don’t want to tell anyone (about the child’s death). I have packed all her belongings into a suitcase, but I avoid looking at it as it evokes painful emotions. (ID1) I couldn’t bear to look at anything related to my child, as it would cause my mind to run wild. I also didn't want to talk to anyone about my child, so I moved. (ID7)
	Intense emotional pain (e.g. sorrow, anger, guilt/self- blame)	11	Those who have not experienced it cannot understand the anguish brought about by losing an only child. It is an ineffable sorrow for a parent to bid farewell to their child. I assert that no suffering surpasses this. The grief is enduring and insurmountable. (ID4) At that time, I thought if I saw the driver, I would definitely beat him up. I even wanted him to pay for it with his life. (ID9) He used to stay up late and didn’t take care of his health. Sometimes I feel angry with my child, blaming him for not taking good care of his health. (ID7) Sometimes I just wonder, was it inevitable that my child got sick? If I tried my best and didn’t put too much burden on him, maybe he won’t be sick. Did I cause his death? (ID2)
	Difficulty re-engaging in life	9	My child is gone forever, and I will never have the heartfelt joy I once had. (ID4) I no longer enjoy what I once liked. Nothing appeals to me now. I have no goals or aspirations. (ID5)
	Emotional numbness or shock	10	During that period, I experienced a lack of affection. It seemed as though my capacity to love had waned. I even didn’t love my parents, my partner, or my friends. (ID5) I felt on the verge of losing consciousness. My mind went blank, leaving me disoriented and devoid of cognition. It felt as if the world around me was collapsing. (ID7)
	Loss of meaning or hope in life	8	When a child is gone, there is nothing left, and there is no hope for the future. (ID2) If a family has no children, what is the meaning of life? We live for our child. (ID9)
	Intense loneliness	11	With the child gone, I now feel isolated in this world. (ID1) I'm alone at home. I don’t want to socialize with others, and I’m also afraid of connecting with others. (ID9)
	Sense of inferiority or shame	7	Ever since this happened, I feel like others look down on me. If other people knew that my child had passed away, they would definitely not want to have contact with people like us, fearing that we might bring bad luck to them. (ID1) Currently, I experience significant feelings of inferiority during social interactions and activities with others. I perceive instances of discrimination or ridicule. Because I don’t have kids and I'm a failure now. (ID3)
	Suicidal ideation and behaviour	7	Now I just hope that there will be an accident that ends my life. This would be the happiest thing. At least I don’t have to think about my child and the death every day. I would be relieved immediately and no longer suffer from this pain. (ID3) At that time, I just wanted to die with my child. We lived on the fifth floor and I thought about jumping out of the window. I distinctly remember having this intense urge twice. (ID5)
Somatic responses	Crying	8	I tried to control myself from crying, but I couldn't. I cried whenever I talked about my child, as if I couldn’t help myself. (ID2)
	Deteriorating physical health	6	This incident was so shocking to me that I developed a heart condition afterwards. (ID6)
	Loss of appetite	3	The daily thoughts of my child were incredibly distressing, affecting my appetite and sleep patterns significantly. (ID1)
	Sleep disturbance	7	I often experience distressing dreams. Upon awakening from these dreams, regardless of the time, I am left feeling deeply distressed and unable to return to sleep. Sometimes the dreams are very scary, like my child walks in front of me and then she disappears. I don't know where she went and I can't find her. (ID1) I often wake up at 2 or 3 o’clock in the morning and can’t fall asleep again. (ID6)
Changes in grief responses	Gradually accepting reality	9	Initially, I struggled to accept it, but over time, I am gradually coming to terms with this reality. However, there are moments when I still question whether this truly happened. (ID3)
	Decreased emotional pain	9	Initially, I experienced constant distress, persisting every minute of the day. Currently, although I still experience daily episodes of grief, these periods are significantly shorter in duration. (ID6) Although I feel much better now, there remains a persistent conflict between my mind and my emotions. Sometimes I feel great, then suddenly disrupted by episodes of emotional breakdown, followed by a return to stability. (ID11)
	Experiencing positive emotions	5	During dinner, my husband and I frequently engage in natural conversations about our child. We experience both sorrow and joy in equal measure. (ID11)
	Heightened grief on special times of holidays	5	We are afraid of Lunar New Year and other festivals. It is extremely painful for us because many people gather at home during Lunar New Year and other festivals, but our children are not there. (ID1) Some time ago, on the anniversary of my child’s death, I was so upset that I couldn’t sleep. (ID3)
	The timing of the change in grief reactions	6	I feel like I’m a little better this year than before, five years since I lost my child. (ID1) It has been nearly four years since my son passed away, and I’m only now struggling to see a glimmer of hope. (ID4) I went through 3 years of pain, then time is a potent healer. (ID5) I am just getting better now. It took at least 5 years to feel a little better. (ID7) It took me about 4 or 5 years before I gradually and slowly changed. (ID9) It would be great if there could be a slight improvement after three years. (ID11)

Note: n: the number of interviewees who mentioned this code; Bold indicates associated symptoms not included in the DSM-5-TR and ICD-11.

3.1.1. Separation distress

Almost all participants reported experiencing separation distress following the death of the child, which is the core symptom of PGD. Nine interviewees expressed a strong yearning and/or longing for their child, coupled with a desire for reunification. Ten bereaved parents indicated that they were frequently absorbed in memories of their children and/or preoccupied with thoughts of them, which hindered their ability to engage in other activities.

3.1.2. Cognitive, emotional, and behavioural symptoms

Cognitive, emotional, and behavioural symptoms of shidu parents shared many commonalities with those of other bereaved people across different cultures, such as identity confusion, disbelief or difficulty accepting the death, intense emotional pain, difficulty re-engaging in life, emotional numbness or shock and a sense that life is meaningless or hopeless. The following highlights symptoms that may be less described in the ICD-11 or DSM-5-TR diagnostic criteria for PGD.

Avoidance and intense loneliness are listed as the symptoms of PGD in the DSM-5-TR diagnostic criteria but are not included in the ICD-11 guidelines. However, avoidance behaviours related to people, objects, or places associated with the child or the death were very common among interviewees (n = 10). They were also reluctant to talk to others about their child or the death event. Two bereaved parents even relocated to avoid reminders of the death and their social networks. Additionally, all participants in this study reported experiencing strong feelings of loneliness following the loss of a child.

All interviewees expressed intense emotional pain following the loss of a child, including feelings of sorrow, anger, and guilt/self-blame. They emphasized that those who have not experienced such a loss cannot fully understand the profound grief associated with losing a child. Four respondents specifically stated that the pain of losing a child is everlasting and cannot be alleviated. Additionally, two respondents described experiencing psychological pain that manifested without any physical stimuli, indicating subjective sensations of pain. As one respondent said (ID5), ‘Not only do we experienced emotional pain, but our bodies also really hurt. Sometimes, I feel a sharp pain in my heart, like being squeezed or struck. I finally know what heartache feels like. That is, my heart truly hurts.’ Guilt/self-blame is one of the diagnostic criteria for PGD in ICD-11 but is not included in DSM-5-TR. Regardless of their actual responsibility, shidu parents often experienced intense guilt and self-blame following the death of their child. This guilt may arise from their perceived failure to prevent the death or from actions they did or did not take, such as restricting their child’s spending or not preparing more desirable meals.

Grief reactions of shidu parents encompass not only the symptoms outlined in the ICD-11 and DSM-5-TR but also culturally relevant reactions, such as sense of inferiority or shame. Influenced by traditional views that emphasize the continuation of the family lineage and regard the loss of a child as inauspicious, shidu parents often felt they have failed to meet the expectations of their own parents or ancestors, or believed they have not conformed to societal norms. They may perceive themselves as unlucky or fear being stigmatized by others. Some individuals also believed that losing a child is a punishment for past misdeeds, as one participant expressed (ID6), ‘Others surely would say that I am not a good person. If I were a good person, how could my child have fallen ill and passed away? So I feel particularly inferior.’ Consequently, feelings of inferiority or shame are quite common among shidu parents.

While the diagnostic criteria for PGD in ICD-11 and DSM-5-TR do not encompass suicidal ideation or behaviours, such reactions are frequently observed among shidu parents. The overwhelming pain of losing the only child or an intense longing to reunite with the deceased child may trigger suicidal thoughts or behaviours.

3.1.3. Somatic responses

Somatic responses were also prevalent among shidu parents, manifesting as crying, deteriorating physical health, loss of appetite, and sleep disturbance. Eight participants reported reactions of crying following the loss of a child, including describing their experience of crying or crying uncontrollably during the interviews. One shidu mother (ID11) reflected on her experience: ‘Every morning when I open my eyes, tears flow uncontrollably. It is not that I consciously choose to cry or that I intentionally think about my child. It seems that my mind independently triggers these emotions, leading to uncontrollable tear.’ Additionally, because the death event was too overwhelming or traumatic, shidu parents’ physical health might deteriorate from then on, including issues such as gastrointestinal discomfort, cardiovascular problems and hypertension. Participants also reported a reduction in appetite and sleep disturbances, with many suffering from insomnia and, in some cases, nightmares related to the death of their child.

3.1.4. Changes in grief responses

As time goes by, shidu parents’ grief may change in terms of intensity, frequency and manifestations. Most shidu parents gradually came to terms with the reality of the loss, leading to a reduction in the severity of grief. They may experience bittersweet feelings when thinking about their child and may also begin to experience positive feelings about their lives. However, the reduction in grief severity did not follow a linear trajectory. Shidu parents would oscillate between disbelief, reflection and acceptance. Notably, during special times (e.g. child’s birthday or death anniversary) or holidays, their grief reactions tended to intensify. Six participants reported that it took them at least 3–5 years to feel (a little) better or have these improvements.

3.2. PTG of shidu parents

Three themes of shidu parents’ PTG were defined: (1) Changes in self-perception, (2) Changes in interpersonal relationships, and (3) A changed philosophy of life. Themes, codes and illustrative examples are presented in Table 3.

Table 3.

Themes of PTG and illustrative examples.

Themes	Codes	n	Illustrative examples
Changes in self-perception	Living for self	8	I started living for myself. I used to work hard to save money for my child, so that she could live a better life. I refrained from buying expensive fruits for myself due to financial concerns. But now I have started to treat myself better, and I will buy whatever I want to eat. This is a significant change, not a minor one. (ID1)
	Developing new interests	7	Actually, I like calligraphy very much. But when my child was around, I didn’t have time to learn it. Now I have enrolled in both a calligraphy class and a modeling class, allowing me to engage in physical exercise and learn calligraphy. (ID6)
	A new lifestyle or new goals	6	Over the years, I have dedicated all my time and energy to my child and never participated in any activities. Now that I have more time to relax, I want to engage in various activities. (ID6) Previously, I was highly dedicated to my work. Now, I aspire to engage in more meaningful activities that serve society and enhance the meaning of my child’s life. (ID10)
	Positive mindset	8	I now understand that everyone has their own sufferings and setbacks. But we should treat life with an optimistic attitude, have confidence to face the difficulties in life, look at things in a positive way, and not get stuck in a dead end. This is a positive way of life. (ID4) Think about life, there are gains and losses. Each gain entails a loss, and each loss brings a gain. (ID5)
	Feeling stronger	6	Having experienced this loss, I now feel that no difficulty can overwhelm me. I don't think any problem is difficult. (ID7)
	Being a better self	3	Because my son loved helping others when he was alive. I now consider him my role model. As long as I am able, I am willing to help others. I strive to be the best version of myself in his honor. (ID2) I want to carry on my child’s legacy of compassion, believing this would align with my child’s wishes. I hope that when I eventually reunite with my child, I can say, ‘In the years after your passing, mom didn’t bring shame to you.’ Mom took you as an example and became a better person. (ID11)
Changes in interpersonal relationships	More compassion and empathy for others	5	Since the loss of my child, I have developed a heightened sense of compassion for individuals who are ill or in poor health. I now exhibit greater kindness and empathy towards the suffering of others than I did before. (ID1)
	Being closer and more caring to others	10	I have developed closer relationships with others. My friends and relatives, noticing my loneliness, feel sympathy for me and show greater care. My friends are all very kind, and as a result, I have become closer to them and cared more about them (ID7)
	Altruistic behaviours	8	When my child was ill, I received help from many people, reaffirming my belief that there are still so many good people. This experience motivated me to assist others whenever possible. (ID6) Initially, I became involved in volunteer work unintentionally through invitations from others, but I have continued ever since. I find it highly fulfilling, as helping others brings happiness not only to those we assist but also to ourselves. I want to keep doing this work. (ID9)
A changed philosophy of life	Living in the present	7	At present, I choose not to dwell on uncertain future events, as worrying about the unknown is useless. Instead, I focus on living in the present and living each day well. (ID5)
	A new understanding of the meaning and value of life	5	I have come to realize that death is inevitable, whether it occurs sooner or later. What matters is living a life of value. This is my current perspective. (ID2) By providing warmth and assistance to others, we can also experience a sense of personal value and meaning. (ID10)
	Accepting the natural laws	5	I refrain from commenting, criticizing, or arguing about certain matters, maintaining a neutral stance. I believe that all aspects of human existence should exist. For example, no matter I am poor or rich now, I have to accept this. Including the loss of my child and other events that occurred, I try to tolerate and accept them. (ID5)
	Recognition of the preciousness of life	2	Now when I see stray animals, I feel that they are suffering. In the past, I didn’t think too much when I saw chickens and pigs being killed. Now, I feel a deep sense of pity for these animals, recognizing they are also lives. (ID1)
	Changing priorities in life	7	Previously, I believed that I should work hard to attain a leadership position. However, after the loss of my child, I feel like none of that matters anymore. Although money is important, it is mere material wealth. (ID5) The most important thing is to have a good mood and a good attitude. (ID9) I now prioritize the health and well-being of children above all else, recognizing the critical significance of physical health. (ID11)

Note: n: the number of interviewees who mentioned this code.

3.2.1. Changes in self-perception

Chinese parents often prioritize their children in their daily lives. However, the loss of an only child compelled some shidu parents to reorient their lives and focus on themselves. Consequently, ‘living for oneself’ may represent a unique positive change for this group. They cultivated new interests or hobbies, established a new lifestyle, and set new goals to enrich their lives. Some of them developed a more positive, optimistic, and open mindset towards themselves and life. Having experienced such a significant loss, they might perceive themselves as stronger and more resilient, believing that they can overcome any subsequent challenges. Some shidu parents viewed themselves as better versions of themselves by considering their child a role model, striving not to disappoint their child, or setting new personal goals.

3.2.2. Changes in interpersonal relationships

After experiencing their own suffering and hardships, shidu parents might develop a heightened sensitivity to the difficulties and pain of others, resulting in increased empathy and compassion. They tended to become more caring and considerate towards others, exhibiting altruistic behaviours and a greater willingness to help others. For some, assisting others became a significant part of their lives, bringing them a sense of joy and fulfilment.

3.2.3. A changed philosophy of life

The loss of the child may lead shidu parents to recognize the impermanence of life and the inevitability of death. Consequently, some interviewees realized the importance of living in the present and making the most of each day. The loss prompted them to actively or passively reflect on the meaning and value of life, potentially gaining new insights. Five shidu parents noted a realization that many events are beyond individual control, leading to a greater acceptance of natural laws. Only two individuals reported a deeper appreciation for the preciousness of life, fostering a greater respect for the lives of others, including small animals. More than half of the participants have changed their life priorities, placing less importance on material possessions and more on well-being and physical health.

4. Discussion

The current qualitative research found that shidu parents exhibited a wide variety of grief reactions and positive changes similar to other bereaved individuals across cultures, with some important exceptions. For instance, ‘feelings of inferiority or shame’ and ‘somatic responses’ may be culturally relevant grief reactions for shidu parents, and ‘living for self’ may represent a unique positive change for this group.

The grief responses outlined in the ICD-11 and DSM-5-TR were evident within shidu parents, indicating that there are some important commonalities in the reactions to loss, regardless of the relationship to the deceased or the cultural context. The loss of the only child can profoundly affect several key domains of the parents’ life (Albuquerque et al., 2016). Consistent with a previous qualitative study on parents bereaved by drug-related deaths, our study provided additional evidence that parents who have lost their only child experience significant challenges in adapting to their changed circumstances (Titlestad et al., 2020). Consequently, shidu parents often experienced pervasive, intense and enduring grief reactions, such as strong yearning or longing, avoidance of reminders, intense emotional pain, a sense of meaninglessness or hopelessness, and intense loneliness and so on. Notably, two respondents reported experiencing psychological pain, a symptom associated with an increased risk of PGD, depression, and suicide. However, this symptom has received little attention in previous empirical studies (Frumkin et al., 2021). Therefore, further research on psychological pain is warranted in bereaved individuals, including shidu parents.

The study also identified grief responses of shidu parents that may be culturally influenced, with the primary one being ‘feelings of inferiority or shame’. Shidu parents may feel bad for end of family lineage and believe that others may look down on them due to childlessness (Shi et al., 2019). Moreover, the loss of a child may be unfairly perceived as bad luck or retribution for past immoral action (Xu et al., 2020), and parents may even be blamed for the child’s death (Yuan et al., 2024). As a result, feelings of inferiority or shame are highly prevalent among shidu parents. Although further research is needed to validate whether feelings of inferiority or shame should be included as diagnostic criteria for shidu parents, therapists and social workers still recommend being sensitive to this symptom due to its cultural relevance.

The somatic responses observed in shidu parents could be associated with cultural norms in Eastern societies that discourage direct emotional expression (Shen & Yan, 2015). Research has shown that Western outpatients reported more psychological symptoms, whereas Chinese outpatients often reported more somatic symptoms (Ryder et al., 2008). Some researchers have advocated for including somatic symptoms as one of diagnostic criteria for PGD in the ICD-11 for Japanese bereaved individuals (Killikelly et al., 2023). Building upon existing literature, our findings indicated that it might be beneficial to consider somatic responses when evaluating the grief severity, particularly within Eastern cultural contexts.

Although the loss of a child is one of the most distressing forms of bereavement, over time, most shidu parents tended to gradually accept the reality of their loss or reluctantly compromise with the reality. Consequently, the vast majority of respondents reported a reduction in emotional distress. The results provide additional evidence that most bereaved people would recover from grief naturally (Smith & Ehlers, 2020; Wen et al., 2022). However, this was not an easy process. Shidu parents often oscillated between rational acceptance of the death and emotional disbeliefs, experiencing occasional emotional breakdowns during their recovery. Additionally, during certain times, particularly on anniversaries related to the child or family-oriented holidays, they may experience intense grief. Six participants reported that their grief reactions required at least 3–5 years to show some improvement, significantly exceeding the commonly recognized 6- and 12-month time criteria for PGD. As a unique group of bereaved parents who have experienced an exceptionally challenging type of loss, it is anticipated that their recovery from grief may take an extended duration. The current findings provide further evidence that the shidu parents suffered from severe and prolonged grief (Xu, Xie, et al., 2022; Yuan et al., 2022; Zhou et al., 2020).

With the exception of interviewee ID3, who did not mention changes in life philosophy, all participants reported positive changes across three themes: self-perception, interpersonal relationships and philosophy of life. This may be because all participants in the current study had experienced the death of their only child for over two years at the time of the interview, with the most having been bereaved for 4–5 years. Longer time since loss might allow for the management of intense distress and enable cognitive processing of the death event, thus facilitating growth (Tedeschi et al., 2018). These three themes among shidu parents are consistent with the three broad categories of PTG proposed by Tedeschi and Calhoun (1996), and align with qualitative research findings on individuals bereaved by suicide (Smith et al., 2011). ‘Living for self’ may represent a unique positive change among shidu parents. Most Chinese parents view their children as the centre of their lives and devote themselves entirely to their children (Yu, 2018). The death of a child profoundly disrupts parents’ assumptive world beliefs, leading them to actively or passively engage in cognitive restructuring and reconsider the meaning of their lives (Calhoun et al., 2010). As they no longer see the role of ‘father’ or ‘mother’ as their entire identity, they gradually begin to live for themselves.

Although some scholars argued that PTG contains components of positive illusions and that illusory PTG is much more common than genuine PTG (Boals, 2023), the current study indicated that shidu parents can experience genuine PTG following the loss of a child. This genuine PTG helped them cope better with grief, especially relieving feelings of identity confusion and hopelessness. For example, one interviewee regarded volunteer work as her new life goal after bereavement, finding happiness and the meaning of self through helping others. She dedicated time and energy each day to planning how to assist others and achieve her goals. Consequently, she no longer avoided social interactions and did not dwell on memories or thoughts about her child. She realized that, beyond her role as a mother, she could find other meanings, and her sense of inferiority gradually diminished. Additionally, her physical health and sleep quality improved after engaging in community service, leading her to feel that she had embarked on a new chapter in her life. Therefore, the current study supported that PTG has a significantly positive effect on adaptation following bereavement, regardless of the levels of distress (Hamby et al., 2022).

4.1. Implication

The qualitative investigation may enhance cultural understanding of PGD symptoms and PTG among shidu parents. The findings reveal that shidu parents experienced significant feelings of inferiority or shame, as well as various somatic responses. Over half of the participants reported that it took them at least 3–5 years to experience any improvement in their intense grief, indicating that shidu parents may experience persistent intense grief for many years. It is important to identify vulnerable shidu parents at risk, so that timely interventions can be provided (Pohlkamp et al., 2018). Therefore, regularly screening for grief severity and other physical issues are necessary for shidu parents. Notably, 7 out of 11 participants in this study mentioned suicidal thoughts or behaviours, emphasizing the critical importance for families, social workers, and therapists to remain vigilant for signs of suicidal ideation or behaviour among shidu parents, especially during the early stage of bereavement. Providing appropriate psychological support and culturally sensitive interventions to this high-risk group should be considered (Yuan et al., 2024). When working with shidu parents, therapists may need to acknowledge and validate their thoughts or feelings, including sense of inferiority or shame, and then find ways to help mitigate their distress.

Furthermore, our study indicated that shidu parents can experience genuine positive changes from struggling with such a loss. Promoting the development of PTG among shidu parents may facilitate coping with grief and adapting to life without their child. Consequently, it may be advantageous for social workers and therapists to seek opportune moments to discuss positive changes with shidu parents. For parents who view their child as the central meaning of their lives, guiding them towards living for themselves, establishing new goals, and developing a new life philosophy may be beneficial.

4.2. Limitations

Some limitations of the current study should be mentioned. First, participants were recruited as part of a larger research project and through recommendations. Additionally, most interviewees were female. Such a biased sample may limit the transferability. Second, although some of the respondents were selected from shidu parents with obvious grief or growth, the qualitative interviews were conducted approximately six months after questionnaire assessments. Consequently, the respondents’ levels of grief and PTG may have changed during this interim period. Third, due to the impact of the COVID-19 pandemic, all interviews were conducted via video or audio formats. Future research should consider conducting in-person interviews to further validate and extend the findings of this study. For instance, longitudinal studies with larger and more diverse samples, including participants with varying durations of bereavement, would offer valuable insights into how time since the loss influences grief and growth among shidu parents.

5. Conclusion

In summary, the PGD symptoms and PTG experienced by shidu parents shared several commonalities with those of bereaved individuals in other cultures, alongside distinct characteristics influenced by traditional Chinese culture. When working with shidu parents, it is essential to consider these possible cultural differences, such as ‘feelings of inferiority or shame’, ‘somatic responses’ and ‘living for self’.

Funding Statement

This work was supported by the National Social Science Fund of China [grant major program 16ZDA233], the Social Science Foundation of Jiangsu Province [grant number 23SHC011], Philosophy and Social Science Research Fund for Universities of Jiangsu Province [grant number 2023SJYB1400]. The funding agency had no role in the study design, data collection, analysis, or interpretation, or manuscript preparation or submission.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The raw data from interview transcripts are not publicly available due to protection of personal information.