“As Long as I Live, My Sweet Boy You'll Be:” Parents' Continuing Bonds in Early Bereavement

ABSTRACT

Background

Bereaved parents seek ways to maintain connections with their deceased child throughout their lifelong grief. These continuing bonds may bolster parental social functioning, yet limited research has explored continuing bonds early in bereavement.

Aims

To explore how parents maintain connection with their child within the first 2 years following death.

Methods

Parents of children who died from cancer 6–24 months prior completed the 11‐item Continuing Bonds Scale (CBS) and an open‐ended question querying ongoing connections. CBS scores ranged from 11 to 55, with higher scores indicating stronger continuing bonds. We examined associations between CBS scores and parent/child factors and qualitatively analyzed free‐text responses.

Results

Among 128 parents who completed the CBS, 103 (80%) provided free‐text responses. Most respondents identified as non‐Hispanic (91%), white (81%), and female (63%). Surveys were completed a mean of 15 (range 8–26) months after the child's death. The mean CBS score was 45.6 (SD = 7.8), indicating strong continuing bonds. Mothers reported higher scores than fathers (mean 46.9, SD = 7.2 vs. 43.4 SD = 8.2, p = 0.023). Free‐text responses fell into five thematic domains: (1) physical connection; (2) symbolic and spiritual connection; (3) emotional and relational connection; (4) continuing shared experiences; and (5) legacy and action. Most parents described ongoing connections across multiple domains.

Conclusion

Bereaved parents exhibit strong and complex continuing bonds in early bereavement. Improved understanding of these continuing bonds may help to develop supportive interventions focused on strengthening bonds that facilitate grief integration and potentially mitigate long‐term psychosocial sequelae.

1. Introduction

The death of a child has dynamic, perpetuating effects on bereaved parents [1, 2, 3]. Parental grief is lifelong, and bereaved parents are at increased risk for depression, anxiety, post‐traumatic stress disorder, physical health decline, marital distress, and social isolation [4, 5, 6, 7, 8]. These outcomes are often compounded by significant financial hardship from medical expenses and lost income during the child's illness [9, 10]. Furthermore, the death of a child defies the natural life order and can profoundly challenge parents' identities as caregivers and protectors [2]. Although many parents face a crisis of identity after the death of their child, it is widely documented that the parent‐child bond endures beyond death and physical existence [11].

Rather than being severed, these relationships evolve into what are known as continuing bonds, which represent the unique ways bereaved individuals maintain a relationship with the deceased. Continuing bonds can provide comfort while simultaneously posing emotional challenges. First measured in cases of spousal loss, continuing bonds were shown to persist through diverse modalities, including narrative, ritual, memory, and social engagement [2, 12, 13, 14]. Continuing bonds following a child's death is unique in that it is not only about maintaining a connection to who the child was, but also who and what they would have become [15]. Among parents whose children have died from cancer, continuing bonds have been found to influence adjustment to loss, though the effects vary across individuals [16, 17]. While psychosocial bereavement outcomes are well‐documented in the long‐term, less is known about parental outcomes and continuing bonds in the early bereavement period. In fact, much of the bereavement literature documents grief experiences two or more years after the child's death, overlooking the evolving nature of grief and dynamic role of continuing bonds in early parental bereavement [18, 19]. Emerging evidence suggests that continuing bonds during early bereavement are linked to parental social functioning—a crucial marker of overall well‐being [8].

We conducted a secondary analysis of a cross‐sectional survey of parents whose children died from cancer within the past 2 years to examine the role of continuing bonds in early bereavement. We aimed to gain new insights into how such bonds manifest and are used during early parental bereavement. Understanding the continuing bond experiences of bereaved parents can inform strategies to support families in fostering connections that facilitate grief integration. This process involves incorporating the reality of the child's death and ongoing relationship into one's sense of identity, daily life, and future orientation [20], and may mitigate long‐term psychosocial sequelae.

2. Methods

This is a secondary analysis of a dual‐site survey‐based study. Survey design, recruitment procedures, and enrollment details have been described previously [8]. Briefly, eligible participants were parents whose child had died from cancer 6–24 months prior to survey administration after receiving care in the pediatric clinic at Dana‐Farber Cancer Institute (DFCI) or St. Jude Children's Research Hospital (SJCRH). Both parents from an eligible household could complete surveys, which were mailed to eligible participants, with the option to return them via prepaid postage or complete them online. IRB approval was obtained at both institutions (DFCI Protocol No. 19–160; SJCRH Protocol No. 20–0503). Survey packets included an information sheet with all elements of informed consent, and consent was implied by completion of survey.

2.1. Measures

Complete details and scoring information for all validated instruments included in the larger survey have been published previously [8, 21]. Parents self‐reported sociodemographic information, including age, gender, race/ethnicity, education, current employment and relationship status. They also identified their caregiving role for their deceased child and rated their religiosity and spirituality on a 4‐point Likert scale. Child age, diagnosis, race, date of cancer diagnosis and death were abstracted from the electronic health record.

For this analysis, we focused on data from the 11‐item Continuing Bonds Scale (CBS‐11) [22] which was followed by free‐text responses to an open‐ended question querying how parents maintained connections with the deceased child. The CBS measures the extent to which bereaved individuals maintain a bond with the deceased, with each item rated on a 5‐point Likert‐type scale: Not true at all (1), Slightly true (2), Neutral (3), True (4), or Very true (5). Total scores range from 11 to 55, with higher scores reflecting stronger continuing bonds [22]. The open‐ended question was, “What are some ways in which you have maintained a connection with your child following his/her death?” and provided space for a narrative response. We did not group CBS items into internalized versus externalized categories or classify bonds as inherently beneficial or harmful; instead, informed by recent psychometric work [23], we treated continuing bonds as a multifaceted construct and focused on overall patterns of endorsement and thematic expression.

2.2. Quantitative Analysis

We conducted descriptive analysis on the sociodemographic characteristics using mean and standard deviation (SD) for normally distributed data and median and interquartile range (IQR) for skewed data. The CBS‐11 was scored according to published guidelines [22]. To examine endorsement patterns at the item level, we dichotomized Likert responses: True and Very true were classified as “endorsed,” while all other responses were grouped as “not endorsed.” Associations between total CBS scores and child and parental factors were examined using nonparametric analyses. Spearman's rank correlation coefficients were used to assess associations between CBS total scores and continuous variables, and Wilcoxon rank‐sum tests were used to compare CBS total scores across dichotomous child and parental factors.

2.3. Qualitative Analysis

One researcher (B.H.) conducted the initial inductive coding of parents' free‐text responses, generating and refining codes iteratively. A second coder (C.L.) separately and blindly reviewed each free text response using the initial codebook. Using an inductive, iterative review process [24], the two primary coders (B.H. and C.L) discussed discrepancies until consensus was reached. A third team member (J.S.) reviewed the consensus coding, resolved any disputes in coding between the two primary coders, and finalized the thematic analysis. Codes were captured by five thematic domains; codes within these domains were mapped to CBS items to evaluate the extent to which the CBS captures parental continuing bonds. Qualitive methods and findings were reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [25].

The authors who conducted coding and the thematic analysis are all experienced in qualitative methods and maintain awareness of the personal and professional experience they bring to the analysis. Of the primary coders, B.H. is a male post‐graduate research assistant with a bachelor's degree, and C.L. is a female post‐doctoral pediatric Hematology/Oncology fellow. The third senior coding team member, who refined and finalized the code book and thematic analysis, J.S., is a female pediatric Hematology/Oncology and palliative care physician‐researcher and principal investigator of the primary study. The full study team engaged in regular discussions during analysis, enabling them to challenge and refine interpretation of the free‐text responses and application of codes and thematic domains. Coding was performed using qualitative software (Dedoose, version 10.0.35, 2025).

3. Results

3.1. Participant Sociodemographic Data

One hundred twenty‐eight parents completed the full survey; all (100%) provided responses to the CBS and 103 parents (80%) offered free‐text responses. Most respondents identified as White (104, 81%), not Hispanic (113, 91%), female (80, 63%), and primary caregivers for their deceased child (87, 68%); Table 1. Over half of parents worked full‐time (87, 68%) and held an associate or bachelor's degree or higher (79, 62%). Most respondents (101, 79%) were married to the child's other parent. Parents rated the extent to which they considered themselves religious or spiritual; 27 (22%) reported being “very religious,” and 44 (35%) “very spiritual.” The surveys were completed an average of 15 (range 8–26; median 14) months following the child's death.

TABLE 1.

Respondent sociodemographic characteristics.

Label	Response	N (%)
Parent characteristics, N = 128
Sex	Female	80 (63)
	Male	47 (37)
	Unknown	1
Age (in years)	Mean (range)	45.8 (25–71)
	Median (IQR)	47 (14)
Racial identity	White	104 (81)
	Black or African American	6 (5)
	Asian	1 (1)
	Multiracial or other	15 (12)
	Unknown/declined to answer	2 (2)
Ethnic identity	Hispanic or latino/a	11 (9)
	Not hispanic or latino/a	113 (91)
	Unknown	1
Highest parental level of education	High school diploma or equivalent	44 (34)
	Associate degree or bachelor's degree	52 (41)
	Master's degree	21 (17)
	Doctorate (PhD, etc.) or professional (MD, JD, DDS, etc.)	6 (5)
	Other	5 (4)
Current employment status	Working full‐time (> 30 hours per week)	87 (68)
	Working part‐time (< 30 hours per week)	10 (8)
	Not currently working, retired, or other	16 (12)
	Caring for home or family (not seeking paid work)	11 (9)
	Unable to work due to illness or disability	4 (3)
Current relationship status	Married to child's other parent	101 (79)
	Married to another individual	12 (9)
	Divorced	7 (6)
	Not married or never married	7 (6)
	Separated	1 (1)
Degree of religiosity, n = 125	Very	27 (22)
	Somewhat	54 (43)
	Not very	22 (18)
	Not at all	22 (18)
Degree of spirituality, n = 126	Very	44 (35)
	Somewhat	58 (46)
	Not very	14 (11)
	Not at all	10 (8)
Site	Dana‐Farber cancer institute	58 (45)
	St. Jude children's research hospital	70 (55)
Caregiving role	Primary caregiver	87 (68)
	Secondary caregiver	39 (31)
	Other/not answered	2 (2)
Other living children	Yes	109 (85)
	No	19 (15)
Time from Child's death to survey completion (in months)	Mean (range)	14.7 (7–26)
	Median (IQR)	13 (10)
Child characteristics, N = 88
Child's age (years)	Mean (range)	13.4 (0.5–29)
	Median (IQR)	13 (11)
Child's sex at birth	Female	34 (38.6)
	Male	54 (61)
Child's race	White	71 (81)
	Black or African American	5 (6)
	Asian	1 (1)
	Multiracial or other	7 (8)
	Unknown/declined to answer	4 (5)
Child's cancer diagnosis	CNS/brain tumor	34 (39)
	Hematological malignancy	25 (28)
	Non‐CNS solid tumor	26 (30)
	Multiple/other	3 (3)
Time from cancer diagnosis to death (in months)	Median (IQR)	27 (62)

Abbreviations: CNS, central nervous system; IQR, interquartile range; SD, standard deviation.

Parent respondents represented 88 children, ranging in age from 6 months to 29 years, who died from a variety of cancers. The median time from cancer diagnosis to death was 27 (IQR = 62) months.

3.2. Continuing Bonds Scale (CBS) Results

Parents strongly endorsed most of the CBS item statements, including those related to retaining child belongings (item 2, 96%), having fond memories of the child (item 9, 96%), being aware of the child's positive influence (item 7, 92%), reminiscing (item 3, 90%), feeling a loving presence (item 5, 84%), carrying out the child's wishes (item 8, 84%), and seeking out reminders (item 1, 76% endorsement). Parents were less likely to endorse items related to experiencing the child continuing to live on through them (item 11, 66%), having inner conversations for comfort or advice (item 4, 62% endorsement), using the child's viewpoint in decision‐making (item 10, 59%), and taking on the child's habits, values or interests (item 6, 55%) (Table 2).

TABLE 2.

Parental continuing bonds scale outcomes in early bereavement, N = 128.

Question	Response options	No. (%)	Mean	SD	Median	Affirmative endorsement by item
Participant level data, N = 128
1. I seek out things to remind me of my child	Not true at all	6 (5)	4.1	1.14	4
	Slightly true	8 (6)
	Neutral	15 (12)
	True	35 (27)
	Very true	62 (48)
	Unable/declined to answer	2 (2)
2. I keep items that belonged to or were closely associated with my child as a reminder of him or her	Not true at all	0 (0)	4.7	0.63	5
	Slightly true	4 (3)
	Neutral	1 (1)
	True	20 (16)
	Very true	103 (80)
	Unable/declined to answer	0 (0)
3. I like to reminisce with others about my child	Not true at all	1 (1)	4.5	0.83	5
	Slightly true	5 (4)
	Neutral	7 (5)
	True	33 (26)
	Very true	82 (64)
	Unable/declined to answer	0 (0)
4. I have inner conversations with my child where i turn to him or her for comfort or advice	Not true at all	18 (14)	3.7	1.53	4
	Slightly true	20 (16)
	Neutral	11 (9)
	True	19 (15)
	Very true	60 (47)
	Unable/declined to answer	0 (0)
5. Even though no longer physically present, my child continues to be a loving presence in my life	Not true at all	5 (4)	4.4	1.1	5
	Slightly true	8 (6)
	Neutral	8 (6)
	True	19 (15)
	Very true	88 (69)
	Unable/declined to answer	0 (0)
6. I am aware of having taken on many of my child's habits, values, or interests	Not true at all	21 (17)	3.4	1.41	4
	Slightly true	13 (10)
	Neutral	24 (19)
	True	35 (27)
	Very true	35 (27)
	Unable/declined to answer	0 (0)
7. I am aware of the positive influence of my child on who I am today	Not true at all	1 (1)	4.6	0.75	5
	Slightly true	3 (2)
	Neutral	5 (4)
	True	26 (20)
	Very true	92 (72)
	Unable/declined to answer	1 (1)
8. I attempt to carry out my child's wishes	Not true at all	4 (3)	4.3	1.02	5
	Slightly true	6 (5)
	Neutral	10 (8)
	True	35 (27)
	Very true	72 (56)
	Unable/declined to answer	1 (1)
9. I have many fond memories that bring joy to me	Not true at all	0 (0)	4.8	0.6	5
	Slightly true	3 (2)
	Neutral	2 (2)
	True	17 (13)
	Very true	106 (83)
	Unable/declined to answer	0 (0)
10. When making decisions, I imagine my child's viewpoint and use this as a guide in deciding what to do	Not true at all	13 (10)	3.6	1.3	4
	Slightly true	11 (9)
	Neutral	27 (21)
	True	34 (27)
	Very true	42 (33)
	Unable/declined to answer	1 (1)
11. I experience my child as continuing to live on through me	Not true at all	19 (15)	3.7	1.45	4
	Slightly true	8 (6)
	Neutral	16 (13)
	True	29 (23)
	Very true	55 (43)
	Unable/declined to answer	1 (1)

The mean parental CBS score was 45.6 (SD = 7.8), with scores ranging from 22 to the maximum of 55. Items 9 (“I have many fond memories that bring joy to me”) and 2 (“I keep items that belonged to or were closely associated with my child as a reminder of him or her”) had the highest mean scores at 4.8 (SD = 0.6) and 4.7 (SD = 0.6), respectively. The lowest mean score at 3.4 (SD 1.4) was seen for Item 6 (“I am aware of having taken on many of my child's habits, values, or interests”); Table 2.

3.3. Correlation Between Continuing Bonds Scores and Parental and Child Factors

In this cohort, prior analysis showed that parental continuing bonds scores correlated with scores for depression, anxiety, post‐traumatic stress, and prolonged grief, but also with higher scores for social functioning, resilience and post‐traumatic growth [8]. Total CBS scores were significantly higher among mothers compared to fathers (mean 46.9, SD = 7.2 vs. 43.4 SD = 8.2, p = 0.023; Figure 1). CBS scores showed a modest, non‐significant association with time since child's death to survey completion (Spearman rho = 0.15, p = 0.057). There was no difference in total CBS score by child's care location or in time from diagnosis to the child's death.

FIGURE 1.

Total continuing bonds scale scores by parent‐identified gender.

3.4. Qualitative Analysis of Free‐Text Responses

Parental narratives describing maintained connections with their deceased child were grouped into five thematic domains: (1) physical connection; (2) symbolic and spiritual connection; (3) emotional and relational connection; (4) continuing shared experiences; and (5) legacy and action (Table 3). Most parents maintained connection across multiple thematic domains.

TABLE 3.

Code categories, descriptions, and example responses illustrating how bereaved parents maintained connection to their deceased child.

Category and explanation	Code	Description	Example responses
Physical connection Tangible items, spaces, or actions that provide a physical or sensory connection to the child, helping preserve their memory through objects and environments.	Physical items	Objects that once belonged to or were associated with the child (toys, clothing, etc.); provide a tangible sensory connection	He loved pokémon (pikachu specifically) and he had 4 little action figures and I keep them on my dashboard in the car.
	Visual/audible memories	Photos, videos, or audio recordings of the child	I have always had pictures up and they still are.
	Preservation of physical spaces	Keeping the child's room, belongings, or spaces unchanged,	We have kept his room just the way it was when he was alive to help us cope a little until we are ready to cope with removing things.
	Creation of dedicated spaces	Building new physical spaces, like gardens, memorial benches, shrines	We have a memorial bench at the cemetery with a quote from her favorite musical.
	Creation of keepsakes	Crafting or curating items in honor of the child	We have also created large stuffed bears that have his voice that we can play when needed and are wearing his shirts. I also created a quilt with his cancer shirts and a quilt with my cancer shirts. The sewing and creating things in his memory helped me to cope.
	Grave site visitation and remains	Visiting the child's grave, memorial site, or ashes	I also go to the cemetery on my drive home from work every day, and visit after church. Even if I don't get out of the car, I drive by and blow him a kiss and tell him, “I'll love you forever, I'll like you for always, as long as I live, my sweet boy you'll be.” Every day.
	Tattoos, jewelry, and piercings	Permanent or semi‐permanent body modifications like tattoos or piercings; personal symbols or tributes to their life.	I got a tattoo on my forearm in his memory.
Symbolic and spiritual connection Personal, cultural, or spiritual symbols and practices that represent the child and maintain an ongoing connection through meaning, faith, or mindfulness.	Nature‐based reminders	Identifying elements of nature (butterflies, birds, etc.) that symbolize the child's presence	Dragon flies. Humming birds. Cardinals
	Music	Songs or music that are tied to the child's memory	We sing her song daily
	Faith‐based action/thought	Engaging in practices rooted in religious beliefs, such as prayer, attending religious services, or rituals	Through my faith in jesus. I know based on this verse “john 3:16: For god so loved this world he gave his only son. Whoever believes in him will not perish but have everlasting life.” I will see my boy again in heaven. I often ask jesus to give him a hug.
	Spiritual actions/mindfulness	Personal spiritual practices (meditation, mindfulness, reflection) that connect the bereaved with the child in a non‐religious, internal way	I meditate each day, having inner conversations with him. Sometimes I will mentally bring him into what I am doing—Letting him see through my eyes, for instance.
Emotional/Relational connection Emotional and relational ways of maintaining closeness to the child, either through personal reflection or interactions with others who were close to the child	Reminiscing and sharing memories	Reflecting on and sharing stories about the child with others, which provides joy or comfort.	Sharing memories of him openly. Speaking when we're reminded of him.
	Conversations with the child	Imagining or having internal/external dialogues with the child, keeping a mental conversation going.	I talk to her. I Say good morning and good night. Talk to her when her favorite songs come on the radio. I tell her what I'm doing.
	Memorial companionship	Maintaining relationships with people or pets that were significant to the child/family	We got her a puppy shortly before she passed and are training her to be a therapy dog. My daughter loved the therapy dogs who visited her and feel we would be making her proud and happy.
	Seeing them in others	Noticing the child's characteristics or mannerisms in other people	My younger daughter is her connection. They look so much alike physically and mentally… there are days that I feel she's in my little one. They have the same facial expressions I could see her.
	Journaling/Writing	Writing about the child, feelings, or memories as a form of therapy and connection	I write down, and record in my notes, the date and as much as I can remember of ANY and EVERY dream I have of him. Some days they make me so sad and aware of my reality, other days they can really motivate me and remind me not even death can take away mine and [my son's] love for each other.
Continuing shared experiences Ongoing participation in the child's favorite activities, hobbies, or wishes, allowing for the child's presence to be felt in everyday life and decisions.	Engaging in shared activities	Participating in hobbies, sports, or games that were shared with the child	I have replaced my putters with his in my golf bag—I envision him playing along with me.
	Continuing/engaging in Child's activities/interests	Pursuing activities that the child enjoyed or participated in but were not shared directly with the bereaved	We read his favorite books. Blowing wish flowers like he did.
	Carrying out wishes/requests	Fulfilling specific wishes or requests made by the child	We remodeled the downstairs of our home as he wanted to do if he got well.
	Decisional/motivational influence	Feeling the child's influence in decision‐making or thought process	Sometimes in my mind I see what he would say or react to during a similar activity that now I am engaged in without his presence.
Legacy and action Acts of service, advocacy, and communal memorial events done in the child's name, often aimed at making a lasting positive impact or raising awareness	Memorial events	Organizing or attending events such as memorials, anniversaries, or community gatherings to commemorate the child's life	We buy caterpillars and watch them turn into butterflies and release them on his birthday.
	Philanthropic action/service orientation	Engaging in service initiatives, fundraisers, or scholarships in the child's name or related to their illness or interests	We support other kids in the hospital by giving back.
	Advocacy	Raising awareness or participating in legislative efforts that relate to the child's illness or a cause they were passionate about	Our mission is to have her memory live on by raising awareness and funding.

Within the physical connection domain, parents described tangible items, spaces, or actions that provided a physical or sensory link to their child. Examples included keeping physical objects, preserving visual or auditory recordings, maintaining spaces once inhabited by the child, or creating new dedicated spaces or keepsakes. One parent shared, “Her room is still intact and I visit it,” while another noted “We have planted many trees on our property and family properties. These are cherry blossom trees that were her favorite. We also put some of her ashes with each tree.” Some parents chose tattoos or piercings with meaningful symbols: “I have gotten her handwritten name tattooed on my wrist. I have her heartbeat and the last message she wrote me tattooed on my foot. I got my nose pierced, because she wanted her nose pierced.” Other parents reported maintained connection through visiting the child's gravesite, memorial, or keeping of their ashes.

Symbolic or spiritual connections included maintaining or finding connections through symbols in nature, using music, engaging in religious or faith‐based practices, and participating in spiritual practices such as meditation, mindfulness, or reflection. One parent wrote: “I allow myself to be reminded of my child by certain symbols/representations. A red cardinal flying by when I'm at my son's grave, or when I see his favorite sesame street character at the store, or in another child's hands.” Another parent explained, “I think of her every time I pray. I talk to her and ask her to take care of me from heaven.”

For emotional and relational connections, parents described sharing memories with others (“we talk about him all the time”), imagining or having internal or external conversations with their child, experiencing companionship through those important to the child (“I keep in touch with his friends”), seeing elements of the child reflected in others, and journaling or writing. One respondent shared, “I write to [my child] from time to time just letting him know what's happening in the world and how we are doing.”

Parents described continuing shared experiences with their child to maintain connection by continuing activities they once shared or pursuing activities the child enjoyed, with one parent writing: “I read and or build Legos with him nightly, we have a stuffed animal mascot that we take with us anywhere to ‘fill his seat’. I lay out flowers daily. I shoot soccer goals nightly.” Parental narratives also included fulfilling the child's wishes or requests and feeling their child's influence in their decision‐making or thought processes: “I've tried to incorporate acts of kindness on her behalf into my daily life. It seems to be one of the few things that brings joy to my days.”

Finally, legacy and advocacy activities helped parents to sustain their bond with their child. These included organizing memorial events, engaging in service or philanthropic efforts, and advocating on behalf of their child's illness or a cause that was meaningful to them. One parent shared, “[my child's] dying wish was for us to help others and to support [hospital name]. We continue to fund raise and talk with everyone about her journey. A family that we met at [the hospital] also lost their child and we continue to reach out to them to offer support.”

Many of the inductive codes identified in the analysis of parents' free responses overlapped conceptually with items from the CBS (Figure 2). No codes overlapped with CBS items 6, 7, and 8. Questions about physical objects, mementos, and fond memories of the child aligned with codes in the “physical” and “symbolic/spiritual connections” domains. Likewise, CBS items about inner conversations with the child and carrying on the child's wishes corresponded closely to the “emotional/spiritual connection” and “continuing shared experiences” domains. In contrast, codes in the “legacy and action” domain demonstrated thematic overlap with only one CBS item, that is, item 11 (“I experience my child as continuing to live through me”), and this alignment was evident only when applying a more flexible, interpretation of the item's meaning.

FIGURE 2.

Codes and themes derived from parental free text responses mapped to individual items of the continuing bonds scale.

4. Discussion

In our secondary analysis of survey responses from bereaved parents within the first 2 years after the death of their child from cancer, we identified a high degree of continuing bonds. Female‐identifying parents had significantly higher total CBS scores compared to males in early grief. Parents maintained connection with their deceased child using numerous, and often nuanced, strategies. The CBS items that resonated most with parents focused on keeping items belonging to the child, sharing fond memories, and the child being a positive influence; lower rates of parental endorsement were seen for items related to taking on the child's habits, values, or interests, and using the child's viewpoint in decision‐making. Parent free responses offered additional, rich insight, with responses situating across five thematic domains: physical connections, symbolic/spiritual connections, emotional/relational connections, continuing shared experiences, and legacy and advocacy activities. Parents identified various ways of maintaining a connection with their child, often spanning multiple domains. Our qualitative analysis of parental conceptualization and application of continuing bonds through narrative responses was largely congruent with the validated domains of the quantitative CBS items. Most of the inductively derived codes overlapped with CBS items, particularly in the physical and symbolic/spiritual categories. Notably, the legacy and advocacy domain emerging from the qualitative data only loosely aligned with a single item on the CBS, perhaps suggestive of an underexplored strategy for continuing bonds that was able to be elicited narratively in our population of parents in early bereavement.

Parents in our study demonstrated strong continuing bonds, with mean CBS scores higher than those reported in prior bereavement samples, suggesting particularly intense connections in early parental bereavement [11]. In addition to total CBS scores, we reported item‐level endorsement patterns to show which specific forms of connection were most and least common in this cohort. This approach is consistent with the original CBS development work and with subsequent applications of the scale, and it helps clarify the qualitative content underlying high total scores (e.g., frequent endorsement of physical keepsakes and fond memories vs. less frequent endorsement of taking on the child's habits or viewpoints) consistent with prior research which showed that both parents and siblings in early bereavement deliberately chose reminders of the deceased child [11]. Notably, the mean scores for individual CBS items in our cohort were higher than those in a longitudinal study of bereaved spouses [22] and another study of bereaved parents whose child died 1–14 years earlier, where the mean CBS score was 35, that is, more than 10 points lower than in our sample [16]. Moreover, we found females had higher CBS in early grief compared to males and there was a modest, albeit not significant, decrease in total CBS over time. These findings suggest that the relationship between the individuals and the time since death may influence the strength of the continuing bonds. Although it remains unclear if and how these bonds change over time, the dynamic and evolving nature of parental grief [3, 26, 27] suggests that bonds may also shift and evolve. Within the Dual Model of Coping with Bereavement [28, 29],continuing bonds may facilitate oscillation between loss‐oriented and restoration‐oriented coping [17].

Parents reported a spectrum of strategies for maintaining a connection with their child, for example, keeping personal belongings, preserving the child's room or space, thinking about or communicating with their child, engaging in the child's favorite activities, participating in activities to honor the child, and visiting cemeteries or keeping ashes, all consistent with previous qualitative research [11]. Although there was strong parental endorsement for most CBS items, lower endorsement was found among items related to having taken on the child's habits, values, or interests; imaging the child's viewpoint as a decision‐making guide; and experiencing the child as continuing to live on through them. This may reflect differences in parent‐child versus partnered relationships (the CBS's original population) and the age of the child in that younger children may lack clearly defined viewpoints or values.

While the CBS generally aligned well with the qualitative themes, our analysis revealed a few notable exceptions that highlight the potential need for an expanded or new measure. We found that the code for legacy and advocacy, which captures philanthropic efforts and public service in honor of the child, did not neatly map to any single CBS item. While this theme could be interpreted as a form of “living on” through Item 11 (“I experience my child as continuing to live on through me”), this connection is indirect and stretches the item's original intent. Similarly, the qualitative themes of nature‐based reminders and spiritual practices—such as seeing symbols in nature or engaging in faith‐based activities—are not explicitly captured by the CBS. These findings suggest that for bereaved parents, continuing bonds extend beyond the more private or physical acts measured by the scale. The interpretive mapping required to connect these qualitative themes with the CBS underscores the need for a revised instrument that better captures the full breadth of parental continuing bonds, especially those related to spiritual practices and public, legacy‐oriented acts.

The relationship between continuing bonds and bereavement outcomes is complex. A systematic review of nearly 80 studies found that continuing bonds often provide comfort amidst the context of distress and sadness related to the loss [17]. While more than half of newly bereaved parents and siblings found reminders of the deceased child comforting, up to 20% of mothers and 10% of fathers reported discomfort. In another sample of bereaved parents, continuing bonds were positively associated with complicated grief but also with strengthened spirituality and appreciation of life [16]. Stigma and worry about how continuing bonds may be perceived by others has been reported in parents [30]. Other studies found that bereaved individuals who interpreted the continuing bonds they experienced as socially acceptable were less likely to experience complicated grief [31]. These findings suggest a multifaceted and dynamic role of continuing bonds, encompassing both comfort and distress depending on individual and social contexts.

Our sample included a substantial proportion of fathers and non‐primary caregivers, which is less common in bereavement research focused on parents. This broader range of caregiving roles and genders may enrich the diversity of reported continuing bonds, but it may also contribute to variability in CBS scores and themes, as caregiving responsibilities and gendered expectations can shape how parents experience and express ongoing connections with the deceased child. Future studies should examine how caregiving role and gender intersect with continuing bonds more systematically.

4.1. Study Limitations

Our results must be viewed within the limitations of this study. Most participants identified as female, white, and not Hispanic. The lack of gender, cultural, and ethnic diversity may make these findings less generalizable, especially as continuing bonds are likely influenced by both individual and relational factors. Because eligible parents were identified through their child's medical record, we were unable to obtain reliable sociodemographic data for all eligible parents and therefore could not assess differences in responders and non‐responders on these factors. The response rate for the larger survey study was 37% by household and although all parents completed the CBS, 80% offered free‐text responses. The richness of parental descriptions is likely limited by the free‐text option, and in‐depth qualitative interviews are likely needed to better understand nuances of continuing bonds in this and other populations. In addition, the CBS and the free‐text question were presented in a fixed order within the larger survey, which may have introduced priming effects (e.g., CBS item content influencing how parents described their connections in the narrative response); future work could randomize or separate qualitative prompts from scale completion to minimize potential priming. Because participation was opt‐in, parents who chose to respond may differ systematically from non‐responders in grief experiences, resources, or attitudes toward continuing bonds, introducing potential sampling bias and further limiting generalizability. Finally, unlike many other studies examining continuing bonds in bereavement, we chose not to separate bonds into different categories in our analysis, such as internalized or externalized, or label bonds as being either beneficial or harmful given the lack of clear relationship between each “type” of bond and bereavement outcomes [32]. Recent psychometric work also suggests that the original two‐factor internalized–externalized structure of the CBS shows suboptimal fit and that continuing bonds may be better conceptualized as a network of interrelated experiences rather than two discrete dimensions [23]. Our qualitative findings of multiple overlapping domains (physical, symbolic/spiritual, emotional/relational, shared experiences, and legacy/advocacy) further support the view that parents' continuing bonds are not easily reduced to two categories. With these limitations, we believe that our findings offer an improved understanding of parental continuing bonds early in bereavement and serve as potential targets for supportive interventions aimed at normalizing and augmenting these bonds.

4.2. Clinical Implications

Recognizing the strength and diversity of continuing bonds maintained by bereaved parents within the first 2 years following a child's death provides opportunities for targeted support throughout bereavement. Grief therapy, both individual and group‐based, should include psychoeducation on continuing bonds and invite parents to reflect on their own experiences with these ongoing connections. Clinicians should normalize a wide range of continuing bonds strategies and help parents to identify which bonds are comforting or distressing, tailoring interventions to each parents' unique needs. Additional research is needed to clarify which sociodemographic factors and specific continuing bonds strategies relate to short and long‐term psychosocial outcomes to help inform the development of evidence‐based interventions and meaningful outcomes measures for parents who experience the death of a child.

5. Conclusion

Bereaved parents maintain strong, multifaceted connections with their children who died from cancer, using physical, symbolic, emotional, experiential, and legacy‐related practices. These continuing bonds support social functioning in early bereavement, highlighting the need for interventions that strengthen such connections which may foster grief integration and reduce long‐term psychosocial challenges.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.