Introduction

This case review describes a brief psychological intervention with an 8-year-old child referred to a child and adolescent psychology outpatient service three weeks after his father's death from advanced cancer. Referral concerns included intense sadness, aggression and anger toward the mother, alongside declining school performance. Assessment combined clinical interview with the child and mother with administration of the Roberts Apperception Test for Children-2, indicating overall healthy psychological functioning consistent with normative grief rather than established psychopathology. The brief, structured intervention drew on Turner [1] framework for talking with children about death and dying, including psychoeducation about the life cycle, writing a farewell letter to the father, and recalling shared memories. Over the course of treatment, the child showed progressively greater capacity to integrate the loss, with remission of oppositional behaviour and perceived improvement in school functioning, leading to discharge. The case is discussed in light of contemporary models of childhood grief, including Worden [2] Four Tasks of Mourning, Stroebe & Schut's [3] Dual Process Model, the Continuing Bonds perspective Klass, Silverman, & Nickman [4] and DSM-5-TR (APA, 2022) criteria for Prolonged Grief Disorder, which help distinguish this intense but normative reaction from complicated grief. Limitations of the single-case, retrospective design and the absence of standardised outcome measures are discussed, along with implications for clinical practice in hospital settings.

Keywords: Childhood grief; Parental death; Cancer; Brief psychological intervention; Narrative therapy; Therapeutic writing

Introduction

The death of a parent during childhood is one of the most potentially adverse life events, with significant implications for a child's emotional, behavioural, and academic development. A non-negligible proportion of children and adolescents are estimated to experience the loss of a parent before reaching adulthood, with cancer being one of the most frequent causes of parental death in childhood Christ [5] Historically, the understanding of grief was dominated by models of sequential stages Kubler Ross [6] which have since been widely revised. Contemporary literature instead emphasises the non-linear, individual, and contextually shaped nature of the grieving process. The Dual Process Model [3] proposes that adaptive coping with loss involves an oscillation between loss orientation (confronting the pain and memories associated with the loss) and restoration orientation (resuming daily routines and responsibilities), with both poles being necessary for adjustment. Complementarily, the Continuing Bonds perspective [4] challenges the classic assumption that healthy grieving requires severing the bond with the deceased, proposing instead that maintaining an internal symbolic relationship with the deceased can play an adaptive role, particularly in children, who frequently maintain active internal representations of the deceased parent.

With specific regard to childhood grief, [2] work, grounded in the Harvard Child Bereavement Study, proposes four mourning tasks adapted for children: accepting the reality of the loss, processing the associated emotional pain, adjusting to a world without the physical presence of the deceased parent, and finding ways to emotionally relocate the relationship with the deceased while still investing in new relationships and activities. This framework is particularly useful in clinical practice because it avoids the early pathologisation of intense but normative grief reactions.

This distinction gained particular clinical relevance with the introduction, in DSM-5-TR [7], of Prolonged Grief Disorder as a formal diagnostic entity, whose criteria include, for paediatric populations, a minimum time threshold of six months following the loss (compared with twelve months required for adults), accompanied by symptoms of intense yearning, persistent preoccupation with the deceased, and clinically significant impairment in functioning. It is worth noting that this time threshold excludes, by definition, the application of this diagnosis to grief reactions occurring in the weeks immediately following a loss, as in the case described here, which reinforces the importance of clinically distinguishing between normative acute grief and prolonged or complicated grief before any intervention decision.

Regarding the effectiveness of psychological intervention in childhood grief, a landmark meta-analysis [8] based on 27 controlled and uncontrolled studies, found overall small-to-moderate effects, with larger effects observed in children presenting with clinically significant symptomatology than in preventive interventions aimed at asymptomatic children. This finding is relevant to the interpretation of the present case, as it reinforces the need to calibrate intervention to the specificity and intensity of the clinical presentation, rather than applying a generic protocol indiscriminately.

Beyond effect-size evidence, a growing body of work has examined narrative and expressive writing approaches — including bibliotherapy and therapeutic writing — as tools for supporting emotional processing in children and, more broadly, bereaved individuals. Bibliotherapy has been described as a valuable collaborative tool between psychologists and educators in supporting child development [9] and as a hope-building resource in educational settings [10] while therapeutic writing has more specifically been associated with narrative well-being in the context of grief, including parental and reproductive loss [11]. From a narrative therapy perspective, complicated grief has also been conceptualised as reflecting difficulties in constructing a coherent narrative around the loss, with several reviews highlighting the potential contribution of narrative and constructivist approaches to its prevention and treatment [12-14]. These perspectives provide additional theoretical grounding for expressive writing techniques, such as the farewell letter used in the present case, as tools to facilitate the integration of loss. This article describes, in the form of a case review, the psychological assessment and brief intervention with an 8-year-old child referred for emotional and behavioural difficulties following the death of his father from cancer, discussing the case in light of these contemporary models of childhood grief.

Case Description

The case concerns a male child, 8 years of age, referred to the child and adolescent psychology outpatient service of a child and adolescent mental health unit by his mother, following the recent death of his father from advanced cancer, who was being followed under palliative care. Some identifying details have been altered or generalised relative to the original clinical record to prevent the identification of the child and family, without compromising the clinical substance of the case. The referral was prompted by the child presenting with intense and persistent sadness, aggressive behaviour, and anger directed at the mother since the father's death, associated with a marked decline in school performance. In interview, the mother described the situation as very difficult to witness, reporting daily crying and persistent sadness, while acknowledging the adaptive normality of these reactions; her main concern related to the association between these emotional difficulties and the deterioration in school performance, as well as episodes of aggression and hostile comments directed at herself, during which the child stated that she did not understand what it was like to lose the father.

The mother reported that, although divorced from the child's father for several years, the relationship between them had remained close and affectionate, and had in fact grown even closer during the period of terminal illness, during which the mother took on a central supportive role. The child and father maintained a close relationship and regularly engaged in leisure activities together. In the individual interview, the child appeared sad and apprehensive but cooperative. He demonstrated age-appropriate understanding of the psychologist's role. He expressed intense sadness related to the irreversibility of the loss and the absence of activities previously shared with his father. He acknowledged episodes in which he directed hostile comments at his mother. Still, he demonstrated insight by clarifying that he did not hold her responsible for the father's death, instead attributing the cause to the cancer, which he described, symbolically and in an age-appropriate way, as a "monster".

Psychological Assessment

Assessment combined semi-structured clinical interview with the child and parent figure with administration of the Roberts Apperception Test for Children-2 [15], aiming to characterize the child's emotional functioning and to verify the possible presence of clinically significant indicators of psychological disturbance associated with the grieving process. Results of the protocol showed an overall normative profile on the clinical scales, except for elevations on the Depression and Unresolved scales, interpreted as a direct reflection of the ongoing grieving process rather than an indicator of established depressive disorder. Reduced scores were also found on adaptive scales related to perceived availability of social support, suggesting that, at the time of assessment, the child did not fully perceive his available support network as accessible — a finding clinically consistent with the acute grief period, and not necessarily stable over time. In contrast, the elevated score on the Child Support scale was interpreted as indicating overall positive feelings about himself and confidence in his own abilities, corroborated by clinical observation of an assertive child with good emotional and expressive capacity.

Taken together, the assessment data were interpreted as consistent with an acute, intense, but normative grieving process, without sufficient indicators to justify a diagnosis of an established psychological disorder. This interpretation is reinforced, from a current perspective, by DSM-5-TR (APA, 2022) criteria for Prolonged Grief Disorder, whose minimum time criterion (six months since the loss, for children and adolescents) was not, in fact, even met at the time of referral, which occurred only three weeks after the father's death — further supporting the interpretation of the presentation as normative acute grief rather than a complicated or pathological grief picture.

Therapeutic Intervention

Psychological intervention was brief, structured into weekly sessions of approximately 40 minutes, with the primary aim of supporting the child in adequately processing the grief associated with his father's death. Guidelines proposed by Turner [1] in her reference manual for psychological work with children confronting death and dying were adopted. In an initial phase, psychoeducation was provided regarding death as part of the life cycle, using an analogy appropriate to the child's developmental stage — comparing the human life cycle to the cycle of leaves on trees, which are born, grow, change, and fall Turner [1] allowing the child to cognitively integrate the cause of his father's death (an illness that made it impossible for the body to continue functioning) without recourse to potentially confusing euphemistic explanations.

In a second phase, work focused on constructing a symbolic form of farewell, an element identified in the literature as facilitating recognition of the reality of the loss Turner [1]. The child chose to write a letter addressed to his father, in which he was able to express feelings, thoughts, and concerns associated with the loss, within a protected, non-judgmental space — an approach consistent with the broader literature on bibliotherapy and therapeutic writing as tools for emotional processing in children and in bereavement [9-11]. In addition, shared memories with the father were actively recalled, associated with both sadness and joy, in a process consistent with the Continuing Bonds perspective [4] according to which preserving an internal symbolic connection with the deceased parent — rather than severing it — constitutes a relevant adaptive mechanism in childhood grief. Throughout the sessions, efforts were also made to legitimise and normalise the expression of ambivalent feelings directed at the mother, helping the child differentiate between the intensity of the emotional pain felt and the realistic attribution of responsibility for the father's death, consistent with evidence supporting structured work on emotional recognition and differentiation with children [16].

Clinical Course

Over the course of the therapeutic process, the child showed a progressive capacity to integrate the experience of loss, accompanied by a gradual reduction in oppositional and hostile behaviour directed at the mother, as well as a perceived improvement in school functioning, according to maternal report. This evolution was assessed through direct clinical observation and maternal report throughout the sessions; standardised outcome measures were not administered at post-intervention, which is a limitation to consider when interpreting these results (see Limitations). Once the child's capacity to recognise, express, and progressively integrate his feelings regarding the loss was established, clinical discharge was decided.

Discussion

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This case illustrates the application of brief childhood grief intervention principles within a hospital context of urgent referral, following the recent death of a parent from cancer. In light of framework, the intervention can be understood as primarily supporting the first two tasks of mourning — recognising the reality of the loss, promoted through psychoeducation about the life cycle and the symbolic farewell experience, and processing the associated emotional pain, facilitated by the safe space created for expressing feelings through the letter and the recollection of memories. The oscillation observed across sessions between moments of confrontation with the pain of loss and moments of recovering positive memories and resuming school routine is also consistent with the Dual Process Model Stroebe & Schut [3] which posits precisely this alternation — rather than continuous, exclusive exposure to pain — as the adaptive mechanism for coping with loss. Christ's [5] work, developed specifically with children confronting the death of a parent from cancer, highlights the importance of supporting the child in constructing a positive, integrated representation of the deceased parent, and not merely in resolving acute pain — an aim that the structured recollection of shared memories, as conducted in this case, also sought to promote, aligning with the Continuing Bonds perspective referred to above.

From a narrative therapy perspective, complicated grief is understood as difficulty constructing a coherent, meaningful narrative that integrates the loss into the survivor's ongoing life story, rather than as solely a set of persistent symptoms [12-15]. Viewed through this lens, the present intervention — centred on constructing a symbolic narrative of farewell and actively integrating memories of the father into an ongoing, evolving story — can be understood as precisely supporting this process of narrative integration, thereby complementing the diagnostic distinction between normative and prolonged grief discussed above.

One aspect warranting critical discussion concerns the diagnostic interpretation of the initial presentation. The elevations on the Depression and Unresolved scales of the Roberts-2 could, in isolation, suggest a pathologising reading of the child. However, integrating these findings with the DSM-5-TR (APA, 2022) time criterion for Prolonged Grief Disorder — not met, since referral occurred only three weeks after the loss — reinforces the clinical interpretation adopted, namely that this represented an intense but normative acute grieving process, rather than an established pathological grief picture. This distinction has relevant practical implications: overly medicalized or prolonged interventions at very early stages of grief may, in some cases, interfere with natural adaptive processes, and the brief, focused nature of the intervention described here appears consistent with current recommendations in the literature. The observed clinical outcomes should nonetheless be interpreted with caution in light of the available empirical evidence. The meta-analysis by Currier [8] found generally small effects for childhood grief interventions, particularly in predominantly asymptomatic samples, with larger effects among symptomatic children — consistent with the greater visibility of the clinical improvement observed in this case, given the initial level of behavioural and emotional disturbance presented by the child.

Limitations

This case review has limitations that should be considered when interpreting the results described. First, it is a single, retrospective, uncontrolled case, so conclusions cannot be generalised or interpreted as evidence of intervention effectiveness. Second, clinical evolution was documented through clinical observation and parental report; standardised outcome measures were not used at post-intervention, nor was a medium- or long-term follow-up assessment conducted, so it is not possible to determine the stability of the changes observed over time. Third, some identifying elements of the case were altered or generalised for confidentiality reasons, with institutional authorisation for the retrospective reuse of the clinical material, which, although ethically necessary, limits the contextual detail available to the reader.

Conclusion

This case illustrates the application of a brief psychological intervention, structured around principles of psychoeducation, symbolic elaboration of farewell, and recollection of shared memories, in supporting a child experiencing acute grief following his father's death from cancer. Reading the case in light of contemporary models of childhood grief — Worden's [2] Four Tasks, the Dual Process Model Stroebe & Schut [3] the Continuing Bonds perspective [4,7] criteria for Prolonged Grief Disorder — allows this clinical presentation to be situated as an intense but normative acute grieving process, underscoring the importance of careful diagnostic assessment before any intervention decision involving bereaved children in a hospital context.

References

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