One U.S. child loses a parent or caregiver for every four COVID-19 deaths, a new modeling study published today in Pediatrics reveals.
The findings illustrate orphanhood as a hidden and ongoing secondary tragedy caused by the COVID-19 pandemic and emphasizes that identifying and caring for these children throughout their development is a necessary and urgent part of the pandemic response – both for as long as the pandemic continues, as well as in the post-pandemic era.
From April 1, 2020 through June 30, 2021, data suggest that more than 140,000 children under age 18 in the United States lost a parent, custodial grandparent, or grandparent caregiver who provided the child’s home and basic needs, including love, security, and daily care.
There were racial, ethnic, and geographic disparities in COVID-19-associated death of caregivers: children of racial and ethnic minorities accounted for 65% of those who lost a primary caregiver due to the pandemic.
Children’s lives are permanently changed by the loss of a mother, father, or grandparent who provided their homes, basic needs, and care. Loss of a parent is among the adverse childhood experiences (ACEs) linked to mental health problems; shorter schooling; lower self-esteem; sexual risk behaviors; and increased risk of substance abuse, suicide, violence, sexual abuse, and exploitation.
“Children facing orphanhood as a result of COVID is a hidden, global pandemic that has sadly not spared the United States,” said Susan Hillis, CDC researcher and lead author of the study.
“All of us – especially our children – will feel the serious immediate and long-term impact of this problem for generations to come. Addressing the loss that these children have experienced – and continue to experience – must be one of our top priorities, and it must be woven into all aspects of our emergency response, both now and in the post-pandemic future.”
The study was a collaboration between the Centers for Disease Control and Prevention (CDC), Imperial College London, Harvard University, Oxford University, and the University of Cape Town, South Africa. Published in the Oct. 7 issue of the journal Pediatrics, it was jointly led by CDC’s COVID Response and Imperial College London, and partly funded by the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health (NIH), as well as Imperial College London.
“The magnitude of young people affected is a sobering reminder of the devastating impact of the past 18 months,” said Dr. Alexandra Blenkinsop, co-lead researcher, Imperial College London.
“These findings really highlight those children who have been left most vulnerable by the pandemic, and where additional resources should be directed.”
The analysis used mortality, fertility, and census data to estimate COVID-19-associated orphanhood (death of one or both parents) and deaths of custodial and co-residing grandparents between April 1, 2020, and June 30, 2021, for the U.S. broadly, and for every state.
“COVID-19-associated deaths” refers to the combination of deaths caused directly by COVID-19 and those caused indirectly by associated causes, such as lockdowns, restrictions on gatherings and movement, decreased access or quality of health care and of treatment for chronic diseases.
The data were also separated and analyzed by race and ethnicity, including White, Black, Asian, and American Indian/Alaska Native populations, and Hispanic and non-Hispanic populations.
The study authors estimate that 120,630 children in the U.S. lost a primary caregiver, (a parent or grandparent responsible for providing housing, basic needs and care) due to COVID-19-associated death.
In addition, 22,007 children experienced the death of a secondary caregiver (grandparents providing housing but not most basic needs). Overall, 142,637 children are estimated to have experienced the death of at least one parent, or a custodial or other co-residing grandparent caregiver.
“The death of a parental figure is an enormous loss that can reshape a child’s life. We must work to ensure that all children have access to evidence-based prevention interventions that can help them navigate this trauma, to support their future mental health and wellbeing,” said NIDA Director Nora D. Volkow, MD.
“At the same time, we must address the many underlying inequities and health disparities that put people of color at greater risk of getting COVID-19 and dying from COVID-19, which puts children of color at a greater risk of losing a parent or caregiver and related adverse effects on their development.”
Racial and ethnic disparities in COVID-related caregiver loss
There were significant racial and ethnic disparities in caregiver deaths due to COVID-19. White people represent 61% of the total U.S. population and people of racial and ethnic minorities represent 39% of the total population.
Yet, study results indicate that non-Hispanic White children account for 35% of those who lost a primary caregiver (51,381 children), while children of racial and ethnic minorities account for 65% of those who lost a primary caregiver (91,256 children).
When looking at both primary and secondary caregivers, the study found that findings varied greatly by race/ethnicity: 1 of every 168 American Indian/Alaska Native children, 1 of every 310 Black children, 1 of every 412 Hispanic children, 1 of every 612 Asian children, and 1 of every 753 White children experienced orphanhood or death of caregivers. Compared to white children, American Indian/Alaska Native children were 4.5 times more likely to lose a parent or grandparent caregiver, Black children were 2.4 times more likely, and Hispanic children were nearly 2 times (1.8) more likely.
Overall, the states with large populations – California, Texas, and New York – had the highest number of children facing COVID-19 associated death of primary caregivers. However, when analyzed by geography and race/ethnicity, the authors were able to map how these deaths and disparities varied at the state level.
In southern states along the U.S.-Mexico border, including New Mexico, Texas, and California, between 49% and 67% of children who lost a primary caregiver were of Hispanic ethnicity. In the southeast, across Alabama, Louisiana, and Mississippi, between 45% to 57% of children who lost a primary caregiver were Black. And American Indian/Alaska Native children who lost a primary caregiver were more frequently represented in South Dakota (55%), New Mexico (39%), Montana (38%), Oklahoma (23%), and Arizona (18%).
The current study follows closely in line with a similar study published in The Lancet in July 2021, which found more than 1.5 million children around the world lost a primary or secondary caregiver during the first 14 months of the COVID-19 pandemic.
In both the global and US studies, researchers used the UNICEF definition of orphanhood, as including the death of one or both parents6. The definition includes children losing one parent, because they have increased risks of mental health problems, abuse, unstable housing, and household poverty.
For children raised by single parents, the COVID-19-associated death of that parent may represent loss of the person primarily responsible for providing love, security, and daily care.
“We often think of the impact of COVID-19 in terms of the number of lives claimed by the disease, but as this study shows, it is critical to also address the broader impact—both in terms of those who have died, and those who have been left behind,” said study co-author Charles A. Nelson III, Ph.D. who studies the effects of adversity on brain and behavioral development at Boston Children’s Hospital.
“We must ensure children who have lost a parent or caregiver have access to the support services they need, and that this additional impact of the COVID-19 pandemic is comprehensively addressed in both our rapid response and our overall public health response.”
There are evidence-based responses that can improve outcomes for children who experience the COVID-associated death of their caregivers:
- Maintaining children in their families is a priority. This means families bereaved by the pandemic must be supported, and those needing kinship or foster care must rapidly receive services.
- Child resilience can be bolstered via programs and policies that promote stable, nurturing relationships and address childhood adversity. Key strategies include:
- Strengthening economic supports to families.
- Quality childcare and educational support.
- Evidence-based programs to improve parenting skills and family relationships.
- All strategies must be age specific for children and must be sensitive to racial disparities and structural inequalities. They must reach the children who need them most.
In the closing words of the paper, “Effective action to reduce health disparities and protect children from direct and secondary harms from COVID-19 is a public health and moral imperative.
The coronavirus disease 2019 (COVID-19) pandemic represents a challenge at multiple levels. It is an unprecedented public health crisis with undeniable social, economic, and emotional impact.
The fear and uncertainty along with dramatic changes in our daily lives imposed by physical and social isolation, home schooling, and telework strain families’ lives and may have a negative impact on children and adolescents’ mental health (1).
In a cross-sectional study among 8,079 Chinese adolescents conducted by Zhou et al. during the COVID-19 outbreak, the prevalence of depressive and anxiety symptoms was 43.7 and 37.4%, respectively. More than 30% of the adolescents reported combined symptomatology. Being female, in senior high school, and having low levels of awareness of COVID-19 were related to higher prevalence of depressive or anxiety symptoms (2).
Duan et al. applied online questionnaires to 359 Chinese school-age children and 3,254 adolescents during COVID-19 outbreak and reported high anxiety levels in 23.9% of children and in 29.27% of adolescents. Prevalence of clinical depressive symptoms was 22.28% (3). The pandemic situation can also worsen previous psychiatric disorders, as Nissen reported regarding a sample of children and adolescents diagnosed with obsessive–compulsive disorder (4).
Fear of death may be exacerbated in this period. How children and adolescents understand death and mourn a loved one depends not only on their development stage but also on religion and social aspects, cognitive ability, and prior life events.
Infants and toddlers react to separation from an attachment figure with distress. Due to their sensitivity to routine changes, routines should be maintained as much as possible. Preschool children do not understand death as irreversible, and their characteristic magical and egocentric thinking may lead them to believe they somehow cause the death with their actions, words, or thoughts, inducing guilt and regret. As they do not understand death as irreversible and non-functional, they may believe that the deceased will return or the deceased did not cease to sleep, eat, and feel. They often cope through play, which can be misinterpreted by adults.
As children enter school age, they progressively develop logical, concrete operational thinking. They can understand death’s irreversibility and may ask specific and scientific questions about death and its circumstances. Their thinking is less egocentric than younger children.
Therefore, besides being concerned about their own needs, they also worry about others’ well-being. As adolescents develop existential and abstract thought, they can understand death as irreversible, universal, and non-functional, so their mourning process resembles that of the adults. Structural developmental tasks of adolescence (identity consolidation, separation from family, and identification with peers) can be at risk when a family member dies, as they may feel different from their peers. Depending on their copying style, they may be at risk of developing internalized or externalized perturbed responses to death (5, 6).
All children and adolescents go through a mourning process when someone important dies, and it includes a wide range of emotions, cognitions, physical symptoms, and behavioral changes (6, 7). On death and dying, Kubler-Ross characterized grief as a five-sequential-stage process: denial, anger, bargaining, depression, and acceptance (8).
In the last decades, other models have been presented, understanding grief as a dynamic process that implies proactivity in adaptation to the loss. According to Worden, grief process develops through four tasks: accepting the reality of the loss, processing the pain of grief, adjusting to a world without the deceased, and finding a way to remember the deceased through life (6).
As one of the most personal experience someone lives, grieving takes its own time in a fluid, non-linear process, where tasks are revisited and reexperienced through life. Persistence of grief response and failure to adapt to the loss, with intrusive thoughts, avoidance behaviors, and loss of interest in daily activities are signs of a maladaptive grief response. Complicated grief was previously described in children and adolescents and is associated with increased risk for depression and functional impairment (7, 9).
The 11th edition of the International Classification of Diseases introduced the diagnosis of Prolonged Grief Disorder when it persists for an abnormally long period of time following the loss (more than 6 months) (10). The 5th edition of the Diagnostic and Statistical Manual (DSM) of Mental Disorders considers a specific set of bereavement-related symptoms (Persistent Complex Bereavement Disorder) under the diagnosis of Other Specified Trauma and Stressor-Related Disorder. This diagnosis, which can only be made 12 months (6 months in children) after the loss, is nowadays included in Section III (Proposed disorders for future study) of DSM (11).
Despite its specificity to detect prolonged grief reactions in children, these criteria are not sensitive enough in children, as pointed out in a study conducted by Melhem et al. (12). The addition of a new diagnosis, “Prolonged Grief Disorder,” to the Depressive Disorders Chapter in Section II of DSM was recently proposed, including symptoms of identity disruption, marked sense of disbelief about the death, avoidance of reminders of the loss, difficulty moving on with life, intense emotional pain or emotional numbness, and intense loneliness (13).
It is of consideration that the internal resources someone has and develops to integrate the loss and reconstruct life are as important as the time grief may take. As Worden says, “healing comes from what the grieving person does with the time” (6). In children and adolescents, those resources are inherently changing along with developmental stages. Therefore, they may revisit the grief as they grow, integrating it differently and giving it new meanings, in a developmentally appropriate way (14).
reference link :https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928371/
More information: Covid-19-Associated Orphanhood and Caregiver Death in the United States, Pediatrics (2021). DOI: 10.1542/peds.2021-053760