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Having just lost one parent to COVID-19 and seeing the other hospitalized with the illness, a teenager was in such despair that suicide seemed like the only way out. Fortunately, the youth and the remaining parent survived, but there is no escaping the psychological wounds this young person—and thousands of others—bear in the aftermath of losing a primary caregiver to COVID-19.
“Imagine seeing your parent gasping for air and then watching continual suffering over a month before the death. That’s a very traumatic memory for a child,” psychiatrist Asim Shah, MD, who treated this teen following the suicide attempt, said in an interview. Compounding the trauma was Facetime being the teen’s only contact with a dying parent and the funeral being canceled because of the pandemic. The circumstances prevented the teen from gaining closure, Shah noted.
COVID-19 has taken an extreme toll on a staggering number of children younger than 18 years who have lost the most important people in their lives. The authors of a recent study published in Pediatrics estimated that 142 637 US youths lost a parent, custodial grandparent, or grandparent caregiver to COVID-19 from April 1, 2020, to June 30, 2021. That estimate included direct COVID-19 deaths and indirect fatalities such as those due to pandemic-related difficulties accessing health care. Worldwide, more than 1.1 million children lost at least 1 parent or custodial grandparent in the first 14 months of the pandemic, according to a modeling study in The Lancet.
But unlike other mass casualty events such as natural disasters or terrorist attacks, the threat from COVID-19 is unrelenting, said Shah, a professor and executive vice chair of the Baylor College of Medicine’s Menninger Department of Psychiatry. He counseled 9/11 and Hurricane Katrina survivors and set up mental health facilities at Houston’s evacuation centers after Hurricane Harvey in 2017. “Those disasters were over in a few hours, whereas COVID-19 has lasted 18 months with no end in sight, which is much more traumatic,” he noted.
The ongoing pandemic may make children extremely fearful that the virus will kill a surviving parent or siblings or claim their own lives. “Kids who lose a parent in normal times have very high anxiety that something will happen to their surviving caregiver,” Rachel Kentor, PhD, a child psychologist at Texas Children’s Hospital who specializes in palliative care, grief, and bereavement, said in an interview. “It’s much harder today to offer a child reassurance that the family is safe when everyone is susceptible to infection.”
Deaths from COVID-19 uniquely affect kids in other ways, too. Children grieving a parent or caregiver who shunned getting vaccinated or wearing a mask or even denied the existence of COVID-19, for example, may feel intense anger or shame. They also may face stigma from peers or others outside the family.
“A child may refuse to talk about the death because he doesn’t want others to think the parent did something wrong,” Melissa Brymer, PsyD, PhD, director of Terrorism and Disaster Programs at the UCLA-Duke National Center for Child Traumatic Stress, said in an interview. “Other kids may feel guilty, believing that they may have brought COVID home and killed their parent. And now they don’t want to go to school or be with their friends because they may bring COVID home again and kill the surviving parent,” said Brymer, who has consulted on more than 300 mass disasters.
An Adversity Overload
Losing a parent is among the adverse childhood experiences (ACEs) associated with significant mental health problems: depression, posttraumatic stress disorder (PTSD), suicidal ideation and attempts, and an increased risk of substance abuse, violence, risky sexual behaviors and sexual abuse, and shorter schooling.
The impact of ACEs is cumulative, with kids who have experienced multiple major stressors at the highest risk for severe and long-term mental health consequences. The study in Pediatrics found that 65% of children who lost a primary caregiver to COVID-19 are from racial and ethnic minorities. The authors noted that these groups have greater exposure to the virus because they’re disproportionately represented in essential jobs and are more likely to live in multigenerational homes.
“The death of a parent to COVID may not be the only trauma kids living in marginalized communities have had,” said child psychologist Robin Gurwitch, PhD, a professor of psychiatry and behavioral sciences at the Duke University School of Medicine. She noted in an interview that these children may have experienced racism, maltreatment, or neighborhood violence. Some may live in poverty or unstable housing. Others could have faced educational disparities or poor access to health care. And according to the Pediatrics study, children whose primary caregiver is a grandparent are more likely to have experienced major adverse events, such as a parent’s incarceration, substance use disorder, or mental health problems. It’s also more common for kids raised by their grandparents to have separated or divorced parents or to have experienced domestic violence.
The pandemic itself could be viewed as an ACE for youths who have struggled with poor mental health due to social isolation, school closures, and financial instability. The US is currently facing a national state of emergency in children’s mental health, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared in a joint statement this past October. The pandemic has exacerbated already high rates of depression, anxiety, trauma, and suicide among youths, the groups said as they called for increased funding for access to evidence-based mental health services for kids and families.
In light of the pandemic’s enormous mental health toll on young people, psychologists and researchers who study child bereavement worry that kids who lose a parent to COVID-19 may have greater challenges in grieving. “Kids who have mental health problems before a parental death are at high risk for maladaptive grieving,” Kentor said. In a recent online survey of teens, adults, and health care workers, some adolescents who lost a loved one to COVID-19 experienced intense grief reactions, senior author Nadine Melhem, PhD, MPH, an expert on stress and trauma’s effects on children and families, noted during an interview.
“This grief intensity may put adolescents at higher risk of developing a prolonged grief reaction, which can lead to an increased risk of depression and functional impairment,” said Melhem, an associate professor of psychiatry at the University of Pittsburgh School of Medicine.
Although it’s still too early to understand the long-term effects on these newly bereaved children, findings from Melhem’s 2011 study may offer some insight. The research involved 182 children and adolescents who lost a parent suddenly to suicide, unintentional injury, or natural causes. About 59% of the kids had relatively rapid resolution of their grief within 1 year. But 31% had a sustained grief reaction, although it decreased over 33 months. For 10% of the children, their grief still had not diminished almost 3 years later. The longer the grieving period, the greater the risk that the child would develop significant depression and functional impairment, such as difficulties at home or school and trouble establishing relationships with peers.
“Even 7 years after a parent’s death, some children had high rates of functional impairment, posttraumatic stress disorder, and depression, which shows the long-lasting impact of early parental death in kids,” Melhem said, referring to her 7-year study on youth bereavement. Those who were younger than 12 years when the death occurred struggled the most. That’s not surprising to Melhem: “Exposure to adversity in early life is associated with longer lasting and more severe negative outcomes,” she said.
Another study followed up children who lived through Hurricane Katrina in 2005, which killed more than 1800 people. About 15% of the kids met the criteria for serious emotional disturbances 18 to 27 months after the disaster. And after 36 to 39 months, 12% of youths still experienced significant distress, particularly those who had faced the greatest disruption, losses, and ongoing stressors. A family member’s death had the greatest effect on a child’s long-term mental health problems, the study’s lead author, Katie McLaughlin, PhD, a professor of psychology at Harvard University, told The Harvard Gazette earlier this year.
With Support, Most Kids Will Be Fine
These and other studies show, however, that the majority of children and their caregivers who experience a loved one’s early death have the resiliency to eventually move past their grief. “Most people adapt to loss in their own way, even after experiencing the most horrific situations,” M. Katharine Shear, MD, a professor of psychiatry and director of the Center for Prolonged Grief at the Columbia School of Social Work, said in an interview. “But that doesn’t mean it is not more humane to provide some support,” she added.
A child’s grieving may appear different from an adult’s reactions and varies by age and even from child to child within a family. “It’s important that we don’t jump too quickly to pathologize normal grief reactions,” Kentor said. “One of the most important things a clinician can do is to reinforce to kids and their families that there is no right or wrong way to grieve and that everyone grieves differently.”
It’s also helpful for clinicians to explain to families the difference between normal grieving and prolonged or complicated grief. “If parents know that sleep problems are common or that school performance may falter, they won’t worry excessively or scold their children if their grades suffer,” Gurwitch said.
Clinicians can also help alleviate kids’ anxieties about more COVID-19 deaths in the family by reiterating safety measures. A child’s visit to a clinician may be an opportune time to urge the surviving parent or caregiver to get vaccinated, for example. Gurwitch suggested that one way to do so is by saying “Protecting the rest of the family is a way to honor a loved one’s memory.”
Studies show that the surviving caregiver has a major effect on a child’s ability to grieve normally. “Kids are resilient, but they can’t go it alone,” Shear said. Gurwitch added: “Children and teens look to adults as role models for how they will get through this time.”
Other adults can step in if the surviving parent or caregiver is struggling with their own grief. “A child needs one trusted adult who he or she can talk with openly about his or her loss”—a teacher, grandparent, school social worker, family friend, extended family member, or religious leader, Kentor said.
Families should be encouraged to inform their children’s schools about a death so social workers or school psychologists can check in with the child and so teachers can be sensitive to the situation. Unsurprisingly, bereaved children may have a hard time concentrating in class or may experience grief reactions to certain class assignments, such as readings with tragedy as a theme, Brymer said.
Children, adolescents, and caregivers often benefit from attending a bereavement support group. “These groups may reduce the likelihood of serious long-term health problems from complicated grief, if not for any other reason than problems will be recognized early,” Shear said, adding that the individual then can be referred for therapy. For the youngest children, storybooks about grief can help them express and cope with their feelings. Brymer recommended Sesame Street’s online resources “to help kids feel less alone in their grief.”
In addition to emotional support, some households may also need social services and financial assistance, “especially those families who have lost the primary breadwinner or who suddenly require childcare as the surviving caregiver returns to work outside the home,” Rachel Kidman, PhD, an associate professor in the Department of Family, Population and Preventive Medicine at Stony Brook University, said in an interview.
Kidman’s recent commentary in Nature outlined existing support programs for bereaved families, including the temporary expansion of the child tax credit and Social Security benefits for some children. Programs to improve parenting skills and family relationships can also help caregivers form a strong, nurturing relationship with a grieving child, Kidman said. Many communities also offer evidence-based support programs to youths who have lost caregivers, according to the recent study in Pediatrics.
The federal government has also acknowledged the need to support youth mental health services. In October, the Biden administration announced that the American Rescue Plan pandemic relief package will provide $80 million to integrate behavioral health services in pediatric primary care settings and will allocate $50 million to expand community behavioral health treatment for kids whose mental health the pandemic has affected. Another $60 million will support youth suicide prevention programs, the National Child Traumatic Stress Network, and community-based substance use services. A program called Project AWARE (Advancing Wellness and Resiliency in Education) will receive $30 million for training to help school staff recognize and respond to mental health issues.
Children and teens whose grief reactions last for at least 6 months and leave them feeling emotionally numb or unable to accept the death should receive a referral to a child psychologist or other mental health professional who can evaluate whether the child needs therapy, Brymer said. “Most of these children will not require medication as part of their treatment,” Shah added.
When clinicians assess a child or teen for psychiatric symptoms during bereavement, it’s important to also evaluate the remaining parent or caregiver for problematic grieving. “Prolonged grief in the surviving parent and the child predicts long-term depression in kids,” Melhem said.
A handful of interventions specifically tailored to grieving children and adolescents can help youths process and find meaning from death and discover opportunities to feel connected to the loved one they lost. The Resilient Parenting for Bereaved Families group therapy program for both kids and surviving caregivers has the most robust evidence, according to Kentor. In a late 2020 review article in The Lancet Child & Adolescent Health, she and a coauthor offered guidance for health care professionals who care for bereaved youths.
Kentor noted that until now, little attention has been paid to how COVID-19 deaths affect surviving children. The high estimates of children who have lost a parent or caregiver is “putting a spotlight on how much better we have to be as a country in supporting grieving youth,” she said. “Similar to kids who lost parents in 9/11, a new generation of kids will be marked in distinctive ways by the death of loved ones to COVID-19.”
Where to Find Help
The American Academy of Child and Adolescent Psychiatry has a fact sheet on normal and problematic signs of grieving in children.
The American Academy of Pediatrics and the Children’s Hospital of Philadelphia also have a guide on grieving children.
The National Child Traumatic Stress Network offers a series of tip sheets on how to help children with COVID-19–related grief, including advice for clinicians on how to manage childhood traumatic grief.
The New York Life Foundation, a major funder of childhood bereavement programs, offers extensive online resources for families, schools, and communities.
The Child Mind Institute has a guide written in English and Spanish to help children cope with grief.
Créditos: Comité científico Covid