Helping children grieve the loss of a caregiver due to COVID-19

Tragically, the pandemic has taken a caregiving loved one from tens of thousands of children. How do we, as pediatric health care providers, provide care and comfort?

From April 1, 2020, to June 30, 2021, more than 140,000 children in the United States experienced the death of a primary caregiver, according to findings recently published in Pediatrics. The modeling study calculated COVID-19–associated orphanhood (death of 1 or both parents) and deaths of custodial and coresiding grandparents by using mortality, fertility, and census data. The investigators reported that for every 4 COVID-19 deaths, 1 child lost a parent or caregiver.¹ As a pediatrician, I found that statistic, which highlights a crisis for children in the pandemic, to be profound.

Unsurprisingly, the study also uncovers disparities in COVID-19– associated death of caregivers. American Indian and Alaska Native children were 4.5 times more likely, Black children were 2.4 times more likely, and Hispanic children were 1.8 times more likely to lose a parent or grandparent caregiver than their non-Hispanic, White counterparts. These data mirror the disparate rates of COVID-19 infection and out- comes in communities of color and point to long-standing inequities, such as discrimination, barriers to health care, educational gaps, and economic instability.¹

The loss of a parent or primary caregiver who provides love, safety, and stability is a devastating event and has a long-term impact on a child’s health and well-being. Parental loss is identified as childhood trauma or an adverse childhood experience that, unbuffered, can lead to toxic stress, affecting the developing brain and body and increasing risks of various physical, mental, behavioral, and substance use problems in childhood and beyond.¹

Perhaps the most impactful element of the study is the call for a “care for children,” a comprehensive response to improve outcomes in children experiencing orphanhood. The 3-pronged approach aims to:

• prevent COVID-19–associated death of caregivers through effective and equitable policies and practices that improve access and uptake of COVID-19 vaccines;
• prepare families, offering support and services to help the child experiencing loss of a parent or primary caregiver;
• protect children through programs that build resilience in the family, enhance parenting skills, and improve family relationships.¹

Pediatric health care providers are uniquely positioned to help children grieving caregiver loss from COVID-19. By incorporating strategies from the study and learning from grief experts, such as the Pediatric Advance Care Team (PACT) at Children’s Hospital of Philadelphia in Pennsylvania, we can empower families to overcome traumatic loss by guiding them through the grieving process.

PACT highlights 3 key areas plus tips to help families navigate death and grief²:

IMPROVING COMMUNICATION: Use age-appropriate language, and avoid euphemisms (eg, say “Mom died” in lieu of “We lost Mom”). Allow the child to ask questions, provide helpful books (www.commonsensemedia.org/lists/books-about-grief), prepare the child for what will happen next (eg, the funeral), and how they might feel in the coming weeks/months.

RECOGNIZING THAT GRIEF DIFFERS AND VARIES AMONG CHILDREN: Be prepared for regression (eg, bedwetting), along with sleeping problems, roller- coaster emotions, and behavioral changes eg, anger, withdrawal).

DEVELOPING POSITIVE COPING SKILLS: Encourage honoring (eg, a balloon release) and remembering the loved one (eg, sharing stories, creating a memory box/scrapbook/video, keeping traditions). Grief counseling can help both the child and their current caregiver, who should also practice self-care and understand the stages of grief.²

Pediatric health care providers will encounter children who are orphaned during the pandemic. Developing clinical action steps to address this pandemic-related trauma and the grief that follows is important and should incorporate the following steps:

• Screen for COVID-19 related caregiver loss: “Has this child lost a parent or other caregiver to COVID-19?”
• Assess symptoms of grief and address any maladaptive responses.
• Promote healing and resilience building by encouraging safe, stable, nurturing relationships and environments and positive childhood experiences.
• Provide referrals and resources, such as social services support, United Way 211, bereavement programs, trauma-informed mentoring programs, parenting classes, and quality childcare, as well as literature on grief.
• Advocate for federal, state, and local support of children who have lost a parent or other caregiver to COVID-19, such as coordinating efforts to identify orphans; creating a COVID-19 bereaved children’s fund; and expanding access to community-based, grief-focused, and trauma- informed mental health services.³
• Amplify organizational efforts and trusted voices to reduce health disparities and promote health equity related to the pandemic, such as The Conversation Between Us, About Us, a campaign codeveloped by Kaiser Family Foundation and the Black Coalition Against COVID.⁴
• Continue to promote COVID-19 prevention by encouraging families to practice safety measures including vaccination, mask wearing, hand hygiene, and testing, as well as advocating for community-wide layers of protection to reduce the spread of the virus and associated deaths.

Since Pediatrics published those study results, the number of children orphaned due to COVID-19 has risen to an estimated 200,000- plus.⁵ Health care providers play a critical role in raising awareness, protecting families, and intervening when children experience the loss of a parent or other caregiver to COVID-19.

References

1. Hillis SD, Blenkinsop A, Villaveces A, et al. COVID-19-associated orphanhood and caregiver death in the United States. Pediatrics. Published online October 7, 2021. doi:10.1542/peds.2021-053760

2. How to help children grieve. Children’s Hospital of Philadelphia. December 7, 2021. Accessed December 10, 2021. https://www.chop.edu/news/health-tip/how-help-children-grieve

3. Treglia D, Cutuli JJ, Arasteh K et al. Hidden Pain: Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation Can Do to Help Them. COVID Collaborative. December 2021. Accessed January 27, 2022. https://www.covidcollaborative.us/assets/uploads/img/HIDDEN-PAIN-FINAL.pdf

4. The Conversation: Between Us, About Us. Accessed January 5, 2022. https://www.greaterthancovid.org/theconversation/toolkit/

5. Hill D, Parga-Belinkie J. Pediatrics On Call. Pediatric research roundup, orphanhood due to COVID-19—episode 96. Published January 4, 2022. Accessed January 26, 2022. https://www.aap.org/en/pages/podcast/pediatric-research-roundup-orphanhood-due-to-covid-19/