We have been swamped fighting a virus that has threatened our usual way of living. COVID-19 has made us feel vulnerable and evidenced the fragility of our health care systems. Until now, the most critical efforts have focused on mitigating a virus that seemed to prefer attacking adults over children. The reality is that despite our big sacrifice, COVID-19 has left a death toll of over 800,000 Americans, adults in the vast majority (>99%) (CDC, 2021). These tragic and devastating numbers have collateral effects on our society, including leaving many children without their parents and caregivers, significantly affecting their mental health. A recent study published in the Journal of Pediatrics shows that over 140,000 children in the United States experienced the death of a parent or grandparent caregiver due to COVID-19 (Hills, 2021). This alarming number calls our attention to these well-known devastating consequences of children’s grief, possibly disrupting multiple life domains, including psychological, educational, physical, familial, and existential. Furthermore, studies have suggested that youth losing a parent before 18 years of age are at increased risk for suicide for at least 25 years (Mosher, 2018).
Children losing their parents or caregivers is not a new phenomenon in the United States; pre-pandemic data from the US census bureau estimated that 1 in 20 children under 15 had experienced the death of 1 or both biological parents (Mosher, 2018). However, the pandemic has exacerbated this issue, with the aggravating problem that not enough attention or services are being provided to children who suffered this loss. As a society, we are not good at navigating grief and often feel uncomfortable when dealing with death. Perhaps, for this reason, we prefer to wait for time to pass or act like nothing is happening, missing the opportunity to provide the necessary help to those children that need support and guidance. Most children and adolescents adapt to the loss and recover life enjoyment, typically within 6 to 12 months. However, some children and adolescents develop a complicated grief process, which encompasses thoughts, emotions, and behaviors that persist longer than expected by cultural norms, disrupt the natural progression of the adaptation process, and become maladaptive (Mosher, 2018).
It appears logical that if a child loses a parent, an immediate response will arise from the child’s environment to provide care, support, and guidance to ameliorate the painful symptoms of losing a loved one. However, we have observed an increased number of patients consulting in the inpatient and outpatient psychiatric services with severe symptoms resulting from complicated grief processes. So why are we failing to provide help to children going through these painful processes?
Recognizing Grief
The age and the developmental stage of the child are important considerations when addressing grief in youth. For example, Is the child a preschooler (5 or less), school-age (6-12), or adolescent (13 and older). This can guide us to view the child’s understanding of the loss, consideration of brain development, brain plasticity, cognitive abilities, and other aspects.
Preschool young children do not always understand the permanence and finality of death and might think that the loss is temporary and that maybe the missing parent will come back. The school-age child usually sees things more concretely, while the adolescent has a more adult-like understanding of abstract concepts.
These developmental considerations can assist us in understanding where the child is in their perception of the loss and assisting them in the process of recovery.
Coping with Grief
Most of the children that suffered a loss of a parent and who have adequate support from a surviving parent and extended family will be affected by the loss but will recover fully in most cases. However, the reaction to the loss of a vital life figure can be experienced differently by everyone. Many children may go through the typical stages of grief, including denial, anger, bargaining, depression, and acceptance. In contrast, other children may have difficulty incorporating their loss and may develop clinical disorders like depression, anxiety, or posttraumatic stress that require professional help.
Here the concept of resilience is vital in the process of recovery. Resilience is “the ability to bounce back” to prior functioning. This is usually the case in most children that have received adequate parental support and care prior to their loss; these are likely to fare better. Resilience can be acquired by providing supportive care, guidance, and availability during this challenging period. Children going through grief and bereavement can benefit from support groups, peer support, and mentorships, especially when paired with the right person who can assist them with healing and recovery.
Illiteracy with respect to grief
Pamela Mosher argues that we are often ill-equipped to navigate grief and points out a lack of bereavement training among teachers, counselors, social workers, and other health care professionals. Although there is no apparent reason why, it is evident that there is not enough training in how to help someone navigate the topic of death, and even despite training, just the thought of talking about death might appear overwhelming. Perhaps the general concept that grief is a normal process and will find its way interferes with the notion of getting trained in something that will resolve on its own. Unfortunately, not being knowledgeable about bereavement and grief poses a significant barrier to identifying, supporting, and treating those struggling with complicated grief.
Talking about death
Talking about death is never easy, especially when it comes suddenly and unexpectedly. The irreversibility and uncertainty that surrounds death make us feel anxious and uncomfortable. All too often, we do not know what to say and much less how to act when consoling a grieving person. Sometimes, we are undergoing a grieving process and might be fearful that discussing death will be unsettling and elicit emotions that will be hard to manage. Often we tend to think about our memories of how stressful dealing with death can be. Younger children with more limited language when undergoing a grieving process are more likely to express their emotions through play or behavior. They can feel anxious, guilty, lonely, misunderstood, and confused, which adds a layer of complexity that makes talking about death even harder.
The parent disappearance phenomenon
As mental health experts, we become accustomed to discussing very intimate and often complex subjects with the people we care for. It should not be surprising that talking to a child or an adolescent about grief, the passing of a parent or significant person in their lives is a very complicated and challenging task. This challenge is not a new occurrence, but the training and preparation we receive to deal with these circumstances are never enough. A combination of support from other mental health specialists, using a multi-disciplinary approach, and our own experience, become the foundations of our ability to help children in grief.
This pandemic has added a layer of complexity we had never experienced before to an already complicated mental health crisis. Most children that have lost a parent due to COVID experienced a sort of “parent disappearance.” This was explained to me by an adolescent while admitted to the hospital after attempting suicide. The adolescent described the situation as follows: “My mother just started having a fever and went to the hospital to get tested. I never saw her again”. This “parent disappearance” creates unique and traumatizing grief. COVID had a way of disrupting our health system to the point that we could not even allow families to participate in the disease process and say their goodbyes. How do we explain to a child that this is their reality? How do we tell them this was the best we could do?
This lack of “closure” creates a grief reaction that is difficult to predict and, as a result, difficult to treat from the perspective of a mental health provider. Our experience here at home is that now that the pandemic seems at a different stage and vaccines have allowed the health systems to get back to some baseline, there is a new crisis in Children and Adolescent health. Children, in general, have to deal with a complicated grief reaction, not having a parent or supportive adult to make sense of it, and a changing school system. This unsteady ground worsens our children’s mental health, which is evident by increased admissions to our local inpatient units and more suicidal attempts. How this “parent disappearance” syndrome affects children moving forward remains evaluated. However, it is clear that mental health providers are not fully equipped to deal with these challenges independently and will need to reach out to the interdisciplinary team to augment our efforts to provide the proper recovery environment for these children.
Grief and the contextual environment
Children live within their context; as the Spanish philosopher Jose Ortega Y Gasset noted, “I am I, and my circumstances,” This applies to children more specifically because their world is not only their parents and siblings, but their extended family, friends, school teachers, coaches, and social media. In our community of the Rio Grande Valley (RGV), where it is common to have extended family living under one roof, this might have added repercussions after losing a parent since their blood relatives might also move out. It is essential to understand the impact of a grandparent or uncle’s death on a child, especially when they are closely bonded and maybe have been the primary caregivers while the parents work.
After the death of the primary breadwinner in the home, there is a likely to be a significant financial impact on family resources, at times losing their house, having less money for other essentials, including the ability to buy toys or electronics which are essential to children. In our community, where a large segment lives at or near the poverty line, the loss of one of the primary wage earners can make an already tricky circumstance worse when the surviving parents must get a second job to make ends meet, diminishing the availability of this parent to provide essential support for the grieving children, needed during this crucial period.
What can we do?
First, we must become aware that Children’s grief exists and explore its presentation, including taking into consideration the child’s appropriate developmental stage. If they lose a caregiver or an important life figure, it should trigger an immediate response that provides support and an assessment of maladaptive bereavement processes. Second, we need to know that every child is different and copes with loss differently. It is essential to understand where the child is at the moment of their loss and what interventions are needed to support a healthy bereavement process. Third, we need better efforts to improve bereavement training among frontline professionals and educate the community. It is essential to recognize potential red flags that should prompt interventions to help those dealing with the grieving process. The goal should be to explore the bereavement process early enough to avoid its potential progression toward a complicated clinical presentation. Forth, creating awareness of the parent disappearance phenomenon, its impact on the family system, and assisting with “closure .”This phenomenon creates a grief reaction that is difficult to predict and address. Lastly, we need to identify resources in the community that can provide professional assistance to help with the bereavement process. For instance, in the Rio Grande Valley (RGV), several agencies provide mental health services, including Tropical Texas Behavioral Health (956-289-7000) and the Children’s Bereavement Center (956-368-4065). If immediate need also contact South Texas Behavioral Health at (888) 977-1400.
References
1. Provisional COVID-19 Deaths: Focus on Ages 0-18 years/ (2021). CDC. COVID-19 Death Data and Resources – National Vital Statistics System (cdc.gov)
2. Hills, S.D et al. (2021). COVID-19–Associated Orphanhood and Caregiver Death in the United States. Pediatrics Journal. Volume 148, issue 6
3. Mosher, P.J. (2018) Everywhere and Nowhere Grief in Child and Adolescent Psychiatry and Pediatric Clinical population. Child and Adolescent Psychiatric Clin N am 27
Shrink Box is a social and mental health initiative carried by Dr. German Corso, Dr. Daniel Gutierrez and Dr. Ricardo Irizarry. We are a group of mental health experts proudly serving our community at South Texas Behavioral Health and Tropical Texas Behavioral Health