key: cord-0856206-7ae6ya83
authors: Gray, Tamryn F.; Zanville, Noah; Cohen, Bevin; Cooley, Mary E.; Starkweather, Angela; Linder, Lauri A.
title: Finding New Ground – Fostering Posttraumatic Growth in Children and Adolescents Following Parental Death from COVID-19
date: 2021-10-20
journal: J Adolesc Health
DOI: 10.1016/j.jadohealth.2021.10.016
sha: 8c8bcdcefa944ffc3ef59e5de25cf1fc39b3616a
doc_id: 856206
cord_uid: 7ae6ya83

nan

With 4.7 million deaths worldwide and counting, the SARS-CoV-2 pandemic has secured its place as one of the deadliest public health crises in a century. To date, public health efforts have focused largely on reducing morbidity and mortality [1] , but a new pandemic-a pandemic of grief-has emerged.

The majority of COVID-19 deaths have occurred in adults, and what limited resources we have allocated towards grief have mostly been directed to them [1] . This strategy overlooks the seismic impact that losing a close caregiver-in some cases one or both parents-to COVID-19 can have on children [1, 2] .

In April 2021, researchers estimated that nearly 40,000 children under the age of 18 in the U.S. had lost a parent to COVID-19-a statistic made even more sobering by the fact that data shows that this tragedy disproportionately impacts Black children [2] . International data show similar trends towards 'pandemic orphanhood', with as many as 1.5 million children worldwide having lost a parent, grandparent, or adult caregiver due to COVID-19 [1] .

The sheer size of these statistics as well as certainty that the number of bereaved children and adolescents will continue to grow as the pandemic rages on underscore the urgent need for clinicians, teachers, policy makers, and researchers to develop strategies to help pandemic orphans not only cope with the loss but grow and find meaning from trauma.

The importance of meeting this goal cannot be overstated. With a few exceptions, losing a parent is one of the most life-altering experiences for children and adolescents [3] , especially when the death is unexpected. Studies show that parental death can have profound short-and long-term consequences for children and adolescents [4] , including traumatic grief, depression, poor educational outcomes, and unintentional death or suicide compared with their non-bereaved peers [5] . Even more troubling, without adequate counseling and support, these sequelae can persist into adulthood [6] , putting children and adolescents at increased risk for future mental health crises, maladaptive coping, abuse, chronic diseases, and poverty [1] .

New research on trauma points to possibilities for helping pandemic orphans, recognizing that the impact of trauma is not universally negative. In particular, research into a phenomenon known as post-traumatic growth, originally conceived by Tedeschi & Calhoun (1996) [7] , suggests that while profoundly sad, the psychological struggle during and following a stressful life event such as losing a parent can act as a catalyst for positive changes such as increased appreciation for life, fuller understanding of one's own personal strength, enhanced spiritual development, and a deepening of intimate relationships [7] .

First, as a society and a healthcare community, we must acknowledge that a growing number of children and adolescents will share the experience of pandemic orphanhood-which is likely to become a central part of their identities. Healthcare providers, teachers, and other pediatric service personnel will need training on how to assess for and respond to grief related to the pandemic, and research will be needed to identify the most effective strategies to help children and adolescents work through trauma, loss, and grief from the pandemic.

Well-intentioned adults want to protect children and adolescents by avoiding conversations about death and grief [8] , however research shows that in most cases, children and adolescents want information about death as they maneuver through the grieving process [9] . As health care professionals, we can lead the way by normalizing discussions around death and teaching children and adolescents to express their grief. Simple, honest conversations about the death and dying process provide assurance that the COVID-related death is not their fault, and allow them permission to express feelings of sadness, anxiety, and grief.

Without question, the death of a parent or caregiver to COVID-19 will alter the lives of children and adolescents in profound ways. As healthcare professionals, it is essential we help them navigate the pain and grief associated with loss and adapt to many changes that will follow. How children and adolescents learn to manage trauma now will set a precedence for how they will approach adversity in the future. Wherever possible, clinicians should use trauma-informed care strategies based on current evidence to help children grieving the death of a parent or close caregiver from COVID-19 [10] . Health systems should invest in tools and resources to help pandemic orphans. Long-term support is needed for both children and adolescents as well as their surviving parent and family members to help them develop skills to adapt to new challenges they will experience.

Children are susceptible to identity changes and can struggle with how to make sense of loss. Fostering meaning, normalcy, and belonging during the grief process is crucial. Key strategies include resuming normal activities (e.g., after-school activities, sports, friendships), providing a constant presence by the surviving family members, and addressing separation anxiety by offering reassurance that they will be cared for. A sense of normalcy and belonging not only shapes children's ongoing beliefs and expectations following a loss, but also contributes to rebuilding their sense of meaning and purpose in childhood and into adulthood.

Children possess a remarkable ability to translate parental death into personal growth and skills for adapting to trauma, but most will need the help of informed and caring adults to do so. Knowing that they are not alone in their hardships and given strategies to adapt to the unexpected loss, children and adolescents can grow and become resilient despite enduring one of life's most tragic experiences. As the COVID-19 pandemic continues to ravage communities, now is the time to support children and adolescents who are navigating the loss of parents or close caregivers as they seek to find new ground.

J o u r n a l P r e -p r o o f

Global minimum estimates of children affected by COVID-19-associated orphanhood and deaths of caregivers: A modelling study

Estimates and projections of COVID-19 and parental death in the US

Evidence-based practices for parentally bereaved children and their families

Parental death during childhood and depression in young adults-a national cohort study

Losing a parent to cancer as a teenager: Family cohesion in childhood, teenage, and young adulthood as perceived by bereaved and non-bereaved youths

When a parent dies: A systematic review of the effects of support programs for parentally bereaved children and their caregivers

The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma

Protecting the psychological health of children through effective communication about COVID-19

Do you remember being told what happened to grandma? The role of early socialization on later coping with death

Trauma-informed care and posttraumatic growth among bereaved youth: A pilot study