Hidden

Pain
Children Who Lost a Parent or Caregiver
to COVID-19 and What the Nation
Can Do to Help Them

SOCIAL POLICY ANALYTICS COVID COLLABORATIVE

Dan Treglia, PhD, University of Pennsylvania John M. Bridgeland
J. J. Cutuli, PhD, Nemours Children’s Health Gary Edson
Kamyar Arasteh, PhD, Nemours Children’s Health Steven Phillips
Anjali Balakrishna

DECEMBER 2021
Hidden Pain
Children Who Lost a Parent or Caregiverto COVID-19
and What the NationCan Do to Help Them

SOCIAL POLICY ANALYTICS

Dan Treglia, PhD, University of Pennsylvania

J. J. Cutuli, PhD, Nemours Children’s Health
Kamyar Arasteh, PhD, Nemours Children’s Health

COVID COLLABORATIVE

John M. Bridgeland
Gary Edson
Steven Phillips
Anjali Balakrishna
Table of Contents

Open Letter to the American People 4

Executive Summary 6

Introduction 12

Estimates of Caregiver Loss to COVID-19 14

Parental Loss in the Contexts of Development and the COVID-19 Pandemic 17

Reviewing the Evidence for Preventive and Clinical Interventions 26

Recommendations: Addressing the Clinical and Economic Needs of COVID-Bereaved Children 34

Identifying Children Who Lost a Parent to COVID-19 34

Screening for Complicated or Traumatic Grief 38

Enhancing Community-Based Support for COVID-19 Bereaved Children 38

Clinical Care for COVID-Bereaved Children 45

Addressing the Economic Needs of Children who Lost a Parent or Caregiver to COVID-19 50

Need for Additional Research 56

References 60

Appendix I: Tables and Figures 72

Appendix II: Methods 78

Suggested citation:

Treglia, D., Cutuli, J. J., Arasteh, K., J. Bridgeland, J.M., Edson, G., Phillips, S., Balakrishna, A. (2021).
Hidden Pain: Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation Can Do to
Help Them. COVID Collaborative.

HIDDEN PAIN 3
Open Letter to
the American People
America’s COVID-19 crisis has not ended, but we have begun to count the staggering size of our loss. An
outbreak beyond precedent has led to deaths on the scale of a global war. These tragedies were experienced
in the isolation of pandemic precautions and hospital wards. Hundreds of thousands have died at the same
time, but largely apart. An event causing mass casualties has left lonely grief.

Some of the cruelest pain has come to a group with the least capacity to understand and cope with it. More
than 167,000 children—roughly one in 450 of all children in the United States—have lost at least one of
their caretakers to COVID. More than 70,000 children have been deprived of a parent. Nearly the same
number have lost a grandparent who lived in the home. At the extreme of this need, more than 13,000
children have lost their only in-home caregiver.

For these children, COVID has done more than hurt their lives; it has ended their world. Especially early
in development, a parent or family caregiver fills a child’s entire sky—providing most of his or her
stability, confidence and care. The sudden, seemingly unexplainable departure of a caregiver leaves a void
of affection and direction that each child will struggle to fill. And the outcome of that struggle will
determine much about their future. The traumatic loss of a caregiver has been associated with depression,
addiction, lower academic achievement, and higher dropout rates. It represents lost potential for
individuals and our society.

COVID can strike anyone, but it concentrates its cruelty on certain groups. Because of racial inequities in
American healthcare, and because people of color risked greater exposure as frontline workers, a higher
proportion of minority caregivers have lost their lives. This means COVID’s hidden loss falls heaviest on
minority children. Non-White children lost caregiving adults up to nearly four times the rate of their White
peers. Any solution we seek must accommodate this grim reality.

HIDDEN PAIN 4
The grief and confusion of these young people is concealed by being scattered across the country. Unless
we know one of them personally, empathy requires analogy. COVID’s hidden loss is the moral equivalent
of children calling to us from the wreckage of a collapsed building. We must do everything necessary to
rescue and comfort them.

There is no precedent for this challenge, but we have a good idea how this kind of grief can be confronted.
The vast majority of these children do not require treatment in a clinical setting. But all of them require
loving people in their lives who understand the depth of their loss and are dedicated to their well-being.
This may come from extended family, peer support groups, grief camps, or mentoring programs. A
smaller group—perhaps 5 to 10 percent of children—will experience traumatic, prolonged grief that
requires clinical intervention. In every case, we need to act quickly to provide these children with
the tools of resilience.

What follows is a comprehensive blueprint for outreach and care for children who have lost caregivers
during the pandemic. It is a plan that requires action from all sectors across the nation in a manner that
transcends politics and other divisions.

COVID-19 has challenged us as a people as seldom before. Some things we have liked about ourselves.
Some things we have not. Now we have a chance to show that America is a single moral community,
dedicated to the welfare of children carrying a heavy burden of pain and loss. This is an effort we can
undertake as a united country. We experienced the unity of grief; now we must embrace the higher unity
of hope and possibility. There can be no partisan division in caring for these children in need. We know
they have hard paths ahead. But we want each of their difficult stories to be stories of recovery and healing.
We want each child to know they are not alone. And we hope others will join us as we stand beside these
hidden victims during the toughest days of their lives and beyond.

HIDDEN PAIN 5
Executive Summary
The COVID-19 pandemic has been the single deadliest acute public health crisis in American history,
exceeding the death tolls of both the 1918 flu and HIV/AIDS since the 1980s. These deaths are a salient
threat to the functioning of family and social networks. Among the more than 760,000 deaths from
COVID-19 in the United States in the last 22 months are many parents, custodial grandparents, or other
caregivers on whom more than 160,000 children had relied for financial, emotional, and developmental
support. Many of these children—aged under 18—already faced significant social and economic adversity,
and these devastating losses can impact their development and success for the rest of their lives.

Non-White children suffered losses up to

In short, the children most likely to
nearly four times that of White children. While
lose a parent or other caregiver to COVID-
significant losses occurred in all states, half the
19 are most likely to have faced significant
losses were found in five states. The vast previous adversities that hinder their
majority of these children will experience ability to successfully adapt to new
normative grief that can be managed through experiences of adversity or trauma.
non-clinical, community-based interventions, Children who have lost a co-residing
such as grief camps, peer support, mentoring parent, grandparent, or other caregiver are

programs, and the Family Bereavement presently facing personal tragedies

Program. Other children may experience occurring in a period of national and

traumatic, prolonged grief requiring clinical international uncertainty, stress, and

turmoil, and policymakers and other
treatment. In all cases, supports and care will
leaders face a responsibility to minimize
be needed.
the clinical, social, and economic impacts
these children face.
Addressing the needs of these children who
experienced such loss must be a high priority,
and this report provides guidance to leaders in the public and private sectors. First, we estimate the
number of children and teenagers under 18 years of age who have lost a parent or other co-residing
caregiver to COVID-19, and then we discuss the impacts of parental and caregiving loss on children and

HIDDEN PAIN 6
adolescents. Following that, we review evidence of interventions commonly used to address grief and other
traumas that may be applicable in this context. Finally, we offer a set of recommendations that integrate
best practices into the current policy and political realities that we face as this crisis persists; and we call
on the nation to act.

Key Findings

ESTIMATING COVID-19-RELATED LOSS ON CHILDREN

The magnitude of the total loss of life from COVID-19 outpaces deaths in every U.S. war, and the impact
of that loss on children in less than two years is profound. The numbers present a challenge to the nation.
● Total Loss: 167,082 children under 18—more than one out of every 450—lost a parent or other
in-home caregiver to COVID-19.
● Loss of A Parent, A Grandparent Caregiver, or Their Only Caregiver: More than 72,000
children lost a parent to COVID-19 and over 67,000 lost a grandparent caregiver in the home,
while more than 13,000 children lost their only in-home caregiver.
● Loss by Age: Seventy percent of caregiver loss (117,948) affected those aged 13 and younger.
Fifty percent of caregiver loss (83,798) was among elementary and middle-school age children
(5-13 years old) and 20 percent (34,150) was among those from birth through 4 years old. More
than 29 percent (49,134) of caregiver loss affected youth who were high school age (14-17 years
old).
● Loss by Race & Ethnicity: Non-White children lost caregiving adults at higher rates than their
White peers. American Indian and Alaska Native and Native Hawaiian and Pacific Islander
children lost caregivers at rates of nearly 4 times the rate of White children; Black and Hispanic
children at nearly 2.5 times the rate of White children; and Asian children at 1.6 times that of
White children.
● Loss is Concentrated, but Also Found in Every State in the Country: Five states—California,
Florida, Georgia, New York, and Texas—accounted for half (50 percent) of total caregiver loss
from COVID-19. Arizona, Mississippi, New Mexico, and Texas had the highest rates of caregiver
loss, while Maine, New Hampshire, Vermont, and Wisconsin had the lowest rates.
● Loss by Geography, Race, and Ethnicity: The District of Columbia had the widest disparities in
caregiver loss, where Black and Hispanic children’s rates of caregiver loss were 11 and 18 times
the rates of loss for White children, respectively. The rates of caregiver loss for American Indian
and Alaska Native children were more than 10 times those of White children in Mississippi, New

HIDDEN PAIN 7
Mexico, North Dakota, South Dakota, and Utah.

IMPACTS OF LOSS OF A PARENT OR CAREGIVER

Beyond the data are the impacts of such loss on children.

● Grief is a normal process following loss, though how it manifests varies as a function of the age
of the child, the characteristics of the loss experience, and the quality of the supports, especially
from the surviving caregiver.
● The vast majority (90 to 95 percent) of children will experience a normative course of grief
that can be managed through existing familial and social supports and non-clinical community-
based interventions like grief camps, peer support groups, or a mentoring program. The
remaining 5 to 10 percent may experience traumatic, complicated, or prolonged grief, for which
clinical therapy may be required.
● The consequences of losing a parent or other caregiver can persist through a child’s lifetime.
They can include depression, post-traumatic stress disorder (PTSD), anxiety, lower rates of
academic attainment and higher dropout rates, higher rates of alcohol and other substance use,
suicide, and reduced employment.

ASSESSING THE EVIDENCE OF PREVALENT INTERVENTIONS FOR GRIEF AND

TRAUMA

Decades of study around the interventions for grief and other traumas provide guidance on the way
forward.
● Group peer-support and grief camps are commonly used non-clinical interventions to normalize
feelings of loss and provide emotional support from peers and counselors. They reduce or prevent
symptoms of anxiety and depression and decrease the likelihood of complicated grief.
● Social and emotional learning in schools and early childhood programs can help students and
families cope with feelings of loss in contexts of positive relationships, but surveys show more
work needs to be done to prepare educators and schools to help bereaved children.
● Evidence-based mentoring programs can support bereaved family members. Though evidence
focused on bereaved children is lacking, trauma informed mentoring programs for youth facing a
high degree of adverse childhood experiences have a robust evidence base demonstrating positive
impacts on mental health, educational attainment, civic engagement, and healthy relationships
with peers and adults.

HIDDEN PAIN 8
● The Family Bereavement Program (FBP) provides group counseling to bereaved children and a
surviving caregiver with a focus on improving the caregiver’s mental health so they can better
attend to the needs of those in their charge. FBP is well-developed with a robust evidence base.
● Cognitive Behavioral Therapy (CBT) is an evidence-based clinical intervention for children
experiencing more severe forms of grief,
including childhood traumatic grief (CTG) or
Approximately one out of
symptoms of prolonged grief disorder (PGD),
every 450 children and
with noted improvements in anxiety,
depression, PTSD, and traumatic grief. adolescents under age 18
Variants of trauma and grief-focused CBT have in the United States lost a
been developed over the last 15 years, and they caregiver to COVID-19.
tend to be more effective than CBT that is not
specific to grief and other treatment modalities.

Recommendations

Based on best evidence and practice, there are important steps that policymakers, educators, and leaders
in the nonprofit and private sectors can take to help children who have lost a parent or other caregiver to
COVID-19. We recommend:
● Undertaking a coordinated strategy to comprehensively identify children who have lost a
parent or caretaking guardian to COVID-19 through schools, community-based organizations,
primary care settings, and the use of municipal administrative records. Some of these efforts can
be accomplished through executive action, and others through federal, state, and local
governments and partnerships with private service providers. Federal funding may be required to
facilitate action by state and local governments and non-governmental stakeholders.
● Creating a COVID-19 Bereaved Children’s Fund, drawing lessons from those established for the
families of September 11, 2001 and HIV/AIDS orphans. This fund can provide short-term financial
assistance and support the mental health and other needs of COVID-19 bereaved children. Priority
attention should be given to the 13,000 children who lost their only in-home caregiver.
● Creating a public education campaign that encourages families, youth, and children to seek help
and connects them to resources in their communities and schools.

HIDDEN PAIN 9
SCHOOL AND COMMUNITY-BASED INTERVENTIONS

● The federal government should provide funding and technical assistance through the U.S.
Department of Education and the U.S. Department of Health and Human Services to expand the
grief-competence of schools, community-based organizations, faith-based institutions, and other
community leaders. We recommend federal policymakers provide funding and technical
assistance to expand the capacity of community-based organizations to manage “light-touch”
bereavement interventions like peer support and mentoring programs with the support of
national-level organizations and through additional public and private funding.
● Federal policymakers should expand access to high-quality early childhood programming
for COVID-bereaved children, with categorical eligibility for publicly funded programming like
Head Start and Early Head Start and the waiving of parent-activity requirements and co-
payments.
● School districts, states, and the federal government should support the expansion of the
integration of social and emotional development and evidence-based mentoring within
academic learning, including the skills of building and sustaining supportive relationships, self-
awareness, self-management, resilience, collaboration, and problem-solving. States and school
districts should make COVID-bereaved children a priority for social and emotional learning
through the Collaborating States Initiative and Collaborating District Initiative led by the
Collaborative for Academic, Social, and Emotional Learning (CASEL). Surveys show the vast
majority of students, parents, teachers, and administrators support such efforts for all students
and that such development is critical to enable bereaved children to cope with loss.
● National grief-focused nonprofits in coordination with community-based organizations
should develop a registry of available grief services to inform referral efforts and make those
widely available through communities, states, and national platforms.
● Strengthen social service systems providing critical resources to COVID-bereaved children and
their families, which will have impacts beyond the immediate crisis.

CLINICAL INTERVENTIONS

● Expanding access to mental healthcare in schools through additional training plus

partnerships with external mental healthcare providers.

HIDDEN PAIN 10
● Expanding access to outpatient mental healthcare through increased co-location of services,
integrated behavioral healthcare, and telehealth access. Pending rule changes from CMS, with
some amendment, can drastically improve access to teletherapy.
● Reducing cost-sharing responsibilities or facilitating pro bono provision of outpatient mental
healthcare associated with COVID-19-based parental loss.

ECONOMIC INTERVENTIONS

● Congress should make permanent the Child Tax Credit as revised by the American Rescue
Plan, which will benefit families experiencing loss.
● The White House and Congress should provide categorical eligibility for COVID-19 bereaved
children for a range of means-tested economic supports, including TANF, SNAP, Medicaid,
and the recently amended Child Tax Credit.
● State, tribal, and local governments should provide pre-emptive outreach, case
management, and eligibility screenings for families with a COVID-19 decedent to facilitate
enrollment in protective supports and services.
● The federal government should improve outreach and accessibility for FEMA’s Funeral
Reimbursement Assistance program, and Social Security Death and Survivor’s Benefits.

ADDITIONAL RESEARCH

Through funding, convening, and other supports, the federal government and foundations should
facilitate research that:
● Improves the enumeration and identification of COVID-bereaved children, by race, ethnicity,
income, and age, with a focus on socioeconomically vulnerable populations.
● Improves our understanding of the long-term impacts of parental and caregiver loss.
● Supplements the field’s sparse evaluation literature by rigorously testing a range of prevention
and therapy-focused grief services through randomized controlled trials when possible.
● Further documents the clinical impacts of COVID-19-induced parental bereavement on
children, with a comparison to child bereavement for other causes and in other circumstances.
● Further documents state, tribal, local, and nonprofit best practices in addressing the needs of
COVID-bereaved children.

HIDDEN PAIN 11
Introduction
The COVID-19 pandemic has been the single deadliest acute public health crisis in American history. As
of November 15, 2021, more than 760,000 Americans have died from COVID-19 infections, exceeding
U.S. mortality from both the 1918 flu epidemic and HIV/AIDS over the last 40 years.1,2 These deaths are
a salient threat to the functioning of family and social networks. Though largely ignored in the pandemic
policy-response to date, the death of a caregiver represents a potentially catastrophic way in which
COVID-19 can influence development not only during childhood but across one’s life. Among these
760,000 deaths are parents, custodial grandparents, or other caregivers on whom children and
adolescents relied for financial, emotional, and developmental support.3–7

A high priority for policymakers is estimating the number of children made acutely vulnerable because
their caregiver died from COVID-19. The impacts of losing one or both parents—defined by the United
Nations as “orphanhood” for anyone under the age of 18—are well documented.8–13 These can include poor
mental health, poor academic outcomes, increased rates of high school dropout, economic turmoil, and
general instability in the short-term, with long-term consequences like higher rates of alcohol and other
substance use disorders, worse peer relationships, and reduced employment into adulthood.10,11,14–17 These
adversities may be especially salient for the 26 percent of children and adolescents under 18 living with
only a single parent. These households are disproportionately low-income and Black or Hispanic, meaning
that economic hardships and structural racism predating the pandemic and the death of a caregiver make
resilience in the wake of trauma even more challenging.18

Changes in the American household over the last 70 years require us to look beyond biological parents
when considering the impacts of caregiver death on children. Nearly one-quarter of children live in a
multigenerational household (one with a child, parent, and grandparent) by age five, a household
structure more common among non-White children and among adults with low-educational attainment.19
The consequences of a grandparent’s death can resemble those of parental loss, especially when the
grandparent provides nurturing and material support. More than one-third of co-residing grandparents
are responsible for meeting most of their grandchildren’s basic needs, and they are about 30 percent more

HIDDEN PAIN 12
likely to live below the federal poverty level.20 Nontraditional households extend beyond biological
relatives, and a growing number of American households are “doubled up” in housing with non-family
members, who may assume some caregiving role. Data from disparate Census Bureau surveys tell roughly
the same story: doubled-up households are nearly twice as likely to be poor, to have less education, and to
be led by a Black or Hispanic householder.21

Moreover, low-income and Black and Hispanic populations were also most at-risk of COVID-19-related
mortality.22,23 Many occupied low-wage essential positions that kept them in proximity to customers and
coworkers throughout the pandemic.24 These communities also have higher rates of comorbidities
associated with COVID-19 mortality, including overweight, obesity, diabetes, hypertension, and other
morbidities.25,26

In short, the children most likely to lose a parent or other caregiver to COVID-19 are most likely to have
faced significant previous adversities that hinder their ability to successfully adapt to new experiences of
adversity or trauma. Children who have lost a co-residing parent, grandparent, or other caregiver are
presently facing personal tragedies occurring in a period of national and international uncertainty, stress,
and turmoil, and policymakers and other leaders face a responsibility to minimize the clinical, social, and
economic impacts these children face.

This report seeks to guide government, nonprofit, business, and philanthropic leaders to assist the most
vulnerable COVID-19 survivors. First, we produce estimates of COVID-19-related loss to children for each
state by age of the child and by race and ethnicity. We also highlight the additional adversities already
faced by disadvantaged children, allowing policymakers and other leaders to target interventions based
on social risk factors and children’s developmental stage. Second, we discuss the clinical and economic
consequences of COVID-19 bereavement on children and families and provide recommendations for
addressing them and review the evidence for several relevant interventions. Finally, we provide
recommendations for comprehensive action, for school, community-based, clinical and economic
interventions, and for additional research to continue to build the evidence and innovate over time.

HIDDEN PAIN 13
Estimates of Caregiver
Loss to COVID-19
We estimate childhood and youth caregiver loss from a COVID-19 infection by combining COVID-19 death
counts by state, race/ethnicity, and age group with population data from the American Community
Survey’s 2019 Public Use Microdata Sample (PUMS), which provides representative household and
person-level samples of the United States. This unique combination of data allows us to create a child-
centric assessment of caregiver loss by race, ethnicity, age, and state. Additional methodological details
can be found in Appendix II.

Approximately one out of every 450 children and

Children from racial and adolescents under age 18 in the United States, 167,082
ethnic minority groups in total, lost a caregiver to COVID-19 through mid-

were, by far, more likely November 2021. More than 72,000 of them suffered the
death of a parent, and 13,047 lost their only at-home
to lose a caregiver than
caregiver. More than 118,000 children losing caregivers
White, non-Hispanic
were under the age of 14. Children from racial and
children.
ethnic minority groups were, by far, more likely to lose
a caregiver than White, non-Hispanic children. More
than 100,000 non-White children lost a caregiver to COVID-19; the largest group were Hispanic children
(64,163). American Indian and Alaska Native children and Hawaiian and Pacific Islander children had the
highest rate of caregiver loss at nearly four times that of White children. High-population states had the
highest number of children who lost a caregiver. Five states—California, Florida, Georgia, New York, and
Texas—account for half (50 percent) of total caregiver loss, though Arizona and Mississippi had the
highest rates of caregiver loss. Tables and maps are displayed in Appendix I.

The numbers presented throughout this section are conservative estimates, representing the lower bound
of COVID-19 related caregiver bereavement. There is ample evidence of undercounting of deaths from

HIDDEN PAIN 14
COVID-19 infections—this was particularly true in the early days of the pandemic when infections and
deaths were heavily concentrated in urban, low-income areas with higher concentrations of racial and
ethnic minorities. This means that perhaps the most vulnerable children are the ones most likely to be
excluded from this estimate. Second, additional deaths are attributable to the increases in suicides and
decreases in healthcare access that were compounded effects of COVID-19. Third, we do not include deaths
of non-custodial parents or other caregivers who do not live with the child but whose loss may trigger the
same level of grief.

Familial Roles

Our results estimate that 72,699 children lost a parent and 94,383 lost at least one other caregiver in the
home. Other sorts of caregivers were frequently co-residing grandparents, and their higher rate of loss is
consistent with COVID-19 mortality rates that increase with age.

More than 13,000 children lost their sole caregiver to COVID-19. While all instances of caregiver loss are
a threat to a healthy child and family functioning, these children are likely at highest risk because they
lack an established second caregiver while they also were likely already more socially and economically
vulnerable due to other factors. This group of children warrant special attention in the policy and practice
responses to COVID-19 bereavement. Differences are apparent in caregiver loss by family roles based on
race and ethnicity, as described below.

Disparities by Race and Ethnicity

Non-White children had the highest rates of caregiver loss. Nationally, Non-Hispanic Black and Hispanic
children lost caregivers at rates more than double those (2.4 and 2.5 times, respectively) of White
children, and American Indian or Alaska Native (AI/AN) children and Native Hawaiian and Pacific
Islander children had the highest rate of caregiver loss, at nearly 4 times the rate of White children. These
differences are due to two factors: higher COVID-19 death rates and larger average household sizes, with
co-residing grandparents or others being more common among non-White populations. These disparities
are most concentrated in the youngest age cohort.

These disparities varied by state and territory. The District of Columbia had the highest rates of Black and
Hispanic caregiver loss relative to their White peers—11 and 18 times higher than the rates of loss for
White children, respectively. In general, states with larger American Indian populations had the highest

HIDDEN PAIN 15
risk of COVID-19 caregiver loss for AI/AN children. In Mississippi, New Mexico, North Dakota, South
Dakota, and Utah, the rate of caregiver loss for AI/AN children was more than 10 times that of White
children.

There were differences by race and ethnicity in family roles among lost caregivers. Black children had the
highest rates of sole caregiver loss, consistent with higher rates of COVID-19 mortality and single
motherhood among the Black population. AI/AN children had the highest rates of loss for all caregiver
roles except sole caregiver, and Black, Hispanic, and Hawaiian and Pacific Islander children were also
notably high relative to their White peers across caregiver categories. Asian children had rates similar to
those for White children for most categories of caregiver loss but lost grandparents at more than double
the rate.

Caregiver Loss by Child’s Age

Older children and teens were more likely to lose a caregiver to COVID-19 infection, though considerable
numbers of younger children also experienced loss. A meaningful number of children in each age group
lost a caregiver to COVID-19. About 20 percent (34,150) of children with a caregiver death were in
the youngest age group (birth through 4 years old), 50 percent (83,798) were elementary or middle-
school age (age 5 through 13 years old), and 29 percent (49,134) were high school age (age 14 through
17 years old). While all children and adolescents warrant support when they lose a caregiver, those
supports should be tailored to their developmental needs. This is especially true for young children
who rely on caregivers to meet a more diverse set of needs.

Correcting for the size of each age-band, 14- through 17-year-olds were most likely to experience the
loss of a caregiver, followed by 5- through 13-year-olds, and then the birth- through 4-year-olds group.
This is again consistent with COVID-19 mortality rates that increase with age: older children are more
likely to have older parents and grandparents as caregivers. However, we reiterate the above-described
differences in child age by race: Children of color or Hispanic ethnicity who lost a caregiver, as a group,
were more likely to be younger compared to White, non-Hispanic children. This underscores the
increased levels of risk borne by children and adolescents from historically marginalized backgrounds.

HIDDEN PAIN 16
Parental Loss in the
Contexts of Development
and the COVID-19 Pandemic. 1
I

The death of a parent or other primary caregiver is a severe, though not terribly uncommon, occurrence,
and there is a large body of related research through which we can understand the impacts of a COVID-19
death on children. Approximately 5 percent of children in the United States will lose a parent or guardian
by the age of 15.27 This tragedy poses a threat to short and long-term outcomes for that child, warranting
immediate and sustained mobilization of support to promote resilience. When a parent dies, the child is
challenged in the short-term to cope with grief and the circumstances of the loss through bereavement.II 2

The child must meet this challenge without the lost parent, who may have been a primary resource for
structuring his or her experiences and co-regulating their emotions.28,29 Children and families are
challenged to adapt in other ways to the parent’s absence in both the short and long terms. Family
functioning must be preserved so that children’s needs (e.g., cognitive, emotional, relational, academic)
continue to be met across development.30

Despite these challenges, many children who experience the death of a parent go on to show resilience.
Resilience refers to the absence of serious impairments in functioning across important areas of living. For
example, resilient children are able to have positive relationships with family and friends, show good
academic achievement and attainment, and have positive emotional/behavioral health and the like,

I
This section is based largely on research that predates the pandemic, given a lack of studies specifically
about childhood bereavement of parents who died of COVID-19. We extrapolate key findings to the current
situation.
II
In this section we use the terms ‘parent’ and ‘primary caregiver’ interchangeably for simplicity’s sake;
Primary caregivers do not need to be biological parents and processes of childhood bereavement and
adaptation are similar or the same.

HIDDEN PAIN 17
despite experiencing some event or circumstance that threatens good outcomes. Modern developmental
science explains that this resilience comes about because of a combination of contextual and individual
factors in children’s lives.31 While individual factors are important, resilience is frequently found in how
children’s contexts support them when it comes to responding to threats like parental death and
bereavement. Resilience is most common when children’s contexts recognize and respond to their
developmental needs. This section discusses the dual developmental processes associated with parental
death, namely managing grief and adaptation through bereavement in the short and long terms. We
present normative processes associated with resilience as well as findings on maladaptive processes that
portend problems.

Grief and Bereavement

Grief is a normal and usually intense emotional reaction that follows loss and the realization that the
individual will need to go on without the deceased. Children of all ages experience grief and enter a process
of bereavement when a parent dies, though the emotional experience and behavioral manifestations are
highly individual. They also vary as a function of the circumstances of the loss, the child’s age, and
developmental level.32,33 Many children feel depressed or anxious, and grief often resembles many aspects
of clinical depression. Some may feel guilt related to the circumstances of the loss. Still others may
experience anger, sometimes directed at the person who died or toward someone else. Crying is common
but not universal. Children may lose interest in activities that they used to enjoy. Behavior problems are
not rare. Younger children may be more likely to display anxiety symptoms, such as separation anxiety
and clinging to remaining caregivers, and may repeatedly ask questions about the deceased caregiver, not
understanding the permanency of death.

The death of a parent will continue to be a profound experience that affected children will revisit
throughout their lifetimes, though pronounced grief is relatively temporary. In most cases, grief peaks in
the first 12 to 18 months following loss, although grief tends to be phasic, meaning children and their
family members may experience periods of reemergent, intense grief from time to time for months and
years after the initial bereavement period.29,32 During the first 12 to 24 months following the loss,
successful childhood bereavement typically involves accepting the loss and experiencing the emotional
distress that accompanies it, coping with changes in the environment and the child’s self-perception
without the lost caregiver, making meaning from the loss, and forming close relationships with other
adults who can help meet the child’s developmental needs.34,35

HIDDEN PAIN 18
About 5 to 10 percent of bereaved children are thought to experience some clinical level of impairment.36
Some experience prolonged grief that persists, often signaling some difficulty or complication in the
bereavement processes. Prolonged grief predicts increased risk for later and lasting problems, such as
depression, anxiety, suicide, and symptoms of post-traumatic stress disorder, though duration of
symptoms might be less important in children.29 Grief can also co-occur with symptoms of post-traumatic
stress disorder, referred to as traumatic grief. In brief, symptoms of traumatic stress become associated
with the loss, often in a way that interferes with successful coping and bereavement.37 For example,
children might avoid thinking or talking about the lost parent because of intense memories about the
events surrounding the death. Children might also avoid contexts that remind them of the death, like
school, activities, or friends of the deceased parent. Children who experience traumatic grief are at
particularly high risk of persisting mental health problems and other impairments in functioning.

Adaptation to Parental Loss

Promoting resilience among parentally bereaved children requires attending to both the shorter-term
bereavement processes around the time of the loss as well as the longer-term processes of supporting the
child development without the parent.30 When a parent dies, most children are cared for by their other
parent or another close family member, with a small minority entering the child welfare system.38 In the
short term, the remaining parent or new caregiver may be experiencing their own grief, which may make
it difficult to optimally respond to children’s needs. Caregivers and other family members’ adaption
following the loss and how well families ultimately function have important implications for a child’s
wellbeing. Many grieving families draw on friends, extended family, religious communities, and other
sources of social support, all of which are important predictors of resilience to a wide range of
developmental risk factors.39

Long-Term Risk Indicators for Children Who Experience Parental Loss

Parental loss is associated with a higher risk of poor outcomes into adulthood. Though 90 to 95 percent of
children who experience the death of a parent will not ultimately manifest problems, longitudinal studies
of groups of children who experienced parental loss often find higher rates of mental health diagnoses like
depression and anxiety,40–42 higher rates of alcohol and substance abuse disorders,43 worse peer
relationships,44 higher rates of suicide, and lower rates of educational attainment, adult employment, and
other indicators of human capital.44–47 Studies have tested for characteristics of the experience that may

HIDDEN PAIN 19
help target efforts to promote resilience where they are needed most. These include different aspects of
the loss itself, as well as characteristics of the child and family.

YOUNG CHILDREN MAY BE AT HIGHER RISK.

Parental loss is especially pernicious during early childhood (infancy, toddlerhood, and preschool-
aged). Studies based on samples limited to middle childhood and adolescence tend to find no
differences in child outcomes based on the age of the child when the death occurred.44 Parental
loss, however, during early life (birth to age 5 years) appears to put children at higher risk for
later poor mental health and academic outcomes compared to older children who
experience parental loss and among younger middle-childhood aged children.40,48,49,50 This is
consistent with rapid developmental change and plasticity in early childhood. Major stressful
disruptions during this period can be especially detrimental to the child’s developing
physiology and cognitive and social/emotional skills if they are not protected by the presence of
one or more warm, consistent, and nurturing caregivers.51

CAUSE AND SUDDENNESS OF

THE PARENTAL DEATH.
Childhood resilience
Mental health and other problems are
following parental death during COVID-19
more likely when childhood parental
will be especially challenged because
loss is caused by an external factor, already-disadvantaged families are more
such as an accident, disaster, likely to be affected. COVID-19 is
homicide, or suicide. 40,52,53
These disproportionately impacting groups that
deaths are usually sudden and are less likely to be well-equipped to
unexpected. Sudden deaths are more successfully cope because of longstanding

likely to involve trauma and generally societal disinvestment.

permit less time for social supports and

other protective factors to mobilize in anticipation. In contrast, deaths due to illness are more
likely to involve a longer period of treatment and, sometimes, hospice during which children,
families, and broader social support systems can anticipate the loss and prepare to cope.

HIDDEN PAIN 20
MATERNAL VERSUS PATERNAL DEATH.

The literature paints an inconsistent picture about whether the death of a mother or father has a
distinguishable impact. Some studies find a stronger relation between some mental health
problems and maternal death,54 others show a stronger influence of paternal death,12 and still
others find no difference.40 Nevertheless, it is critical to note that maternal death may increase the
risk of child welfare involvement, especially in some cases for young children.40 Meanwhile,
paternal death may more greatly reduce socioeconomic resources in many families and may be
more likely to be a sudden death.55,56 It is likely that the specific contexts and sequelae of the
maternal or paternal deaths are influential. Future research may help disentangle the relative
impacts of maternal versus paternal loss.

CASCADING NEGATIVE EVENTS.

Developmental science and related fields recognize that adverse experiences tend to accumulate
in children’s lives, often in non-random ways.16 Children who experience parental loss may be
more likely to encounter subsequent hardships as a result which, in turn, further reduce the
likelihood of resilience.52,57 For example, the loss of a family breadwinner often results in reduced
family income. Children sometimes are forced to move residences or may enter the child welfare
system in families with fewer socioeconomic resources, previously single-parent households, or in
cases where both parents have died. These moves may disconnect some children from teachers,
coaches, and other mentors who are powerful resources for children who experience adversity.
These additional losses of close relationships, familiar contexts, and routines cascade from the
initial parental loss and represent additional challenges when it comes to supporting children’s
needs and promoting resilience.

SUBSEQUENT POSITIVE PARENTING.

Children who received more child-focused, warm, and consistent parenting from the remaining
caregiver are more likely to show resilience. Oftentimes the remaining parent is challenged by
their own processes of bereavement, grief, and trauma from the loss of a partner and/or co-parent.
Parents differ on how much they are able to support and respond to the needs of their children.
Positive or child-centered parenting is warm, involves consistent discipline, and is attuned and
responsive to the needs of the child. Positive parenting and maintaining positive family routines
are associated with fewer mental health symptoms for the child and other correlates of good

HIDDEN PAIN 21
functioning.58,59 These parenting behaviors promote child resilience and positive development
through responding to the child’s needs while also reducing the likelihood of the child
experiencing cascades of additional negative events.60 Meanwhile, diminished parental
functioning and mental health problems are associated with worse child outcomes, presumably in
part due to difficulties in providing warm, consistent, child-centered parenting.44 Evidence-based
therapies for parentally bereaved children include components to directly support caregivers in
their role as a parent, helping them assist the child in discussing the loss and their feelings as part
of their bereavement.33,61,62

PREEXISTING INEQUITY.

Families where a parent dies are more likely to have experienced other disadvantages compared
to other families. For example, affected families are more likely to be experiencing poverty,9 less
likely to have mothers with very high academic attainment, less likely to have fathers in
professional jobs, and more likely to have paternal unemployment than intact families.46 Children
who struggle following parental loss are also more likely to have a preexisting mental health
diagnosis and/or exposure to trauma, which at least partially accounts for any effect of the loss on
later problems.43 These findings are consistent with a developmental view of risk and resilience:
better-resourced children and families with histories of competence are generally more likely to
show resilience to new adversities, like parental death, as they tend to have more internal and
contextual resources at their disposal. Families who experienced preexisting inequity will be less
likely to successfully adapt to adversity, resulting in a higher likelihood of problems.63

AVAILABILITY OF OTHER SUPPORT SYSTEMS.

As alluded to in the above sections, children and families typically rely on extended social support
systems during bereavement, including extended family members, friends, neighbors, faith
communities, and teachers, to name a few. Memorialization rituals and traditions help encourage
this sort of support, such as funeral rites. Social support is a powerful resource for children who
experience the death of a parent and is associated with fewer long-term mental health problems
and better functioning.39 The death of the parent, however, and any resulting cascade of other
negative events, can also threaten important social network connections, resulting in an erosion
of social support for the child and remaining family members that increases the likelihood of long-
term child impairment.56

HIDDEN PAIN 22
Applying Existing Findings to Childhood Parental Death During the
COVID-19 Pandemic
The experiences of parental death during the pandemic are likely different from experiences of parental
death on which much of the childhood bereavement research is based. We consider these differences
below, underscoring that there are currently no rigorous findings on childhood bereavement during the
COVID-19 pandemic on which to confirm our expectations.

PREEXISTING SOCIOECONOMIC AND PSYCHOSOCIAL INEQUITY WILL

FURTHER IMPEDE FAMILY AND CHILD RESILIENCE.

COVID-19 infections and deaths in the U.S. have been disproportionately borne by persons from
racial or ethnic minority groups.64 Where socioeconomic data are available, COVID-19 disease
burden and mortality have been greater among lower-income groups.65 Furthermore, the
pandemic has had massive economic impacts and caused high rates of unemployment.66 As seen
in our estimates, these factors mean that children and families who experience parental death are
more likely to be from socioeconomically disadvantaged groups.

Childhood resilience following parental death during COVID-19 will be especially challenged
because already-disadvantaged families are more likely to be affected. COVID-19 is
disproportionately impacting groups that are less likely to be well-equipped to successfully cope
because of longstanding societal disinvestment. Put simply, resilience occurs when children amass
resources that can be used to successfully cope with adversity, such as parental death.
Socioeconomic resources can be important, especially to the degree that basic needs are being met
and surviving caregivers are able to avoid financial stress that might interfere with parenting, for
example. In addition, developmental histories marked by long-standing track records of
competence equip children and families with psychosocial skills, like better child self-regulation
and more flexible parenting strategies, that can be deployed to cope with new adversities, in this
case aiding in bereavement and avoiding cascades of additional negative events.63 Both sorts of
resources are less likely among groups that have experienced systemic disadvantage throughout
their development.

HIDDEN PAIN 23
CASCADES OF NEGATIVE EVENTS ARE ESPECIALLY LIKELY.

Before the pandemic, parental death was related to an increased likelihood that the child and
family would experience subsequent hardships as a result. Often these are characterized in the
literature as related to socioeconomic factors, such as a reduction in income, a necessary
residential move, or lost health insurance.67 Widespread economic fallout from the pandemic may
exacerbate these sorts of negative cascades, especially among families who are already in financial
crisis. The timing or extent of these cascades, however, may be initially unclear as a number of
emergency policies have been enacted and
supports put in place targeting basic needs. For
While the context of
example, increased efforts to distribute food,
the pandemic is unique, studies of
increases in food subsidies, eviction and children across a range of adversities,
foreclosure moratoria, and the provision of the even if severe, affirm that resilience
new child tax credit may be preventing or is surprisingly common and arises
delaying components of these cascades of from ordinary processes in the lives
negative events in the short term. If or when of most children, especially warm,

these protections are removed, it is likely that consistent relationships with

children experiencing grief and bereavement will remaining caregivers and other
important adults.
be affected, thereby causing harm and reducing
the likelihood of resilience.

EXTERNAL SOURCES OF SOCIAL SUPPORT WILL BE CHALLENGED.

Social distancing, restrictions on gatherings, and the interruption of routine supports (e.g., in-
person school) associated with the pandemic likely make it more difficult for children and families
to engage important social supports. Past research underscored that both the parental death and
subsequent cascades of negative events were linked to an erosion of social support that, in turn,
were linked to worse outcomes for the child.56 Pandemic-related restrictions likely exacerbate this
process, making it less likely that children and families will be able to easily access social support.

TRAUMATIC GRIEF MIGHT BE MORE COMMON THAN BEFORE THE

PANDEMIC, BUT THIS IS UNCLEAR.

Grief that includes symptoms of traumatic stress is more difficult to address and is more likely to
result in persistent mental health problems, especially in children.37,68 Traumatic grief is more
common in sudden deaths, usually the result of accidents, suicides, disasters, and other mass

HIDDEN PAIN 24
trauma events, which also prevent support systems from mobilizing in anticipation of the death,
as is more common in deaths caused by illness.29 While COVID-19 deaths are due to an illness,
COVID-19 patients who die are typically in the hospital for barely a week before they pass. This
suggests that responses to COVID deaths may be more typical of sudden deaths than those of
chronic illness like cancer.

RESILIENCE WILL BE COMMON AND WILL LARGELY REST ON FAMILY

FUNCTIONING.

Despite the multifaceted challenges and ways that parental death threatens good outcomes, most
children show resilience. The caregiving context is perhaps the most important contributor to
childhood bereavement and adaptation. Remaining parents who are able to adequately manage
their own grief and attend to the child’s needs, such as through positive parenting, conveying
accurate information, and maintaining healthy family routines, are much more likely to bring
about resilience.29,69–71 During COVID-19, parents were additionally challenged by reduced
opportunities for social support, reduced or absent routine supports for children (e.g., in-person
school and early child care and education programs), increased likelihood of financial crisis, and
other pandemic-related factors, all which can immensely increase parents’ stress and make
positive parenting and healthy family functioning difficult. While the context of the pandemic is
unique, studies of children across a range of adversities, even if severe, affirm that resilience is
surprisingly common and arises from ordinary processes in the lives of most children, especially
warm, consistent relationships with remaining caregivers and other important adults.72 Resilience
will be evident for many children affected by parental death during the COVID-19 pandemic.
Promoting resilience for even more of these children requires supporting families.

HIDDEN PAIN 25
Reviewing the Evidence for
Preventive and Clinical
Interventions
For the 90 to 95 percent of children who experience normative and short-term grief, ordinary supports,
including positive parenting, supportive teachers, mentors, peers, and, for some, specialized-but-not-
clinical services like grief camps and peer-support groups, may be enough to bring about resilience. The
remaining 5 to 10 percent of children will experience complicated grief and will be much more likely to
show more severe impairments.

The variability in grief eliminates the possibility of a one-size fits-all approach to addressing COVID-
related bereavement among children, and interventions must be targeted appropriately. Offering a light-
touch service to children with severe needs will leave them vulnerable to severe negative outcomes, while
more intensive and expensive interventions to those who need no more than comfort and coping skills may
leave that need unfulfilled while wasting scarce therapeutic resources. Here, we review the evidence for
common interventions for children who have experienced grief and other traumas.

Grief Camps

Grief camps are a common short-term intervention for bereaved children. They generally last from a
weekend to a week and focus on normalizing death, grief, and responses to grief, in the context of everyday
life in the hopes of removing feelings of isolation and angst that come from losing a loved one. Grief camps
tend to incorporate outdoor recreational activities like rope courses and rock climbing and artistic
endeavors like poetry and painting with peer and counselor-led group discussions about their loved one
and their death. Some employ Substance Abuse and Mental Health Services Administration (SAMHSA)-
described, trauma-informed therapy, and Cognitive Behavioral Therapy (CBT) techniques for brief
periods. Mixing play with difficult discussions about loss and death allows children to have positive

HIDDEN PAIN 26
experiences and approach their grief from a place of comfort and security. These camps are designed to be
short-term ways to help children develop coping skills, promote resilience, and prepare children to
continue their positive development. Some camps involve a surviving parent, though most focus
exclusively on the child.73–76

Relevant research is largely focused on short-term indicators of psychological and social well-being rather
than broader and downstream metrics of more interest to policymakers but offer meaningful insight into
that limited set of outcomes. Camps enable children to better articulate their feelings of loss and grief and
think of their feelings as “normal.” Participants widely felt that they learned healthy grieving and coping
skills and gained a sense of autonomy often lost during grief.73,77 They are also associated with reductions
in Childhood Traumatic Grief (CTG) and Post-Traumatic Stress Disorder (PTSD).75 One camp found a
significant decrease in anxiety and improvement in self-concept, a characteristic that is often correlated
with self-efficacy, agency, and autonomy. Another found improvements in a child’s peer relationships,
social and behavioral well-being, and, most directly, indicators of prolonged grief.78

Group aspects of the camps are critical to program efficacy. Group therapy and collaborative activities are
crucial to forming relationships and normalizing grief, and participants reported that they were critical in
helping them “get over (their) anger” because they were “not the only one going through losing
somebody.”74 Seeing how other children grieve and hearing other children’s stories of grief in moderated,
structured settings allow them to learn new coping mechanisms and reinforce the normalcy of their
experience.

Some camps involve parents, which can improve communication between the child and parent in a way
that enhances coping and the child’s ability to speak about their loss.74,77 This supports findings from the
Family Bereavement Program (FBP), discussed below, which found that many of the program’s positive
impacts in children were mediated by the program’s association with improved parenting and better
parent-child communication.61

Bereavement camps, as any intervention, have limitations. First, we are not aware of notable impacts on
depression or on a well-validated measure of varied emotional and behavioral problems, though families
note that they found value in the learned coping skills and understanding of death.79 To the extent there
was parental dissatisfaction, it largely stems from a mismatch between the limits of a group camp setting
and the needs of the family. In some cases, it was parents themselves having difficulties coping, which the

HIDDEN PAIN 27
camps were not meant to address. In others, the child exhibited significant mental health concerns prior
to program enrollment, and the parent had hoped that the camp would address this higher-level
problem.76

Mentoring

Mentoring is a widely used and flexible intervention applicable to traumatized or vulnerable children in a
wide breadth of contexts, and is perhaps best known as the program model for Big Brothers Big Sisters of
America (BBBSA).80–83 They provide positive relationships and role models to youth in need of additional
support from a caring adult, and have more than 5,000 programs across the country.84,85

Though a host of mentoring organizations specialize in trauma informed mentoring, Tuesday’s Children
emerged as a leader in applying that model to bereavement in the face of tragedy, providing mentoring to
children of those who perished on 9/11. They have since expanded their work to the children of victims of
terrorism, military action, and disasters. There is a wide body of evidence and a diverse set of mentoring models
attuned for young people facing various degrees of trauma and loss. Trauma-informed mentoring is especially
beneficial for grief-stricken children and adolescents who need support through new relationships with trained
and supported adults. The developmental literature emphasizes the importance of these sorts of relationships
with mentors outside of the immediate family, especially for children and adolescents who feel abandoned or
alone following experiences of loss. A good mentor may be supportive—helping a mentee establish more
adaptive perspectives and behaviors.81

Studies of mentoring interventions have found that enrolled adolescents were less likely to begin using
drugs or alcohol or hit others. They also saw improved attitudes toward school and school attendance, and
better relationships with peers and family. On average, caregivers of enrolled children noted positive and
persistent changes in children’s behaviors.80,81,86–88 Young people who had mentors report setting higher
educational goals and are more likely to attend college than those without mentors; they are also more
likely to report engaging in productive and beneficial activities than youth without a mentor.88 Beyond the
nonprofits in which mentoring programs are usually housed, rigorous evaluations have also tested the
model in school settings. Though the program improved academic achievement in year 1, those gains were
not sustained in the year-2 follow-up and the program did not produce positive outcomes across other
domains like problem behaviors or peer relationships.87 This is a reason for investment in longer-term
relationships, especially in response to traumatic loss.

HIDDEN PAIN 28
Mentoring programs are more likely to be effective when mentees are more vulnerable, meaning that they
have faced significant levels of challenges.80,81 This may be part of the reason that mentoring programs
have been used widely, with demonstrated efficacy, for children of incarcerated parents.83,89 The acute
challenges imposed by the death of a parent or guardian suggest that mentoring may have a similar role to
play for the decedents of victims of COVID-19. They are also more effective when services are tailored to
the specific vulnerabilities of the targeted youth.83

Evaluations of mentoring programs largely exclude policy relevant variables, limiting our ability to assess
their effectiveness in many domains of interest. There is also limited relevant cost-benefit analysis. In one
study of BBBSA, the program largely broke even and had a $2,822 net positive return per mentee when
the only costs assessed were public dollars.90 Because the analysis excluded many policy-relevant
outcomes with costs associated with them—like public assistance, criminal justice involvement, and
substance use disorders—it likely understates program-related financial benefits in the form of defrayed
service expenses.

A mentoring program’s impact is largely contingent on the quality of the match between mentor and
mentee.82,86,89 Mentor-mentee relationships are most effective with increases in length of relationship,
frequency of phone contact, and the mentee’s perception of the closeness with their mentor.81,91,92 Youth
whose match lasted for longer than one year had increased self-worth, perceived social acceptance,
perceived academic competence, a better relationship with their parent, and decreases in substance use,
compared to youth with shorter, or less substantive relationships.

The evidence-based Elements of Effective Practice for Mentoring and the parallel National Quality
Mentoring System outline the practices that produce high quality matches. These include screening,
training, match support, and closure. Matches are most likely to be successful when mentors are
emotionally committed to the mentee and see themselves as instruments of change. Beyond the
motivations of the mentor, the quality of the pairing is also vitally important. Programs that place an
emphasis on systematically matching youth and mentors have larger impacts than those that did not, and
the evidence says that these matches should be built around shared life experiences and ambitions, not
exclusively or primarily on commonly held demographic characteristics.86

Two other program elements beyond high-quality matches are key to program success. The first is care in
program implementation, with emphases on mentor screening, established expectations and guidelines,

HIDDEN PAIN 29
professional support, and adaptation. The second element focuses on external partnerships. Some youth
will have needs too complex to be addressed through a relatively light solution like a mentorship
program.93,94 Having a network of clinical providers capable of managing those needs can improve
program success. There are also efficiency gains when partnerships with clinical providers facilitate the
sharing of resources for training and screening mentors. These partnerships may also empower mentors,
by providing readily available resources to which to refer mentees who have needs beyond their
capability.88

Peer Support Programs

Peer support services have a long history, most notably in mental illness and substance abuse, and are
increasingly common as a form of grief therapy. Like mentorship programs, evidence suggests that peer
support programs are most efficacious when peers share similar backgrounds, interests, and life
circumstances.95 And, similar to mentorship programs, there is little research of peer support programs’
impact on bereavement, though that body of literature is growing.

A systematic review of bereavement-focused peer support programs found robust evidence for the
interventions’ effectiveness.95 Recipients of peer support show lower levels of anxiety, avoidance, and
depression, and higher levels of grief resolution. Evidence suggests that these benefits exist whether the
support is provided through in-person or online interactions, increasing opportunities for well-matched
peer supports. Two studies have tested the model’s efficacy on youth bereavement. One observational
study found that informal peer support resulted in lower depression, better academic and employment
functioning, and greater engagement in life generally.37 In a separate qualitative study, teenagers reported
that their peer support group was the most helpful, especially because families were distraught or dealing
with the logistics of their parent’s death.96

HIDDEN PAIN 30
Peer support lends itself especially well to particularly difficult or sensitive deaths. Suicide survivors
received the most beneficial support from others who experienced the suicide of a loved one. There is
stigma around COVID-19 deaths because of the
politicization of public health interventions and
The variability in grief
restrictions, now including vaccination. Survivors—
eliminates the possibility
especially ones who disagree with their deceased loved
ones’ COVID prevention decisions—may be hesitant to
of a one-size fits-all
seek support from a general peer support group due to approach to addressing
feelings of social stigma.95,97 COVID-related
bereavement among
Matching through shared experiences is the core of some children, and
support programs in place for bereaved children and interventions must be
families. Two notable examples are the Tragedy targeted appropriately.
Assistance Program for Survivors (TAPS)98 and an
emerging pilot from the Children’s Brain Tumor
Foundation’s (CBTF). TAPS provides one-on-one mentoring support to family members of a deceased
member of the military, and CBTF runs a Bereaved Sibling Mentor Program for children who had a sibling
die from a brain or spinal cord tumor. Both seek to create matches that maximize the overlap in life
experiences between the mentor and the mentee. CBTF’s program does that, in large part, by focusing on
a specific set of cancers. In turn, TAPS attempts to keep matches within the same branch of the military
because of the unique experiences of each service.

Family Bereavement Program

The Family Bereavement Program (FBP) is a bereavement program for children and their caretakers
from Arizona State University rooted in a developmental perspective, seeking to enhance protective
factors that promote resilience while alleviating risk factors that threaten long-term child development.
Unlike other prevention programs that focus primarily on the child, the FBP is explicitly focused on
providing care to both the child and their parent or other caregiver because it recognizes the importance
of strong parent-child relationships in promoting resilience. The FBP’s caregiver and child/adolescent
programs consist of 12 group sessions plus two individual sessions for families’ specific needs. The
program aims to facilitate positive caregiver-child relationships, positive coping self-esteem, and
adaptive coping skills and sessions led by masters-level counselors.99

HIDDEN PAIN 31
The Family Bereavement Program, due to its roots within a university, has a more complete grief-focused
evaluation record than any other intervention we examined. More so than the mentorship and grief camp
evaluations, the FBP examines psychological and policy-relevant outcomes and finds that impacts are
largely positive and long-lasting. Children who went through the program have lower rates of problematic
grief, social detachment, and insecurity six years after their participation in FBP. Academically, children
with fewer behavioral problems had increased educational expectations, and younger children saw
improvements in their GPA.99–102

Much of the program’s success can be attributed to its effect on surviving caregivers. In one study, effective
parenting mediated the effect of the program on GPA for families with younger children, and FBP’s
improvement in effective parenting led to reduced internalizing and externalizing problems at the six-year
follow-up. In general, caregivers of resilient children reported themselves as having fewer mental health
problems than the caregivers of children more impacted by a parent’s death.100,103

The FBP is, of course, not the only program serving a caregiver alongside a bereaved child. Pathfinders,
for example, is a 10-week therapist-led prevention program run by Judi’s House, a bereavement center in
Colorado, that centers theory and strengths-based practices in its approach.104

Therapy—Cognitive Behavioral Therapy (CBT)

For 90 to 95 percent of COVID-bereaved children, preventative, non-clinical measures like grief camps,
mentoring, peer supports, and the Family Bereavement Program, should be sufficient to stave off
traumatic or prolonged grief. For the remaining 5 to 10 percent who require the most intensive services,
psychotherapy is generally the indicated treatment for those that fall into that category.105

This support can come in several forms, but the relevant literature overwhelmingly suggests Cognitive
Behavioral Therapy (CBT), and variants of CBT focused on trauma and grief, as the preferred treatment
modalities for treating either complicated or traumatic grief. CBT is a three to six month talk therapy led
by a psychologist, psychiatrist, or licensed social worker to interrupt automatic thoughts and activities to
replace them with intentional and mindful ones.106 By learning how cognitive processes lead to emotions
and behaviors, traumatized individuals can interrupt negative thought processes and replace them with
more productive ones.

HIDDEN PAIN 32
CBT, across its subtypes, has been found to be more effective at reducing Post-Traumatic Stress Disorder,
Childhood Traumatic Grief (CTG), and Prolonged Grief Disorder (PGD) compared to other support
therapies. Trauma-Focused (TF) CBT is perhaps the most researched and standardized intervention
applicable to this challenge—dating back to the 1990s, it has been established as a reliable tool to reduce
PTSD, depression, and anxiety symptoms among children who have suffered a range of traumas.107 A trial
of its use in helping individuals suffering from complicated grief showed improved outcomes at three and
six months, including significant reductions in anxiety and PTSD. Notably, one trial of an adaption of the
CBT program showed that school-based programs with components similar to TF-CBT can be
implemented in a school setting, which may make this hard-to-find and often expensive intervention
available to students who might otherwise be unable to access it.108

Other forms of CBT are especially focused on dealing with death. CBT Grief-Help is a manualized
individual treatment for PGD in bereaved children and adolescents and is meant to be combined with
parental counseling.109 A randomized controlled trial found that it reduced depression significantly more
than supportive counseling alone. In addition, several versions of CBT-CTG (Childhood Traumatic Grief)
have found both statistically and clinically significant reductions in PTSD, depression, CTG, and several
other standardized measures of complicated grief.107 Additional work has found exposure therapy to be a
potentially helpful boost for CBT interventions, finding that it reduced complicated grief, PGD,
depression, and functional impairment significantly more than traditional CBT alone or supportive
therapy.110,111

HIDDEN PAIN 33
Recommendations: Addressing
the Clinical and Economic Needs
of COVID-Bereaved Children

Identifying Children Who Lost a Parent to COVID-19

We recommend undertaking a coordinated strategy to comprehensively identify children who have

lost a parent or other caretaking guardian to COVID-19. Identifying COVID-19 bereaved children is the
first step in providing any type of support. To date, no comprehensive or systematic effort to identify these
families or children has taken place, though smaller efforts have sought to identify children or families of
specific COVID-19 decedents. One example is the Brave of Heart Foundation, providing up to $75,000 for
families of healthcare workers and others who worked in healthcare settings who died because of COVID-
19. They have the advantage of working with specific employers to identify family members of employees
who died from COVID-19, yet much of their work has required time-intensive and unscalable efforts like
calling funeral homes and reviewing obituaries.

In general, though, children and families of COVID-19 decedents are only identified as they seek services.
This, like any count or outreach effort predicated entirely upon service utilization, is certain to undercount
and underserve COVID-bereaved children. Below, we provide specific recommendations for a multi-
pronged approach to comprehensively identify COVID-19 parentally bereaved children.

UNIVERSAL SCREENING IN SCHOOL AND PEDIATRIC HEALTHCARE SETTINGS

Universal screeners are ideal for identifying rare events like COVID-related caregiver loss. We
recommend a White House Executive Order to provide for screening in public and publicly
subsidized schools, early

HIDDEN PAIN 34
childhood education, and healthcare settings, along with public-private partnerships to facilitate
screenings in other circumstances.

Schools are a common source of social needs screenings because they are a nearly universal touch
point for school-aged children and because they can provide many services on-site or through
partnerships. School systems already screen for household income for the U.S. Department of
Agriculture’s National School Lunch Program, homelessness, and physical health challenges at
the beginning of each school year. The U.S. Department of Education can provide universal
screenings in all public schools and Head Start and other pre-K programming run through Local
Education Agencies (LEAs). The U.S. Department of Health and Human Services can make the
same provisions for screenings through non-LEA Head Start programs, as well as early childhood
education programs receiving federal child-care subsidies.

Though screening for social determinants of health is not universal in healthcare settings, the
practice has been endorsed by the American Academy of Pediatrics and has become standard in
many healthcare systems. A well-documented example is the U.S. Department of Veterans
Affairs’ (VA) routine screening of housing instability and homelessness among outpatients. From
2012 to 2014, the two-question screener for housing instability and homelessness was
administered to 5.8 million veterans and identified 1.7 percent who were homeless but not yet
receiving VA homeless services.112

The Center for Medicare and Medicaid Services can provide for these screenings at all Federal
Qualified Healthcare Center’s (FQHC’s). The private and philanthropic sectors have a large role
to play here. Providers of electronic health records—notably EPIC—can include screening
questions as a standard package on the EHR systems it sells to healthcare systems. In addition,
widespread adoption by major healthcare systems could provide near-universal coverage, as
consolidation of the healthcare system means that larger systems have more reach than they once
did.

HIDDEN PAIN 35
Administrative Data

We recommend that state, tribal, and local governments use administrative records to identify
family members of COVID-19 decedents. The federal government can facilitate this effort through
funding, technical assistance, and data availability.

Death data maintained by public health agencies can be matched to birth certificates, child education
records that include guardianship, or records of government assistance, including SNAP, Medicaid,
TANF, homelessness, and others containing information about all household members. Similar efforts
have been undertaken in other contexts. Allegheny County, which includes Pittsburgh, used its well-
established integrated data system to identify children whose parents died because of opioid use. County
health officials found 664 deceased parents on the birth certificates of 989 children under the age of 18,
25 percent of whom were younger than 5 years old.113

Municipalities with robust integrated data systems or histories of data sharing are likely first places to
explore using such an approach. Matching COVID-19 death records with social services and education
systems would be particularly useful for identifying areas of high concentration of children with the
greatest economic and clinical needs. In these instances, careful consideration would need to be given to
any universal or special privacy protections that are relevant to each class of data (e.g., public versus
private records; Privacy law of 1972; HIPAA, FERPA or CR 42 part 2 regulations, etc.), which may be
based in either state or federal law, and any restrictions related to specific proposed uses without
individuals’ consent (e.g., research versus direct contact uses).

Administrative data maintained by private entities can also be used to identify parentally bereaved
children. Health insurance companies have access to medical records that include diagnoses and cause of
death, and family members enrolled in the same insurance plan as a decedent could be identified with
relative ease. Life insurance providers, though they lack diagnosis and cause of death information, have
beneficiary information and could systematically identify children of a parent who died of COVID-19.

HEALTHCARE SYSTEMS TREATING COVID-19 PATIENTS

Hospital social workers in communication with COVID-19 patients and their families are
positioned to gather information about dependents. This information can be collected by social
workers from patients directly (while capable of communicating) or from their family members

HIDDEN PAIN 36
either pre- or post-mortem. Collecting these data before or immediately proximal to a patient’s
death may be more likely to have higher capture rates than sweeping, population-level screening
tools already discussed. There are, however, notable constraints, including understaffed
hospitals, limitations of existing EHR systems, and potential reluctance among overwhelmed
family members.

CAMPAIGN TO ENROLL AND IDENTIFY COVID-19 PARENTALLY BEREAVED

YOUTH AND CHILDREN

A broad, mass media campaign could encourage families to identify themselves as survivors of
COVID-19. This could include television, social media, billboard, and radio advertising. It would
need to be paired with an offer of services or other support to incentivize participation and
would—even more than other strategies—require verification of COVID-19 bereavement status.

VERIFICATION OF COVID-19 RELATED BEREAVEMENT

Any program that provides assistance on the basis of COVID-19 caregiver bereavement should
take steps to verify eligibility. This requires eligibility of two relevant criteria:
• The applicant lost a parent or other caretaker; and
• The deceased caretaker died due to COVID-19 infection.

One notable concern is that many COVID-19 fatalities from the pandemic’s early months do not
list COVID-19 as the cause of death. The Federal Emergency Management Agency has developed
relevant guidance for applicants to its funeral reimbursement program which should similarly be
incorporated into any program assisting this population.

AGGREGATING IDENTIFICATION INFORMATION

We recommend the development of a database that aggregates data from each of the above sources
to facilitate a comprehensive and cohesive effort to enumerate and serve children and their
families. The federal government has, in recent years and especially during the Biden
administration, made notable efforts to collect and aggregate data from local and private sources.
The U.S. Department of Veterans Affairs, for example, allows uploads of individual-level
homeless service records from local agencies to better identify Veterans. A separate effort from
the Census Bureau matched local social service data with federal tax and social service records to

HIDDEN PAIN 37
better understand income and benefits use among homeless adults.114 Any use of identified
administrative data for operational purposes must be done with consideration for relevant privacy
laws.

Screening for Complicated or Traumatic Grief

We recommend broad screening for level of need as the critical next step for identifying youth in
need of services, and we recommend that this screening occur in routine settings like schools and
pediatric care in which we suggest initial identification. In-school assessments can be conducted by
school-based resource workers, mental health practitioners, or through partnering external providers.
Primary care clinics and community-based organizations can rely on in-house expertise or partner with
local public and private mental health agencies as necessary. We suggest screening for complicated,
traumatic, or prolonged grief, as well as PTSD, another potential reaction among many bereaved children.

Previously validated screening tools and procedures include:

• The Pandemic Grief Scale;115
• The Persistent Complex Bereavement Disorder Checklist;116
• The UCLA-Posttraumatic Stress and UCLA-Grief Screening Scales;117
• The Grief Screening Scale;118
• The UCLA Trauma-Grief Screening Interview;119 and
• The UCLA PTSD Reaction Index.120

Beyond standardized screening procedures, community leaders in regular contact with children also need
to remain vigilant. Local governments and grief-focused philanthropies should facilitate trainings and
make them aware of training materials developed by the National Child Traumatic Stress Network
(NCTSN), among others, understanding childhood traumatic grief, noting warning signs and methods of
assessing minors for traumatic or prolonged grief in schools and medical settings. These strategies can
also be applied to leaders and staff of community-based organizations and religious institutions.121

Enhancing Community-Based Support for COVID-19 Bereaved Children

In this section, we recommend a series of initiatives to support existing community-based resources

critical for supporting the more than 167,000 children who lost a caregiver to COVID-19. As noted,

HIDDEN PAIN 38
the majority of COVID-19 bereaved youth will need no more than existing care networks, perhaps
supplemented by nonprofit or school-based resources, to avoid problematic grief.

EQUIP SOCIAL FIRST RESPONDERS TO IDENTIFY GRIEF

Social first responders—trusted adults in schools, religious institutions, athletic leagues, and
other community-embedded organizations—already in children’s lives should be leveraged to
identify and respond to grief.122 These adults, however, are not usually trained in identifying
problematic grief and are generally unfamiliar with services that may be available. We suggest a
two-pronged approach to helping equip these adults with information and skills to support
children through bereavement.

First, we recommend information campaigns to educate adults in identifying grief and

fundamental ways to offer basic emotional support to children in need. The National Child
Traumatic Stress Network has a compendium of resources. Local governments can be effective
partners in furthering these campaigns because they are trusted resources, are sensitive to local
concerns, and routinely contract with small community-based organizations and national athletic
programs like Police Athletic Leagues, Little League Federations, early childhood facilities, and
networks of faith-based institutions to recruit staff and volunteers to participate in these
trainings. In addition, the NCTSN and New York Life have a history of providing these trainings
to relevant groups, and we suggest leveraging their experience and resources.

Second, we recommend wide distribution of grief resource directories. Practitioners with

whom we spoke suggested that youth-facing adults had a significant gap in knowledge of
bereavement options. Curated lists of bereavement organizations already exist, including ones
from eLuna, the Dougy Center, and the National Alliance for Grieving Children, and these should
be integrated into the referral and resource lists of schools and community-based organizations.

INCREASE THE CAPACITY OF COMMUNITY-BASED ORGANIZATIONS TO

PROVIDE APPROPRIATE SERVICES

We recommend providing funding and technical assistance to community-embedded

organizations to add or enhance their grief-focused programming. Clinicians and advocates
with whom we spoke noted the shortage of community-based infrastructure dedicated to grief
services. The solution is not to create a new infrastructure, but to harness the breadth and

HIDDEN PAIN 39
credibility of nonprofit community-based organizations, religious institutions, social service
centers, early childhood programs, schools, and other settings embedded within communities
most affected by COVID-19 deaths.

This recommendation includes two components. One is to increase

funding to the many existing bereavement centers that already

Identifying focus on and facilitate peer support and grief-related services. The
second is to create the capacity to provide grief-services at other
COVID-19
community-embedded organizations, and Tuesday’s Children
bereaved provides a model for doing this. This national organization funds
children is the community-embedded nonprofit organizations to integrate
first step in bereavement services like youth mentoring and peer support into

providing any their existing offerings. Their model may be additionally relevant
because it is focused on survivors of decedents in military,
type of
terrorism, or other mass-death events, and there may be lessons
support. learned for setting eligibility criteria for programs focused on
COVID-19 bereaved youth.

CARE FOR CHILDREN WHO LOST THEIR ONLY CAREGIVER

We estimate that 13,047 children lost their only at-home caregiver to COVID-19. In addition,
there are some children who may have two adults at home that appear as caregivers, but perhaps
only one of them is competent to care for a minor. In both cases, a local child welfare system will
be involved in finding alternate housing arrangements for the bereaved youth.

We recommend that child welfare agencies charged with finding a new caregiving
arrangement for a COVID-19 bereaved child have free or subsidized access to tools that
facilitate access to data systems and resources that make such connections. Family Finding,
used by many child welfare agencies to access federal and state databases that can identify a child’s
relatives, is a prevailing option. In addition, we recommend integration of other services to
engender supportive and mentoring relationships between the child and caring adults in their
lives.123

HIDDEN PAIN 40
STRENGTHEN MAINSTREAM SOCIAL SERVICE SYSTEMS

We recommend making systematic and strategic investments to reinforce and strengthen

mainstream social service systems. COVID-related parental loss, combined with the economic
and social stresses of the pandemic generally, are putting additional strain on already under
resourced social service systems. These include child welfare systems, homeless service and
affordable housing providers, and public assistance systems like SNAP, cash assistance, and
Medicaid. Current investments in these systems can ensure that vulnerable families have access
to the resources they need to pay rent, buy food, and care for their health in this moment of acute
need. This support must include resources for the front-line workers in these systems, who face
the lion’s share of the additional work and the secondary trauma inflicted by these tragic
circumstances. Done right, these investments will outlast the current circumstances, and provide
support for the millions of vulnerable children who will continue to need help even after the
pandemic is behind us.

THE CASE FOR MENTORING

We recommend the development of a federally funded mentorship program to ensure that

COVID-bereaved children have access to caring adults. This should be facilitated through:
• Legislation providing mentoring resources for programs serving COVID-19 bereaved
youth; this can be provided through additional support for the existing federal resource,
the National Mentoring Resource Center operated by the Office of Juvenile Justice and
Delinquency Prevention (OJJDP);
• Leveraging the infrastructure, experience, and coordination of the existing mentoring
field leadership of MENTOR, which operates the National Mentoring Resource Center,
their Research Board, scaled direct service providers like Big Brothers Big Sisters of
America, and those with specific expertise in bereavement mentoring like Tuesday’s
Children; and
• Leveraging the infrastructure and experience of existing mentorship and peer-to-peer
services focused on bereavement, like the Tragedy Assistance Program for Survivors
(TAPS) and the Dougy Center.

Mentoring programs likely have the largest infrastructure of any intervention we reviewed. As
noted earlier, they already receive nearly $100 million per year in federal funding, and they have
a field-level national organization in MENTOR that exists to advocate, coordinate, and provide

HIDDEN PAIN 41
training, guidance, and other infrastructure to local mentoring programs. Mentor matching,
training processes, and the resources needed to support and enhance mentor-mentee
relationships have long been studied and systematized. Many of those regimens are publicly
available from BBBSA itself or similar agencies. In its role as a non-direct service field leader,
MENTOR could serve as an umbrella organization that coordinates multiple entities, trainings,
and other infrastructure, relieving local nonprofits of that burden. Additionally, mentorship
programs can be placed in partnerships with schools, leveraging their large infrastructure and
normative existence in the lives of youth, and such arrangements should be explored here.

Mentoring programs have also been the beneficiary of federal and private funding targeted toward
improving outcomes for particularly disadvantaged or vulnerable groups. The federal government
currently provides $97 million for mentoring at-risk youth through the Office of Juvenile Justice
and Delinquency Prevention, including children of incarcerated parents, with an expected
increase to $120 million in 2022.84,124 Additionally, this funding provides the federally subsidized
training infrastructure of the National Mentoring Resource Center. In addition, Congress had
introduced legislation called the Foster Youth Mentoring Act, a bipartisan bill “centered on
expanding resources available to mentoring programs and organizations that serve young people
in the child welfare system.”125

Given the federal government’s history of federal funding for mentoring programs, we
recommend legislation providing grant funding to programs serving youth who lost a parent or
other caregiver to COVID-19. Given the country’s focus on mitigating the repercussions of the
COVID-19 pandemic and the universal interest in protecting vulnerable youth, we believe that this
can galvanize support among advocacy and service groups like the National Mentoring
Partnership and Big Brothers Big Sisters of America, plus—and crucially—bipartisan support in
Congress. Absent a federal initiative, we recommend a philanthropic effort to expand mentoring
programs in the areas hit hardest by COVID-19.

We recommend that a national program operate through or in partnership with an entity like
MENTOR, which has the national experience, evidence-based grounding and coordinating
and training infrastructure to successfully bring these programs to fruition. Given the
specificity of managing grief, especially for children, we also recommend leveraging the expertise
of an established peer-support organization or program, like the Dougy Center or the Tragedy

HIDDEN PAIN 42
Assistance Program for Survivors (TAPS). Funding alone is insufficient to establish and maintain
new mentorship programs at community-based organizations. The relevant literature is clear on
the importance of following best practices in implementation and the significant overhead and
support necessary for mentorship programs to succeed—an endeavor not achievable by the small,
community-embedded and -based organizations that would be responsible for direct program
management.

ENSURE ACCESS TO MATERNAL AND CHILD

We recommend facilitating prenatal, perinatal, and postpartum support for pregnant

mothers who lost a partner to COVID-19, with categorical eligibility for Medicaid-covered
prenatal care. In addition, we recommend screening and response-plans for caregiver depression
and complicated, traumatic, or prolonged grief in pediatric primary care to ensure that caregivers
receive the support they need for their young children. Birth outcomes and early development are
influenced by maternal experiences beginning, at least, during pregnancy.126 Furthermore,
parental depression and other mental health issues have been shown to impact parenting quality
and child outcomes.

In addition, it is a priority to engage COVID-bereaved children in high-quality early care and

education programs promoting early development and resilience. These can include home visiting
programs, center-based or home-based early care and education programs for young children
(from birth to kindergarten), as well as pre-school programs for children aged 3 to 5 years old. All
early childhood programs look to provide a context that is responsive to the needs of young
children and promote healthy early development. More comprehensive programs, such as Head
Start and Early Head Start, also include family workers who collaborate with families to get basic
needs met, often through helping the family connect to other health and human service programs
for which they qualify. Many program models involve caregiver engagement to support positive
parenting.

Head Start curricula that are especially attentive and responsive to children’s diverse
developmental needs, specifically social and emotional learning, are likely well-positioned to be
vital supports for children in processing their experiences of grief in the early childhood program
and also for surviving parents to promote their wellbeing and help ensure that children receive
positive parenting to effectively process grief at home, as well.127,128 Furthermore, Early

HIDDEN PAIN 43
Intervention programs are specialized services for children with special needs that warrant a
higher level of service. It is important that these programs are knowledgeable about grief and
bereavement processes for young children and for caregivers.

The heavy role of federal and state agencies in early childhood education offers opportunities to
intervene for orphaned children. Early Head Start and Head Start are administered federally
through the Office of Head Start in the Administration for Children and Families. Home visiting is
supported through the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program
under Maternal and Child Health in the Health Resources and Services Administration.
Meanwhile, states can receive funds through the Child Care and Development Block Grant
program administered by the Office of Child Care. Early Intervention, however, is administered
by the U.S. Department of Education. Coordinating efforts to assist each of these components in
supporting young children will need to span multiple agencies.

ENSURE ACCESS TO HIGH-QUALITY EARLY CHILDHOOD PROGRAMS

We recommend categorical eligibility for children and families who lost a caregiver to
COVID-19 to enroll in Early Head Start, Head Start, and other public early childhood, home
visiting, and care programs. Beyond facilitating access, these programs have the benefit of being
bound by federal and state certification and curricular rules, meaning that professional
development for providers in grief and grief-relevant programming can be strongly encouraged or
mandated. We also recognize that these programs are not universally available—in fact, rates of
early childhood programming are negatively correlated with COVID-19 death rates. We therefore
recommend providing categorical eligibility for early childhood programming subsidies for
COVID-bereaved children.

We recommend that new early childhood and education programs be attentive to the
sudden shifts in family circumstances associated with caregiver loss and waive all family co-
pays and employment-related parent-activity requirements. The Build Back Better (BBB)
Framework includes subsidized early childhood education (ECE) for children from birth to 3 years
old and universal high-quality preschool. While the final language of the bill continues to be in flux
at the time of writing, the BBB Framework is projecting that federal programs will expand the
availability of new high quality ECE providers, expand existing federal programs like Head Start
and Early Head Start, and provide a subsidy to limit the cost of ECE for families with an infant or

HIDDEN PAIN 44
toddler based on family income. Any new program should include professional development
requirements for staff that involve social and emotional learning, especially supporting normative
grief processes in children and surviving caregivers as well as manifestations of complicated grief
that would warrant referral to mental health services.

Furthermore, new federal early childhood care and education subsidies should provide greater
support to families who experienced the recent loss of a caregiver. Requirements that determine
income in the past year are inappropriate for these families as they will not reasonably estimate
current household income going forward for many. As a result, any co-payments should be waived
for these families for at least 12 months. Otherwise, many families will be uncertain whether care
will be unaffordable, exceeding the 7 percent of household income that the framework is meant to
guarantee.

Finally, all programs, including Head Start, should waive required parent-activities related
to employment and employment seeking for at least 12 months for families who recently lost
a caregiver. Many of these families will be renegotiating family roles, with surviving caregivers
often challenged to take on more caregiving responsibilities while also becoming more responsible
for earning income. These efforts will be complicated by the caregivers’ own grief, and even
normative grief can interfere. Requirements that caregivers be employed or seeking employment
are not meant to add burdens to families while they are renegotiating roles following loss.

Clinical Care for COVID-Bereaved Children

About 5 to 10 percent of children will face problematic grief and need more intensive services than those
discussed above. Here, we offer a set of recommendations to increase the supply and accessibility of grief-
centered mental health services. These include:
• Expanding opportunities for training in grief-focused therapies to mental healthcare providers;
• Increasing access to and affordability of mental health for COVID-bereaved children; and
• Increasing the capacity for mental health provision in schools and creating partnerships between
schools and mental health practitioners.

We note two significant problems in caring for the children who lost a parent or caregiver and face
prolonged or complicated grief. First, “social first responders”—teachers, religious leaders,

HIDDEN PAIN 45
pediatricians, youth athletic league coaches, and social service staff who interact with community
members regularly—are not generally trained to identify and understand grief and grief-related issues.
Data are lacking, though a survey of teachers and other school staff found that 15 percent felt “very
comfortable” addressing students’ emotional needs
that have been “caused or intensified by the” pandemic
and fewer than a quarter (24 percent) felt “very
Five states—California,

comfortable supporting a student who lost someone Florida, Georgia, New

close to them. Despite this lack of training, 87 percent York, and Texas—account
said that at least one student each year typically needs for 50 percent of total
their support due to the loss of a loved one, a number
caregiver loss.
certain to have risen in the midst of the COVID-19
pandemic.129

Second, there are notable shortfalls in the pediatric mental healthcare infrastructure, meaning that for
many children experiencing complicated grief, critical resources are simply unavailable. One-third of
Americans live in designated mental health professional shortage areas (MHPSAs), and these gaps are
concentrated in the rural and low-income urban areas hit hardest by COVID-19.130 In schools, the most
convenient location to identify and serve bereaved youth, school-based mental health professionals are
woefully under-resourced. The ratio of students to school psychologists is 1,211:1, which is more than
double the National Association of School Psychologists’ recommended ratio of 500:1. Only three states
meet the recommended 250:1 ratio of students to school counselors.131,132

Additionally, there is a mismatch in the racial and ethnic composition of the survivors of COVID-19 deaths
and the mental health professionals tasked to serve them. While Black and Hispanic populations are at the
highest risk for COVID-19 mortality, 86 percent of psychologists and 65 percent of social workers are
White.133,134 As cultural competence emerges as a critical component of overall clinical effectiveness, this
will confound efforts to engage and retain racial and ethnic minority children in sorely needed therapy.

Two factors compound these challenges for COVID-bereaved children. First, only a small percentage of
mental health professionals are trained in grief-focused modalities. Only 8 percent of MHPs in a recent
survey had taken any course in grief interventions, and fewer than 20 percent noted that their universities
even offered related courses.135 Additionally, the pandemic has exploded the need for pediatric mental

HIDDEN PAIN 46
healthcare, stretching an already sparse resource. This has prompted pediatric health and
mental health-focused groups to declare a “National State of Emergency in Children’s Mental Health.”136

INCREASE ACCESS TO MENTAL HEALTHCARE

Train Existing Providers in Grief-Focused Therapies

We recommend incentivizing existing mental health providers to become competent in grief-
focused therapies through short-term and readily available training. We are aware of:
• A web-based course in Trauma-Focused CBT and its adaptation for Childhood Traumatic
Grief (CTG) developed by the National Trauma Child Traumatic Stress Network (NCTSN)
with academic and healthcare partners; and
• One or two-day workshops in therapies for Prolonged Grief Disorder through Columbia
University’s Center for Prolonged Grief.

We recommend that mental health licensing bodies like the Council on Social Work
Education (CSWE) incentivize trainings by providing course subsidies and Continuing
Education (CE) credits. We know that these organizations may lack the resources to provide
financial incentives on such a broad scale and suggest that one or more foundations establish a
“COVID-19 Grief Training Fund” to meet this need.

Telehealth
We recommend improving access to mental health telemedicine by increasing broadband
accessibility and eliminating cost-sharing payments for COVID-bereaved children.

Telehealth has rapidly gained popularity during the COVID-19 pandemic as families, and most
mental healthcare interventions are amenable to delivery through telehealth. Thus, telehealth
increases access to niche interventions like grief-related services not available in many parts of
the country.

It is not, however, an immediate panacea. For one, there are longstanding disparities in telehealth
use by income and race that have widened over the last two years.137 Second, rural and low-income
urban communities hit hardest by COVID-19 are the ones least likely to have reliable home
broadband internet access due to cost, gaps in infrastructure, or digital discrimination. Third,

HIDDEN PAIN 47
mental health services—even those provided over video or phone—can be expensive, and many
insurance companies have not reimbursed telehealth services at the same rates as in-person care.

Federal policymakers are making efforts to close these gaps. The recently passed Infrastructure
Investment and Jobs Act includes $65 billion for enhancing broadband accessibility, including:
• $42 billion to expand broadband infrastructure;
• $14.2 billion for a $30 per month subsidy for low-income households to afford broadband
internet (this reduces the current subsidy by $20 per month, but expands program
eligibility); and
• $2.75 billion to end digital discrimination.138

In addition, the Center for Medicare and Medicaid Services (CMS) is taking steps to expand the
mental health services available via telehealth. It is implementing provisions in the 2021
Consolidated Appropriations Act—which included the third round of federal stimulus
payments—to remove geographic restrictions in telehealth and to allow patients to access
telehealth services offered from any location.139,140 In addition, it is proposing to allow Medicare to
pay for telehealth mental health visits for rural and vulnerable populations when those services
are provided by Rural Health Clinics and Federally Qualified Health Centers. This would include
telephone calls and other audio-only services, which would be particularly helpful for people in
rural areas without sufficient broadband infrastructure, individuals who may not be able to afford
broadband, and people enrolled in Medicare who do not use or are otherwise incapable of using
video services.

We support these steps and suggest expanding them to people on Medicaid, and we encourage
legislative action to require these provisions for private insurers as well.

Expansion of Co-Located and Integrated Mental Healthcare

We recommend incentives to providers offering mental health services co-located with or
integrated into primary care services. Families are more likely to engage providers when they
can be accessed in a single, convenient location. They are more likely to trust and accept help from
a range of associated disciplines (e.g., mental healthcare; social services) that they might
otherwise avoid due to stigma or inaccessibility. Incorporating mental healthcare providers and

HIDDEN PAIN 48
human service into co-located spaces could assist families who would benefit from these services
to address complicated grief.

In integrated primary care, the pediatrician, mental healthcare provider, social worker, and other
disciplines work together as a coordinated care team, sharing information and formulating a
cohesive approach that draws on their different expertise. Integrated care models often involve
the convenience and trust that comes with co-located services with the added benefit of close
coordination between providers. Ensuring that mental healthcare and human service workers are
integrated with pediatrics, and that those providers are knowledgeable about childhood grief,
holds potential for underserved communities with high rates of COVID-related mortality.

Reduce Costs for Mental Healthcare

Even where there is access to mental healthcare, cost is another common barrier. COVID-19
decedents and their families are more likely to be low-income and are less likely to have health
insurance than others.141 Even among families with insurance, there has been a trend toward
increased copayments and deductibles for mental health services.142 In addition, many mental
healthcare providers do not accept Medicaid or even private insurance, further reducing access to
the low-income populations who have the greatest needs.

We recommend efforts to reduce or eliminate the costs of grief-related mental healthcare

for children, youth, and their caretakers who lost a loved one to COVID-19. This can be
operationalized in one (or more) of the following ways:
• Reimbursement of copayments and deductibles through the COVID-19 Bereaved-
Children Fund;
• Private and public insurers waiving patient cost-sharing responsibilities; or
• Therapists forgiving or refunding copayments or deductibles or offering pro bono in-
person and/or telehealth services.

Leverage Schools
We recommend the provision of federal funding and technical assistance to Local Education
Agencies to increase the capacity of school systems to respond to this crisis. We note several
options for doing so.

HIDDEN PAIN 49
First, train teachers in basic information about childhood grief, including recognizing and
responding when a student is grieving. Several programs and curricula already exist. The National
Child Traumatic Stress Network, for example, has a comprehensive array of online workshops and
materials that would provide teachers and school administration with a basic competence in
dealing with grief.

We also suggest leveraging New York Life’s Grief Sensitive Schools Initiative (GSSI). Through the
program, school staff are trained by grief-focused mental health professionals to better
understand and address the needs of students who have lost a loved one. At least five personnel
from a school are trained, and they provide materials and workshops to their colleagues. GSSI
offers a $500 grant to “improve grief support and resources” to incentivize participation.143

Second, supplement mental health resources by increasing staff competence and creating
pathways to new capacity. Incentivize partnerships with external therapists and healthcare
organizations that can provide grief-focused mental health services. Mental health professionals
can engage students and families through their partnership with the schools. Notably, because
these services would be arranged through the school and because outside services are being sought
due to capacity and competence deficits within the school system, these arrangements should be
made through contracts between schools and districts and mental health professionals, with no
cost-sharing burden falling onto the students or their families.

Finally, leverage on-line and in-person trainings for grief-specific therapies, as noted earlier in
this section.

Addressing the Economic Needs of Children who

Lost a Parent or Caregiver to COVID-19
Any meaningful intervention to address COVID-19 related caregiver loss must acknowledge that affected
households are disproportionately low-income and susceptible to sudden income loss, and many need
imminent economic support.

Programs serving this population must ensure streamlined enrollment and participation, avoiding the
problems evident in some other programs unveiled during the COVID-19 era, such as COVID-19-focused
eviction prevention funds. While we address specific programs below, we recommend establishing

HIDDEN PAIN 50
presumptive eligibility for families who lost a caregiver to COVID-19 for existing support programs,
such as the Earned-Income Tax Credit, Child Tax Credit payments established by the American
Rescue Plan, the Supplemental Nutrition Assistance Program, Temporary Assistance for Needy
Families, Medicaid, and subsidized early childhood programs such as Early Head Start and Head
Start. This presumptive eligibility acknowledges that families who lost a parent to COVID-19 had
disproportionately lower incomes prior to the loss and were more likely to have only a single person
working.

There also should be a concerted effort to inform families of programs that they become eligible for
following death of an adult family member. This effort should be proactive and include any programs that
involve categorical eligibility specifically for this group as well as existing programs that the family may
now be eligible for based on changes in income. Outreach efforts could include general information
campaigns, targeted stakeholder communications (e.g., to health systems and other human service
providers), and specific collaboration on process with other federal and state programs that enroll children
and families.

PROVIDE SHORT-TERM FINANCIAL ASSISTANCE BY EXPANDING FEMA’S

FUNERAL REIMBURSEMENT PROGRAM

We recommend an expansion of FEMA’s funeral reimbursement program. The Federal

Emergency Management Agency has been authorized to reimburse up to $2 billion for funeral-
related expenses for COVID-19 decedents. We recommend expansion of this program coupled
with community-based outreach efforts to increase awareness and facilitate enrollment.

More than half of allotted program funds have been spent on fewer than half of COVID-decedents
as case and death counts grow nearly unabated, and the program will hit its $2 billion ceiling well
before all COVID-19 funeral expenses are covered. This is especially important as those most
vulnerable and hesitant families who are unaware of or do not fully understand the program or
application may seek assistance later than others and, perhaps, do so after allocated funds have
already been spent.

While more than 760,000 Americans have died because of COVID-19, only 321,191 applications
for funeral-related relief have been filed. In addition, only 61 percent of completed applications
have been granted, varying from 43 percent in Alaska to 73 percent in Connecticut and South

HIDDEN PAIN 51
Dakota.144 We cannot offer any definitive determination regarding the reasons for these low
uptake and acceptance rates. Conversations with practitioner stakeholders suggest that some
families may have sufficient resources that the effort needed to apply is not worth the amount of
money available. However, many families in
need of these resources simply may not be
aware of them, and the arduous application
The ratio of students to

may discourage many who do not understand school psychologists is

the application process. In addition, many 1,211:1, which is more
families with immigrants—documented and than double the National
undocumented—may be hesitant to apply for
Association of School
fear of additional scrutiny and deportation.
Psychologists’

To improve participation, hospital

recommended ratio of
administrators and funeral directors should all 500:1.
be familiar with FEMA’s Funeral Assistance
Program and encourage families who lost a loved one to COVID-19 (or whose death was likely to
be due to COVID-19) to take advantage of these resources. The National Funeral Directors
Association has a section of its website devoted to the program and created a toolkit for funeral
directors, including sample letters and other information to share with families who may have lost
a loved one to COVID-19.145 This is a good first step but is unlikely to reach many families in need
of the available funding.

We also suggest FEMA create materials for community-based organizations and offer virtual,
recorded trainings for these organizations to help community members apply for these funds. The
local organizations, often embedded in vulnerable communities, are so often critical to building
trust between governments and constituencies leery of government assistance or interference.
Leveraging their role could expand the pool of applications. Allowing them to submit paperwork
on behalf of applicants, like Affordable Care Act healthcare navigators or tax-filing accountants,
could further alleviate some of the burdens on families dealing with struggles on many fronts after
confronting the death of a loved one. This could also lower the rate of failed applications (currently
greater than one-third) which take up valuable FEMA resources from the 5,000 contracted
agents’ management of 25,000 calls per day.146

HIDDEN PAIN 52
CREATE THE “COVID-19 BEREAVED CHILDREN’S FUND” TO PROVIDE SHORT-
TERM FINANCIAL ASSISTANCE AND GRIEF-RELATED MENTAL HEALTHCARE

We recommend the creation of a publicly funded COVID-Bereaved Children Fund to address

the financial and mental health needs facing the more than 167,000 children who lost a
parent or other caregiver to COVID-19. We recommend $2-3 billion in support for this Fund.

The scale of need arising from this crisis is beyond the scope of nearly any private funder, and such
a fund would be in-line with public responses to other tragedies and public health crises. We
recommend that the COVID Bereaved-Children Fund provide $10,000 in one-time payments for
each COVID-19 bereaved child, plus cover the cost-sharing responsibilities of their grief-related
mental health services. These grants would alleviate some immediate financial worry for bereaved
children and their families, which is especially important given the preexisting economic
vulnerabilities facing many COVID-19 victims and the fact that many families lost a primary
earner.

Such an approach is also supported by research on unconditional cash transfers, which notes an
array of benefits to children and their families receiving such financial assistance. In addition, by
reimbursing the patient-borne expenses of grief-related mental healthcare, the Fund would
ensure access to care for those who need it. This is especially important given that COVID-
bereaved children are the most likely to face cost barriers to receiving these services.

We further recommend that a private fund offer the same resources to children who lost a
caregiver but are ineligible to receive funding from the U.S. government. Supplemental
private funds to address an acute crisis or notable subpopulation are not uncommon. Among other
examples, the private Twin Towers Fund provided over $200 million to the families of first
responders who died on September 11th.147

CONNECT CHILDREN AND THEIR FAMILIES TO INCOME AND OTHER

SUPPORTS

As sources of income diminished due to COVID-19 deaths, particularly for low-income

households, we expect that many households will become newly eligible for public benefits like
Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families
(TANF), Medicaid, Affordable Care Act subsidies, early childhood care and education programs

HIDDEN PAIN 53
(e.g., Early Head Start; Head Start), and that some families already receiving those benefits will
be eligible for an increased assistance. In addition, many will also become eligible for tax benefits
like the Earned Income Tax Credit and the Child Tax Credit.

However, many families may not be aware of the benefits for which they are eligible. Only 82
percent of people eligible for SNAP actually receive the program’s benefits.148 The turmoil
associated with a parent’s death likely means that families are less likely to immediately seek out,
understand, or enroll in public assistance programs, especially as many necessitate arduous in-
person appointments and documentation requirements.

We recommend that the relevant departments of local governments undertake extensive

outreach to families of COVID-19 decedents to assess program eligibility for these support
programs. This can be better targeted by matching COVID-19 deaths with social service or wage
data from a local or state finance or labor agency or the IRS. A less arduous effort would involve
working with health systems, community-based organizations, churches, early childhood
programs, and K-12 schools, or public awareness campaigns through billboards and other
advertising.

The same concern—that eligible populations may forego benefits—is true for Social Security
death and monthly survivor benefits, which can go to a spouse or, in the event the decedent is
unmarried, their children. Confusion and lack of awareness around the program have led many
survivors to leave this entitlement untouched. To ameliorate this gap, we recommend matching
COVID-19 death records from state or local health departments with the Social Security
Administration, which can then send communications to the families of decedents explaining the
program, their eligibility, and their anticipated benefit.

MAKE THE NEW CHILD TAX CREDIT PERMANENT

The American Rescue Plan’s amended and expanded Child Tax Credit has had a significant
positive impact on the lives of low-income Americans, and we recommend making it permanent.
It has allowed families of 27 million children who previously received either no credit or only a
partial credit because their incomes were too low to claim the full credit. It also increased the value
of the credit from $2,000 to $3,000 per child, or $3,600 for children aged five and younger.

HIDDEN PAIN 54
Finally, it changed the timing of disbursements from one lump sum per year to monthly
installments.

Because distribution of the new tax credit only began in July of 2021, estimates of its impact are
preliminary, but they are promising. Data from the Census Bureau’s Household Pulse Survey
suggest a marked decrease in food insecurity. About 3.3 million fewer households report having
insufficient food in their home, a nearly one-third decrease from pre-July levels.149 Moreover,
Parolin and colleagues estimate that these payments alone kept 3 million children out of poverty
in July, 2021, reducing the childhood poverty rate from 15.8 percent in June to 11.9 percent in
July.150 Both estimates showed significant impacts across racial and ethnic groups, with Zippel
showing the largest decreases among food insecurity in Black and Hispanic families with children.

These expanded and monthly payments are only in place for the 2021 tax year, meaning we may
revert to pre-July levels of food insecurity and child poverty in a few short months. As noted
earlier, COVID-19 deaths are disproportionately found in low-income households most directly
benefitting from these changes, and we strongly recommend that Congress make these changes
permanent.

HIDDEN PAIN 55
Need for Additional Research
Our work revealed a general lack of information regarding the scope and impacts of parental loss to
COVID-19. Here, we outline a set of inquiries critical to better understanding the current and future
human costs of these tragic circumstances.

BETTER LOCAL ENUMERATION OF COVID-19 RELATED CAREGIVER LOSS

All current estimates of COVID-19 caregiver loss are based on aggregated data and extrapolations.
Despite their value, they
● Contain some level of inherent uncertainty;
● Are limited in their ability to describe these individuals based on demographics,
geographic location, service needs; and
● Are unable to identify individuals who lost a parent or caregiver to COVID-19, meaning
they cannot be used for program outreach or enrollment.

We therefore propose using state, tribal, and local administrative data to examine
prevalence of COVID-19 bereavement among children. As Allegheny County did for opioid
deaths, COVID-19 death records can be matched with birth records. Separately or in addition,
death records can be matched with social service records to better understand the extent of
parental loss among children in households receiving public assistance like TANF, SNAP, or
Medicaid or those involved in the homelessness or child welfare systems. This would provide
insight into the most socially and economically vulnerable COVID-19 survivors in a way that is not
possible through any other method.

DOCUMENTING POLICY-LEVEL IMPACTS OF COVID-19 PARENTAL

BEREAVEMENT ON CHILDREN

Families that lose a parent are at risk for cascades of negative events related to lost family income
and other lost socioeconomic resources, yet these impacts are poorly documented in the
bereavement literature. A series of short- and long-term research on this topic, both generally and

HIDDEN PAIN 56
specific to COVID-19 parental bereavement, is important for providing policymakers and
practitioners with insight into the long-term effects of parental bereavement generally and
specifically for children who lost a parent to COVID-19. Such research could inform interventions
related to eviction prevention, homelessness and housing program utilization, cash assistance,
and the child welfare system.

CONTINUE TO DEVELOP THE EVIDENCE-BASE OF INTERVENTIONS FOR

BEREAVED CHILDREN

There is relatively scant literature assessing the effectiveness of the range of interventions
addressing grief of parental bereavement, even though the phenomenon is relatively common. It
is unclear which grief-related programs address long-term and policy-relevant outcomes, and the
evidence supporting mentoring largely comes from non-bereavement literature. It is therefore
necessary to fund rigorous trials of community-based and clinical interventions to prevent and
alleviate complicated and prolonged grief responses to parental bereavement.

DOCUMENTING THE CLINICAL IMPACTS OF COVID-19 PARENTAL

BEREAVEMENT ON CHILDREN

Our review found no research documenting levels of impacts of parental bereavement related to
the pandemic on measures of anxiety, complicated grief, depression, PTSD, or other clinical
conditions associated with loss. The more than 760,000 deaths and counting are occurring from
a cause and in a moment unlike any others, and it is reasonable to hypothesize that the impacts on
those left behind may differ as well. We suggest research employing qualitative interviews and
validated surveys of relevant clinical measures to assess these impacts relative to other parental
deaths during the pandemic era as well as parental deaths prior to 2020 to better understand the
unique impacts of a COVID-death.

EXAMINING THE RESPONSE

Responses to the COVID-19 pandemic have varied widely across states and localities. While
significant academic and journalistic research has gone into understanding their relative impacts
on COVID-19 infections and deaths, there is little if anything devoted to how municipalities are
caring for surviving family members and other affected community members. A series of case
studies highlighting best practices would provide guidance for municipalities, social service
providers, and funders looking to improve well-being for those most affected by the pandemic.

HIDDEN PAIN 57
FACILITATING THIS RESEARCH

Without intervention, this research will neither emerge nor be conducted in a coordinated way
that facilitates maximal learning and information sharing to improve policy and practice for
COVID-bereaved children. Funders and other facilitators of policy and practice, including
governments, academic and quasi-academic organizations, advocacy groups, and social service
providers must work in concert to facilitate this research. Examples of this work could include:
● Providing funding for these and other COVID-19 parental bereavement research projects;
● Funding and hosting convenings that allow information sharing between researchers,
policymakers, and practitioners; and
● Creating special issues of peer-reviewed journals devoted to the topic.

Conclusion

At least 167,082 children under 18 years old—about 1 in 450—have suffered the death of a parent or other
at-home caregiver to COVID-19 through mid-November 2021, and that number continues to grow. More
than 72,000 lost a parent, and more than 13,000 lost their sole at-home caregiver. Higher mortality rates
and larger household sizes among communities of color, combined with legacies of disinvestment, have
led to consistently disadvantaged communities experiencing COVID-19 related orphanhood at the highest
rates. We are requiring these children and families to bear the heaviest burden of the pandemic, despite
permitting them the fewest resources with which to carry on. Caregiver death can contribute to negative
psychological, economic, and social outcomes, especially for families from these under resourced
communities, and failure to mitigate these consequences is a missed opportunity to promote success for
more than 167,000 children. They have lost the most important people in their lives: their sources of care,
comfort, love, and economic support. A lost parent cannot be replaced, but, in this moment, we have the
opportunity and obligation to help families fill children’s lives with love and support nevertheless. And we
call upon the nation to act in this time of great need.

HIDDEN PAIN 58
Acknowledgments
We have received research assistance, expertise, and general advice from many people whose collective
contributions are critical to this work. First to note is our dedicated Research Assistant Delaney
Michaelson, whose tireless work to keep us informed and organized have been extraordinarily helpful and
appreciated. Thank you also to Dr. Micki Burns, Dr. Laura Landry, and Dave Mills from Judi’s House, a
bereavement center based in Colorado, who guided our understanding of bereavement processes and
whose extensive and continuous modeling efforts ensure that, pandemic or not, bereaved children are
recognized and cared for. We also appreciate the time and tireless efforts of Heather Nesle and Maria
Collins of the New York Life Foundation and Nikki DeVillers of E4E Relief. David Shapiro’s wisdom helped
guide our thinking around mentorship programming. In addition, we appreciate the insight of Dr. Emily
Smith Greenaway, whose groundbreaking work on COVID-bereaved family members informs our framing
and approach. We thank Meagan Cusack for her work in creating the maps. Dr. Dennis Culhane provided
valuable insight on some operational aspects of our recommendations, and we appreciate his wisdom, as
always. Dr. Randall Kuhn offered a critical eye on our modeling, and Dr. Ben Seligman’s prior relevant
work and advice are both very much appreciated. Thank you also to members of the COVID Collaborative
team, including Riley Kennedy and Ellie Manspile, for their thorough review of this document. And finally,
Dr. Johanna Greeson provided critical insight into interventions for youth who have lost their only
caretakers. Importantly, the aforementioned good Samaritans are all absolved of any errors or omissions
contained herein; they are the sole responsibility of the authors.

HIDDEN PAIN 59
References
1. Kaiser Family Foundation. The HIV/AIDS Epidemic in the United States: The Basics. 2021
Available at: https://www.kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united-states-
the-basics/. (Accessed: 5th October 2021)

2. Levin, J. & Brown, K. V. Covid-19 Toll in U.S. Surpasses 1918 Pandemic Deaths. Bloomberg
(2021).

3. Kidman, R., Margolis, R., Smith-Greenaway, E. & Verdery, A. M. Estimates and Projections of
COVID-19 and Parental Death in the U.S. J. Am. Med. Assoc. 175, 745–746 (2021).

4. Kidman, R. Use HIV’s lessons to help children orphaned by COVID-19. Nature (2021).

5. Hillis, S. D. et al. COVID-19-Associated Orphanhood and Caregiver Death in the United States.
Pediatrics e2021053760 (2021). doi:10.1542/peds.2021-053760

6. Hillis, S. D. et al. Global minimum estimates of children affected by COVID-19-associated

orphanhood and deaths of caregivers: a modelling study. Lancet 398, 391–402 (2021).

7. Verdery, A. M., Smith-Greenaway, E., Margolis, R. & Daw, J. Tracking the reach of COVID-19
kin loss with a bereavement multiplier applied to the United States. Proc. Natl. Acad. Sci. U. S.
A. 117, 17695–17701 (2020).

8. Kaplow, J. B. et al. DSM-V diagnostic criteria for Bereavement- Related Disorders in children
and adolescents: Developmental considerations. Psychiatry 75, 243–266 (2012).

9. Kaplow, J. B., Saunders, J., Angold, A. & Costello, E. J. Psychiatric symptoms in bereaved
versus nonbereaved youth and young adults: A longitudinal epidemiological study. J. Am.
Acad. Child Adolesc. Psychiatry 49, 1145–1154 (2010).

10. Azuike, P., Anjoyeb, M., & King, L., Azuike, P., Anjoyeb, M. & King, L. Bereavement and
children’s mental health: Recognising the effects of early parental loss. Nurs. Child. Young
People 33, (2021).

11. Berg, L., Rostila, M., Hjern, A. & Berg, L., Rostila, M., & Hjern, A. Parental death during
childhood and depression in young adults – a national cohort study. J. Child Psychol.
Psychiatry Allied Discip. 57(9), 1092–1098 (2016).

HIDDEN PAIN 60
12. Rostila M, Berg L, A. A. et al. Parental death in childhood and self-inflicted injuries in young
adults-a national cohort study from Sweden. Eur. Child Adolesc. Psychiatry 1103–111 (2016).
doi:10.1007/s00787-016-0833-6

13. Joint United Nations Programme on HIV/AIDS. National AIDS Spending Assessment (NASA) :
classification and definitions. (2009).

14. Keyes, K. M., Pratt, C., Galea, S., Mclaughlin, K. A., Koenen, K. C., & Shear, M. K. et al. The
Burden of Loss: Unexpected Death of a Loved One and Psychiatric Disorders Across the Life
Course in a National Study. Am J Psychiatry 171, 864–781 (2014).

15. SIMBI, C. M. C., Zhang, Y., Wang, Z. & SIMBI, C. M. C., Zhang, Y., & Wang, Z. Early parental loss
in childhood and depression in adults: A systematic review and meta-analysis of case-
controlled studies. J. Affect. Disord. 260, 272–280 (2020).

16. Obradović, J., Shaffer, A., & Masten, A. S. Adversity and risk in developmental
psychopathology: Progress and future directions. In L. C. Mayes & M. Lewis (Eds.),. Cambridge
Univ. Press. The Cambri, 35–57 (2012).

17. Bridgeland, J., DiIulio, Jr., J. J. & Morison, K. B. The Silent Epidemic: Perspectives of High
School Dropouts. (2006).

18. Pew Research Center. Parenting in America: Outlook, worries, aspirations are strongly linked
to financial situation. Numbers, Facts and Trends Shaping the World (2015).

19. Pilkauskas, N. V., Amorim, M. & Dunifon, R. E. Historical Trends in Children Living in
Multigenerational Households in the United States: 1870–2018. Demography 57, 2269–2296
(2020).

20. Pew Research Center. Grandparents living with or serving as primary caregivers for their
grandchildren. (2013).

21. Eggers, F. J. & Moumen, F. Analysis of Trends in Household Composition Using American
Housing Survey Data. SSRN Electron. J. (2014). doi:10.2139/ssrn.2445476

22. Gross, C. P. et al. Racial and Ethnic Disparities in Population-Level Covid-19 Mortality. J. Gen.
Intern. Med. 35, 3097–3099 (2020).

23. Seligman, B., Ferranna, M. & Bloom, D. E. Social determinants of mortality from COVID-19: A
simulation study using NHANES. PLoS Med. 18, 1–13 (2021).

24. Chen, Y. H. et al. Excess mortality associated with the COVID-19 pandemic among Californians
18-65 years of age, by occupational sector and occupation: March through November 2020.
PLoS One 16, 1–10 (2021).

HIDDEN PAIN 61
25. Zhang, H. & Rodriguez-Monguio, R. Racial disparities in the risk of developing obesity-related
diseases: A cross-sectional study. Ethn. Dis. 22, 308–316 (2012).

26. Rosenstock, S., Whitman, S., West, J. F. & Balkin, M. Racial Disparities in Diabetes Mortality in
the 50 Most Populous US Cities. J. Urban Heal. 91, 873–885 (2014).

27. Kliman, G. Childhood mourning: a taboo within a taboo. in Perspectives on Bereavement (eds.
Gerber, I. et al.) (Arno Press, 1979).

28. Clark, D. C., Pynoos, R. S., & Goebel, A. E. Mechanisms and processes of adolescent
bereavement. New York Cambridge Univ. Press. (1994).

29. Kaplow, J. B., Layne, C. M., Pynoos, R. S., Cohen, J. A. & Lieberman, A. DSM-V diagnostic
criteria for Bereavement- Related Disorders in children and adolescents: Developmental
considerations. Psychiatry 75, 243–266 (2012).

30. Brown, A. C., Sandler, I. N., Tein, J. Y., Liu, X. & Haine, R. A. Implications of parental suicide and
violent death for promotion of resilience of parentally-bereaved children. Death Stud. 31, 301–
335 (2007).

31. Masten, A. S. Ordinary magic: Resilience in development. Guilford Publ. (2015).

32. Howarth, R. Promoting the Adjustment of Parentally Bereaved Children. J. Ment. Heal. Couns.
33, 21–32 (2011).

33. Mannarino, A. P. & Cohen, J. A. Traumatic loss in children and adolescents. J. Child Adolesc.
Trauma 4, 22–33 (2011).

34. Wolfet. Healing the bereaved child: Grief gardening, growth through grief, and other
touchstones for caregivers. Fort Collins, CO Companion Press. (1996).

35. Worden. Children and grief: When a parent dies. New York, NY: Guilford. (1996).

36. Dowdney, L. Childhood be- reavement following parental death. Journal of Child Psychology
and Psychiatry. 41(7), (2000).

37. Cohen, J. A. & Mannarino, A. P. Supporting children with Traumatic Grief: What educators
need to know. Sch. Psychol. Int. 32, 117–131 (2011).

38. Berg, L., Rostila, M., & Hjern, A. Parental death during childhood and depression in young
adults – a national cohort study. J. Child Psychol. Psychiatry Allied Discip. 57(9), 1092–1098
(2016).

HIDDEN PAIN 62
39. Ellis, J., Dowrick, C. & Lloyd-Williams, M. The long-term impact of early parental death: Lessons
from a narrative study. J. R. Soc. Med. Suppl. 106, 57–67 (2013).

40. Berg, L., Rostila, M. & Hjern, A. Parental death during childhood and depression in young
adults – a national cohort study. J. Child Psychol. Psychiatry Allied Discip. 57, 1092–1098
(2016).

41. Keyes, K. M., Pratt, C., Galea, S., Mclaughlin, K. A., Koenen, K. C., & Shear, M. K. The Burden of
Loss: Unexpected Death of a Loved One and Psychiatric Disorders Across the Life Course in a
National Study. Am J Psychiatry 864–781 (2014).

42. SIMBI, C. M. C., Zhang, Y., & Wang, Z. Early parental loss in childhood and depression in
adults: A systematic review and meta-analysis of case-controlled studies. J. Affect. Disord.
272–280 (2020). doi:https://doi.org/10.1016/j.jad.2019.07.087

43. Hamdan, S., Melhem, N. M., Porta, G., Song, M. S. & Brent, D. A. Alcohol and substance abuse
in parentally bereaved youth. J. Clin. Psychiatry (2013).

44. Brent, D. A., Melhem, N. M., Masten, A. S., Porta, G. & Payne, M. W. Longitudinal Effects of
Parental Bereavement on Adolescent Developmental Competence. J. Clin. Child Adolesc.
Psychol. 41, 778–791 (2012).

45. Gimenez, L., Chou, S.-Y., Liu, J.-T. & Liu, J.-L. Parental Loss and Children ’ s Well- Being. J.
Hum. Resour. 48, (2013).

46. Parsons, S. Long-term impact of childhood bereavement. 1–22 (2011).

47. Li J, Vestergaard M, Cnattingius S, Gissler M, Bech BH, O. C. Mortality after parental death in
childhood: a nationwide cohort study from three Nordic countries. Natl. Libr. Med. (2014).

48. Clarke, M. C., Tanskanen, A., Huttunen, M. O., & Cannon, M. Sudden death of father or
sibling in early childhood increases risk for psychotic disorder. Schizophr. Res. 143(2–3), 363–
366 (2013).

49. Kailaheimo-Lönnqvist, S. & Erola, J. Child’s age at parental death and university education.
Eur. Soc. 22, 433–455 (2020).

50. Keyes, K. M. et al. The Burden of Loss: Unexpected Death of a Loved One and Psychiatric
Disorders Across the Life Course in a National Study. Am J Psychiatry 171, 864–781 (2014).

51. Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., McGuinn, L. The lifelong
effects of early childhood adversity and toxic stress. Pediatrics e232–e246 (2012).

HIDDEN PAIN 63
52. Azuike, P., Anjoyeb, M. & King, L. Bereavement and children’s mental health: Recognising the
effects of early parental loss. Nurs. Child. Young People (2021).
doi:https://doi.org/10.7748/ncyp.2021.e1387

53. Clarke, M. C., Tanskanen, A., Huttunen, M. O. & Cannon, M. Sudden death of father or sibling
in early childhood increases risk for psychotic disorder. Schizophr. Res. 143(2–3), 363–366
(2013).

54. Misra S, Gelaye B, K. K. et al. Early parental death and risk of psychosis in offspring: a six-
country case-control study 8, 7, 1081. Journal of Clinical Medicine (2016).
doi:10.3390/jcm8071081

55. Azuike, P., Anjoyeb, M. & King, L. Bereavement and children’s mental health: Recognising the
effects of early parental loss. Nurs. Child. Young People 33, (2021).

56. Pham, S. et al. The burden of bereavement: Early-onset depression and impairment in youths
bereaved by sudden parental death in a 7-year prospective study. Am. J. Psychiatry 175, 887–
896 (2018).

57. Kaplow, J. B., Layne, C. M., Pynoos, R. S., Cohen, J. A., & Lieberman, A. DSM-V diagnostic
criteria for Bereavement- Related Disorders in children and adolescents: Developmental
considerations. Psychiatry 243–266 (2012). doi:https://doi.org/10.1521/psyc.2012.75.3.243

58. Hagan, M. J., Roubinov, D. S., Gress-Smith, J., Luecken, L. J., Sandler, I. N., & Wolchik, S.
Positive parenting during childhood moderates the impact of recent negative events on
cortisol activity in parentally bereaved youth. Psychopharmacology, 214(1), 231–238 (2011).

59. Saldinger, A., Porterfield, K. & Cain, A. C. Meeting the needs of parentally bereaved children: A
framework for child-centered parenting. Psychiatry 67, 331–352 (2004).

60. Tein, J. Y., Sandler, I. N., Ayers, T. S. & Wolchik, S. A. Mediation of the effects of the family
bereavement program on mental health problems of bereaved children and adolescents.
Prev. Sci. 7, 179–195 (2006).

61. Sandler, I. N. et al. The family bereavement program: Efficacy evaluation of a theory-based
prevention program for parentally bereaved children and adolescents. J. Consult. Clin.
Psychol. 71, 587–600 (2003).

62. Sandler, I., Ingram, A., Wolchik, S., Tein, J. Y. & Winslow, E. Long-Term Effects of Parenting-
Focused Preventive Interventions to Promote Resilience of Children and Adolescents. Child
Dev. Perspect. 9, 164–171 (2015).

63. Herbers, J. E., Hayes, K. R., & Cutuli, J. J. Adaptive systems for stuent resilience in the context
of COVID-19. Sch. Psychol. 36, 422–426 (2021).

HIDDEN PAIN 64
64. SAMHSA. Double Jeopardy: COVID-19 and Behavioral Health Disparities for Black and Latino
Communities in the U.S. Kaiser Fam. Found. (2020).

65. Hardy, B. L. & Logan, T. D. Racial Economic Inequality Amid the COVID-19 Crisis. Hamilt. Proj.
2020 (2020).

66. Falk. Unemployment Rates During the COVID-19 Pandemic - Google Search. (2021).

67. Kaplow, J. B., Layne, C. M., Pynoos, R. S., Cohen, J. A. & Lieberman, A. DSM-V diagnostic
criteria for Bereavement- Related Disorders in children and adolescents: Developmental
considerations. Psychiatry(New York) 75, 243–266 (2012).

68. Dyregrov, A., Salloum, A., Kristensen, P. & Dyregrov, K. Grief and Traumatic Grief in Children in
the Context of Mass Trauma. Curr. Psychiatry Rep. 17, (2015).

69. Lin, K. K., Sandler, I. N., Ayers, T. S., Wolchik, S. A. & Luecken, L. J. Resilience in parentally
bereaved children and adolescents seeking preventive services. J. Clin. Child Adolesc.
Psychol. 33, 673–683 (2004).

70. Melhem, N. M., Walker, M., Moritz, G., & Brent, D. A. Antecedents and sequelae of sudden
parental death in offspring and surviving caregivers. Archives of Pediatric and Adolescent
Medicine. 2008 403–410

71. Weller, R. A., Weller, E. B., Fristad, M., & Bowes, J. M. (1991). Depression in recently bereaved
prepubertal children. American Journal of Psychiatry. 1536–1540 (1991).

72. Luthar, S. . Resilience in development: A synthesis of research across five decades. In D.

Cicchetti & D. J. Cohen (Eds.). Dev. Psychopathol. Vol. 3. Risk, Disord. Adapt. 2nd ed, 739–795
(2009).

73. Clute, M. A. & Kobayashi, R. Are Children’s Grief Camps Effective? J. Soc. Work End-of-Life
Palliat. Care 9, 43–57 (2013).

74. Nabors, L. et al. A pilot study of the impact of a grief camp for children. Palliat. Support. Care
2, 403–408 (2004).

75. McClatchey, I. S., Vonk, M. E. & Palardy, G. Efficacy of a camp-based intervention for childhood
traumatic grief. Res. Soc. Work Pract. 19, 19–30 (2009).

76. Salinas, C. Playing to Heal: The Impact of Bereavement Camp for Children With Grief. Int. J.
Play Ther. 30, 40–49 (2021).

HIDDEN PAIN 65
77. Creed, J., Ruffin, J. E. & Ward, M. A Weekend Camp for OVERVIEW : Children 9, 176–182
(2001).

78. Griffiths, N., Mazzucchelli, T. G., Skinner, S., Kane, R. T. & Breen, L. J. A pilot study of a new
bereavement program for children: Lionheart Camp for Kids. Death Stud. 0, 1–11 (2019).

79. Stokes, J. & Crossley, D. The challenge of programme. Palliat. Support. Care 179–190 (1997).

80. Dubois, D. L. & Karcher, M. J. Handbook of Youth Mentoring. (SAGE Publications Ltd, 2014).

81. DuBois, D. L., Portillo, N., Rhodes, J. E., Silverthorn, N. & Valentine, J. C. How Effective Are
Mentoring Programs for Youth? A Systematic Assessment of the Evidence. Psychol. Sci. Public
Interes. Suppl. 12, 57–91 (2011).

82. Rhodes, J. E. & Dubois, D. L. Mentoring relationships and programs for youth. Curr. Dir.
Psychol. Sci. 17, 254–258 (2008).

83. Stump, K. N., Kupersmidt, J. B., Stelter, R. L. & Rhodes, J. E. Mentoring program enhancements
supporting effective mentoring of children of incarcerated parents. Am. J. Community Psychol.
62, 163–174 (2018).

84. National Mentoring Partnership. GOOD NEWS OUT OF D.C. – PRESIDENT BIDEN’S FY22
BUDGET REQUEST INCREASES FUNDING FOR MENTORING. (2021). Available at:
https://www.mentoring.org/blog/advocacy/good-news-out-of-d-c-president-bidens-fy22-
budget-request-increases-funding-for-mentoring/. (Accessed: 8th October 2021)

85. America, B. B. B. S. of. Big Brothers Big Sisters of America: 2019 Annual Report. (2019).

86. Tierney, J., Grossman, J. B. & Resch, N. L. Making a Difference: An Impact Study of Big
Brothers Big Sisters. (1998).

87. Herrera, C. et al. Mentoring in Schools : An Impact Study of Big Brothers Big Sisters School-
Based Mentoring Published by : Wiley on behalf of the Society for Research in Child
Development Stable URL : http://www.jstor.org/stable/29782835 Linked references are
available on . 82, 346–361 (2018).

88. Bruce, M. & Bridgeland, J. The Mentoring Effect : Young People’s Perspectives on the
Outcomes and Availability of Mentoring. MENTOR Natl. Mentor. Partnersh. 1–58 (2014).

89. Shlafer, R. J., Poehlmann, J., Coffino, B. & Hanneman, A. Mentoring children with incarcerated
parents: Implications for research, practice, and policy. Fam. Relat. 58, 507–519 (2009).

HIDDEN PAIN 66
90. Miller, M., Fumia, D., Kay, N., Lee, S. & Aos, S. Washington State Institute for Public Policy
Inventory of Evidence-based , Research-based , and Promising Practices : Prevention and
Intervention Services for Adult Behavioral Health. (2014).

91. DuBois, D. L. & Rhodes, J. E. Youth mentoring: Bridging science with practice. J. Community
Psychol. 34, 547–565 (2006).

92. Grossman, J. B., Chan, C. S., Schwartz, S. E. O. & Rhodes, J. E. The Test of Time in School-
Based Mentoring: The Role of Relationship Duration and Re-Matching on Academic
Outcomes. Am. J. Community Psychol. 49, 43–54 (2012).

93. Merenstein, B., Tyson, B., Tilles, B., Keays, M. A. & Rufffolo, M. L. Issues Affecting the Efficacy
of Programs for Children with Incarcerated Parents. J. Correct. Educ. 62, 166–175 (2011).

94. Laakso, J. & Nygaard, J. Children of incarcerated parents: How a mentoring program can
make a difference. Soc. Work Public Health 27, 12–28 (2012).

95. Bartone, P. T., Bartone, J. V, Violanti, J. M. & Gileno, Z. M. Peer Support Services for Bereaved
Survivors: A Systematic Review. OMEGA - J. Death Dying 80, 137–166 (2017).

96. Baumgarten, H. Surviving a parent’s cancer: Adolescents as peer support group leaders.
(2000).

97. Pitman, A. L., Osborn, D. P. J., Rantell, K. & King, M. B. The stigma perceived by people
bereaved by suicide and other sudden deaths: A cross-sectional UK study of 3432 bereaved
adults. J. Psychosom. Res. 87, 22–29 (2016).

98. Dooley, C. M., Carroll, B., Fry, L. E., Seamon-Lahiff, G. & Bartone, P. A model for supporting
grief recovery following traumatic loss: The tragedy assistance program for survivors (TAPS).
Mil. Med. 184, 166–170 (2019).

99. Sandler, I. N., Wolchik, S. A., Ayers, T. S., Tein, J.-Y. & Luecken, L. J. Family Bereavement
Program (FBP) Approach to Promoting Resilience Following the Death of a Parent. Fam. Sci. 4,
(2013).

100. Haine, R. A., Wolchik, S. A., Sandler, I. N., Millsap, R. E. & Ayers, T. S. Positive parenting as a
protective resource for parentally bereaved children. Death Stud. 30, 1–28 (2006).

101. Schoenfelder, E. N., Tein, J.-Y., Wolchik, S. A. & Sandler, I. N. Effects of the Family
Bereavement Program on Academic Outcomes, Educational Expectations and Job Aspirations
6 Years Later: The Mediating Role of Parenting and Youth Mental Health Problems. J. Abnorm.
Child Psychol. 43, 229–241 (2015).

HIDDEN PAIN 67
102. Sandler, I.N., Ayers, T.S., Wolchik, S.A., Tein, J., Kwok, O., Haine, R.A., . . . Griffen, W. A. The
Family Bereavement Program: Efficacy evaluation of a theory-based prevention program for
parentally bereaved children and adolescents.Journal of Consulting and Clinical Psychology.
587–600 (2003).

103. Hagan, M. J. et al. Strengthening Effective Parenting Practices Over the Long Term: Effects of
a Preventive Intervention for Parentally Bereaved Families. J. Clin. Child Adolesc. Psychol. 41,
177–188 (2012).

104. Griese, B., Burns, M. & Farro, S. A. Pathfinders: Promoting healthy adjustment in bereaved
children and families. Death Stud. 42, 134–142 (2018).

105. Currier, J. M., Neimeyer, R. A. & Berman, J. S. The Effectiveness of Psychotherapeutic

Interventions for Bereaved Persons: A Comprehensive Quantitative Review. Psychol. Bull. 134,
648–661 (2008).

106. Craske, M. Cognitive Behavioral Therapy. (American Psychological Association, 2010).

107. Cohen, J. A., Mannarino, A. P. & Staron, V. R. A pilot study of modified cognitive-behavioral
therapy for childhood traumatic grief (CBT-CTG). J. Am. Acad. Child Adolesc. Psychiatry 45,
1465–1473 (2006).

108. Langley, A. K., Gonzalez, A., Sugar, C. A., Solis, D. & Jaycox, L. Bounce back: Effectiveness of
an elementary school-based intervention for multicultural children exposed to traumatic
events. J. Consult. Clin. Psychol. 83, 853–865 (2015).

109. Boelen, P. A., Lenferink, L. I. M. & Spuij, M. CBT for Prolonged grief in children and
adolescents: A randomized clinical trial. Am. J. Psychiatry 178, 294–304 (2021).

110. Bryant, R. A. et al. Treating prolonged grief disorder a randomized clinical trial. JAMA
Psychiatry 71, 1332–1339 (2014).

111. Boelen, P. A., de Keijser, J., van den Hout, M. A. & van den Bout, J. Treatment of Complicated
Grief: A Comparison Between Cognitive-Behavioral Therapy and Supportive Counseling. J.
Consult. Clin. Psychol. 75, 277–284 (2007).

112. Montgomery, A. E. Understanding the Dynamics of Homelessness among Veterans Receiving

Outpatient Care: Lessons Learned from Universal Screening. Ann. Am. Acad. Pol. Soc. Sci.
693, 230–243 (2021).

113. Hulsey, E. G. et al. Potential Emerging Risks Among Children Following Parental Opioid-
Related Overdose Death. JAMA Pediatr. 174, 503–504 (2020).

HIDDEN PAIN 68
114. Meyer, B., Wyse, A., Grunwaldt, A., Medalia, C. & Wu, D. Learning about Homelessness Using
Linked Survey and Administrative Data. SSRN Electron. J. (2021). doi:10.2139/ssrn.3858667

115. Lee, S. A. & Neimeyer, R. A. Pandemic Grief Scale: A screening tool for dysfunctional grief due
to a COVID-19 loss. https://doi.org/10.1080/07481187.2020.1853885 (2020).
doi:10.1080/07481187.2020.1853885

116. Kaplow, J. B. et al. Validation of the Persistent Complex Bereavement Disorder (PCBD)
Checklist: A Developmentally Informed Assessment Tool for Bereaved Youth. J. Trauma.
Stress 31, 244–254 (2018).

117. Grassetti, S. N. et al. Evaluating referral, screening, and assessment procedures for middle
school trauma/grief-focused treatment groups. Sch. Psychol. Q. Off. J. Div. Sch. Psychol. Am.
Psychol. Assoc. 33, 10–20 (2018).

118. M. Layne, C., Steinberg, A., Savjak, M. & Pynoos, R. S. Grief Screening Scale. Unpubl. Psychol.
test

119. Layne, C. M., Saltzman, W. R. & Woods, J. UCLA Trauma-Grief Screening Interview. (1999).

120. Kaplow, J. B. et al. Validation of the UCLA PTSD Reaction Index for DSM-5: A Developmentally
Informed Assessment Tool for Youth. J. Am. Acad. Child Adolesc. Psychiatry 59, 186–194
(2020).

121. Goodman, R. F. et al. Childhood Traumatic Grief Education Materials. (2004).

122. Renelus, B. D. et al. Racial Disparities in COVID-19 Hospitalization and In-hospital Mortality at
the Height of the New York City Pandemic. J. Racial Ethn. Heal. Disparities (2020).
doi:10.1007/s40615-020-00872-x

123. Greeson, J. K. P. Caring Adults ‘R’ Everywhere (CARE): A Natural Mentoring Intervention for
Older Youth in Foster Care. (I Am My Life, 2019).

124. Cornell Law School. Grants for programs for mentoring children of prisoners.
(https://www.law.cornell.edu/uscode/text/42/629i).

125. National Mentoring Partnership. The Foster Youth Mentoring Act. (2021).

126. Shaw, S. H., Herbers, J. E. & Cutuli, J. J. Medical and Psychosocial Risk Profiles for Low
Birthweight and Preterm Birth. Women’s Heal. Issues 29, (2019).

HIDDEN PAIN 69
127. Bierman, K. L., Nix, R. L., Domitrovich, C. E., Welsh, J. A. & Gest, S. D. The head start REDI
project and school readiness. Heal. Educ. Early Child. Predict. Interv. Policies 16802, 208–233
(2015).

128. Nix, R. L. et al. The randomized controlled trial of Head Start REDI: Sustained effects on
developmental trajectories of social-emotional functioning. J. Consult. Clin. Psychol. 84, 310–
322 (2016).

129. New York Life Foundation & American Federation of Teachers. Grief in School survey: key
findings and topline results. (2020).

130. Kaiser Family Foundation. Mental Health Care Health Professional Shortage Areas (HPSAs).
(2020). Available at: https://www.kff.org/other/state-indicator/mental-health-care-health-
professional-shortage-areas-
hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%2
2asc%22%7D. (Accessed: 25th July 2021)

131. Trends, Y. State-By-State Ratio Report. (2015).

132. Psychologists, N. A. of S. Shortage of School Psychologists. (2021). Available at:

https://www.nasponline.org/research-and-policy/policy-priorities/critical-policy-
issues/shortage-of-school-psychologists.

133. Edward Salsberg, Leo Quigley, Nicholas Mehfoud, Kimberley Acquaviva, Karen Wyche, S. S.
SOCIAL WORK. Georg. Washingt. Univ. Heal. Work. Inst. Sch. Nurs. (2017).

134. Lin, L. M., Stamm, K. P. & Christidis, P. P. How diverse is the psychology workforce? Am.
Psychol. Assoc. 49, 5–8 (2018).

135. Cicchetti, R. J., McArthur, L., Szirony, G. M. & Blum, C. Perceived Competency in Grief
Counseling: Implications for Counselor Education. J. Soc. Behav. Heal. Sci. 10, 3–17 (2016).

136. American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry &
Children’s Hospital Association. AAP-AACAP-CHA Declaration of a National Emergency in
Child and Adolescent Mental Health. (2021).

137. Olson, C. A., Mcswain, S. D., Curfman, A. L. & Chuo, J. The current pediatric telehealth
landscape. Pediatrics 141, (2018).

138. Infrastructure Investment and Jobs Act. (2021).

139. Centers for Medicare & Medicaid Services. Calendar Year ( CY ) 2022 Medicare Physician Fee
Schedule Proposed Rule. 1–23 (2021).

HIDDEN PAIN 70
140. Susan Morse. CMS seeks to expand telehealth mental health access. Healthc. Financ. (2021).

141. Chen, Y.-H. et al. Excess mortality associated with the COVID-19 pandemic among Californians
18–65 years of age, by occupational sector and occupation: March through November 2020.
PLoS One 16, e0252454 (2021).

142. Rowan, K., McAlpine, D. D. & Blewett, L. A. Access and cost barriers to mental health care, by
insurance status, 1999-2010. Health Aff. 32, 1723–1730 (2013).

143. Coalition to Support Grieving Students. New York Life ’ s Grief-Sensitive Schools Initiative.
Coalit. to Support Grieving Students 9–12 (2021).

144. Federal Emergency Management Agency. FEMA COVID-19 Funeral Assistance State-by-State
Breakdown. (2021). Available at: https://www.fema.gov/press-release/20211101/fema-covid-19-
funeral-assistance-state-state-breakdown. (Accessed: 15th November 2021)

145. National Funeral Directors Association. FEMA COVID-19 Funeral Assistance. (2021). Available
at: https://nfda.org/covid-19/fema-funeral-assistance. (Accessed: 12th August 2021)

146. Vann, M. Americans seeking FEMA’s funeral assistance eager for help but frustrated by the
process. Washington Post (2021).

147. Philanthropy News Digest. Twin Towers Fund to Close After Disbursing $216 Million. (2003).

148. United States Department of Agriculture. SNAP Participation Rates by State, All Eligible
People | USDA-FNS. (2021). Available at: https://www.fns.usda.gov/usamap. (Accessed: 2nd
September 2021)

149. Zippel, C. After Child Tax Credit Payments Begin, Many More Families Have Enough to Eat |
Center on Budget and Policy Priorities. (2021).

150. Parolin, Z., Collyer, S., Curran, M. A. & Wimer, C. Monthly Poverty Rates among Children after
the Expansion of the Child Tax Credit Measuring Monthly Poverty. (2021).

HIDDEN PAIN 71
Appendix I: Tables and Figures

Table 1: Summary Statistics I

# Rate per 100,000

Total # losing caregiver 167,082 230

Total # losing parent 72,699 100

Total losing a primary caregiver 80,848 111

Total # losing grandparent 67,591 93

Total # losing sole caregiver 13,047 18

Race

Non-Hispanic Black 32,287 334

Non-Hispanic White 51,413 141

Hispanic 64,163 350

Asian 7,974 228

Native Hawaiian or Pacific Islander 776 518

American Indian or Alaska Native 3,946 537

By Age

0-4 34,150 154

5-13 83,798 197

14-17 49,134 257

I. We do not provide separate estimates for those categorized as “Other race’ or ‘Multiracial’ because
we are unable to meaningfully parse those groups, though they are included in total results.

HIDDEN PAIN 72
Table 2: COVID-19 Caregiver Loss by Race and Age

0-4 14-17 5-13 Total

Asian 1,524 2,328 4,121 7,974

Non-Hispanic Black 6,788 9,240 16,260 32,287

Hawaiian or Pacific Islander 216 199 361 776

Hispanic 14,094 17,833 32,236 64,163

American Indian or Alaska Native 848 1,060 2,038 3,946

Non-Hispanic White 9,214 16,772 25,428 51,413

TOTAL 34,150 49,134 83,798 167,082

HIDDEN PAIN 73
Table 3: Number and Rate of COVID-19 Bereaved Children, by State and Race
Non-Hispanic Hawaiian or American Indian Non-Hispanic
Asian Hispanic Total
State Black Pacific Islander or Alaska Native White

74
# Rate (per 100k) # Rate (per 100k) # Rate (per 100k) # Rate (per 100k) # Rate (per 100k) # Rate (per 100k) # Rate (per 100k)
Alabama 22 145 1,296 410 1 170 229 266 5 95 1,560 250 3,233 298
Alaska 2 28 0 3 0 0 5 28 126 359 54 62 199 112
Arizona 124 276 220 288 10 282 3,209 450 1,142 1,217 1,018 161 5,980 366
Arkansas 39 342 401 335 55 1,224 231 270 2 82 889 203 1,676 241
California 2,303 226 1,351 314 198 647 19,282 424 133 185 2,772 123 26,891 304
Colorado 76 213 92 177 0 41 860 224 45 335 575 82 1,723 138
Connecticut 70 209 260 317 0 15 320 176 3 119 395 102 1,097 151
Delaware 3 34 94 182 0 0 28 87 0 10 102 106 248 122
District of Columbia 0 16 265 400 0 0 137 634 0 32 11 36 426 334
Florida 276 271 3,861 483 8 224 4,089 303 25 202 3,744 217 12,533 297
Georgia 189 206 2,701 328 4 171 910 251 12 104 2,343 218 6,391 256
Hawaii 106 140 0 1 147 358 50 101 1 79 14 32 438 146
Idaho 3 63 7 139 0 16 178 226 22 346 453 135 683 152
Illinois 258 188 1,047 254 5 772 1,903 277 6 56 1,281 89 4,657 166
Indiana 35 87 383 224 2 374 368 208 4 107 1,403 128 2,300 147
Iowa 17 124 81 201 0 1 68 94 3 116 448 80 657 91
Kansas 23 123 78 185 0 17 207 162 5 148 507 109 866 124
Kentucky 43 225 176 200 1 276 137 222 1 66 1,328 170 1,760 177
Louisiana 25 141 1,527 392 1 156 165 211 12 146 1,067 194 2,887 266
Maine 1 27 1 14 4 53 0 7 111 51 125 51
Maryland 100 136 1,052 260 4 1,181 663 308 0 13 631 115 2,560 193
Massachusetts 150 165 487 436 1 107 379 148 2 54 971 121 2,097 156
Michigan 82 122 1,006 302 1 195 371 208 26 248 1,598 112 3,202 150
Minnesota 295 415 330 265 2 215 124 110 64 287 429 48 1,342 103
Mississippi 9 121 1,354 464 0 150 112 368 109 2,931 954 279 2,576 370
Missouri 30 133 496 281 5 165 205 225 7 120 1,395 142 2,233 164
Montana 3 154 3 121 0 0 20 192 206 835 239 136 496 220
Nebraska 3 28 43 156 0 1 127 153 2 31 253 78 434 92
Nevada 232 511 242 335 54 1,103 989 355 20 183 498 210 2,177 316
New Hampshire 1 17 0 2 1 285 3 18 0 10 104 48 111 43
New Jersey 413 237 1,171 489 4 664 2,268 424 4 96 1,499 171 5,627 292
New Mexico 6 93 15 205 0 0 650 233 774 1,449 137 122 1,609 341
New York 1,486 486 3,290 566 1 40 4,681 474 36 272 2,659 139 12,784 320
North Carolina 72 111 1,200 235 1 50 621 165 44 134 1,534 130 3,626 158
North Dakota 1 31 0 8 0 33 15 170 141 899 84 62 252 142
Ohio 90 165 691 192 1 132 204 128 2 42 2,337 128 3,484 136
Oklahoma 44 290 240 345 2 172 440 272 379 417 951 190 2,237 236
Oregon 60 176 49 269 2 72 247 133 30 226 490 90 921 107
Pennsylvania 150 166 972 298 3 325 690 212 4 48 2,190 127 4,206 161
Rhode Island 3 63 22 155 0 0 42 79 0 0 192 167 278 138
South Carolina 27 132 1,105 350 1 21 230 224 2 55 1,071 177 2,534 229

HIDDEN PAIN
South Dakota 3 101 1 9 0 0 7 65 249 833 96 62 359 168
Tennessee 59 227 930 340 5 528 427 281 6 138 2,303 237 3,895 258
Texas 585 187 2,653 313 24 434 16,713 460 43 160 5,129 222 25,630 347
Utah 19 173 4 33 140 1,741 330 200 120 1,209 637 94 1,323 143
Vermont 0 0 0 2 0 0 0 4 0 17 18 18 20 17
Virginia 160 143 796 217 2 208 457 177 2 46 978 100 2,541 137
Washington 154 130 85 119 82 665 537 153 80 291 719 78 1,808 109
West Virginia 3 109 10 103 0 0 9 97 0 0 623 196 666 186
Wisconsin 117 261 194 185 1 421 203 137 29 247 541 61 1,145 91
Wyoming 0 48 0 32 7 1,629 21 108 23 517 77 76 135 101
Table 4: Counts and Rate of COVID-Bereaved Children, by Age and State
0-4 5-13 14-17 Total
State
# Rate per 100k # Rate per 100k # Rate per 100k # Rate per 100k
Alabama 634 222 1,593 290 1,006 404 3,233 298
Alaska 50 101 95 103 55 152 199 112
Arizona 1,253 295 3,020 361 1,707 458 5,980 366
Arkansas 314 170 797 227 564 352 1,676 241
California 5,936 251 13,566 303 7,389 367 26,891 304
Colorado 300 92 876 139 547 187 1,723 138
Connecticut 194 108 526 143 377 210 1,097 151
Delaware 46 86 127 127 75 152 248 122
District of Columbia 106 231 225 373 96 448 426 334
Florida 2,596 230 6,280 295 3,657 380 12,533 297
Georgia 1,221 192 3,224 250 1,946 339 6,391 256
Hawaii 96 112 227 149 115 187 438 146
Idaho 104 90 364 159 215 206 683 152
Illinois 921 125 2,351 166 1,386 211 4,657 166
Indiana 493 119 1,107 139 701 197 2,300 147
Iowa 108 57 351 94 198 127 657 91
Kansas 144 78 449 126 273 174 866 124
Kentucky 323 120 876 175 561 247 1,760 177
Louisiana 572 195 1,471 267 844 353 2,887 266
Maine 15 24 59 48 51 85 125 51
Maryland 504 141 1,338 200 718 238 2,560 193
Massachusetts 435 123 932 140 730 225 2,097 156
Michigan 589 105 1,608 150 1,005 201 3,202 150
Minnesota 223 64 697 106 422 143 1,342 103
Mississippi 490 274 1,363 381 723 452 2,576 370
Missouri 442 122 1,092 158 699 228 2,233 164
Montana 87 146 230 202 180 341 496 220
Nebraska 70 55 220 90 144 144 434 92
Nevada 459 248 1,129 323 589 380 2,177 316
New Hampshire 19 30 53 41 38 60 111 43
New Jersey 1,181 234 2,851 292 1,596 359 5,627 292
New Mexico 312 270 860 349 437 396 1,609 341
New York 3,002 271 6,206 315 3,576 391 12,784 320
North Carolina 681 115 1,886 162 1,059 200 3,626 158
North Dakota 50 93 139 156 62 186 252 142
Ohio 639 94 1,727 133 1,118 190 3,484 136
Oklahoma 372 149 1,184 238 681 338 2,237 236
Oregon 159 71 465 105 297 151 921 107
Pennsylvania 756 111 2,157 162 1,293 215 4,206 161
Rhode Island 51 94 135 139 92 181 278 138
South Carolina 487 168 1,256 223 791 313 2,534 229
South Dakota 83 144 178 162 98 212 359 168
Tennessee 777 192 1,971 256 1,148 347 3,895 258
Texas 5,383 272 12,778 342 7,469 447 25,630 347
Utah 292 119 605 126 426 214 1,323 143
Vermont 2 8 9 16 8 28 20 17
Virginia 505 102 1,269 135 767 185 2,541 137
Washington 338 75 922 109 549 150 1,808 109
West Virginia 114 125 340 184 212 262 666 186
Wisconsin 200 62 551 86 395 135 1,145 91
Wyoming 24 71 61 84 51 177 135 75 101
HIDDEN PAIN
Children with Caregiver Loss Due to COVID-19, by State and Age

TOTAL NUMBER OF CHILDREN

12,801 - 26,891

6,401 - 12,800

3,651 - 6,400

1,351 - 3,650

0 - 1,350

AGES 0-4

3,001 - 5,936

1,251 - 3,000

701 - 1,250

201 - 700

0 - 200

AGES 5-13

6,251 - 13,566

3,201 - 6,250

1751 - 3,200

701 - 1,750

0 - 700

AGES 14-17

3,651 - 7,469

1,951 - 3,650

851 - 1,950

301 - 850

0 - 300

Ages 0-4 Ages 5-13 Ages 14-17

Children with Caregiver Loss Due to COVID-19, by State and Race

AMERICAN
INDIAN OR
ALASKA
NATIVE

401 - 1,142

201 - 400

101 - 200

51 - 100

0 - 50

ASIAN

601 - 2,303

301 - 600

151 - 300

51 - 150

0 - 50

HISPANIC

4,701 - 19,282

3,201 - 4,700

1,001 - 3,200

351 - 1,000

0 - 350

NATIVE
HAWAIIAN
OR PACIFIC
ISLANDER

81 - 198

26 - 80

11 - 25

6 - 10

0-5

NON-HISPANIC
BLACK

1,551 - 3,861

801 - 1,550

401 - 800

101 - 400

0 - 100

NON-HISPANIC
WHITE

2,751 - 5,129

1,601 - 2,750

701 - 1,600
American Indian or Alaska Native Asian
Ages 14-17
251 - 700
Hispanic Native Hawaiian or Pacific Islander
0 - 250
Non-Hispanic Black Non-Hispanic White
Appendix II: Methods
DATA SOURCES

We used the Census Bureau’s American Community Survey (ACS) Public Use Microdata Sample (PUMS)
for the survey year of 2019 to calculate the number of households, and to assess the characteristics of
households, including the relationships of household members, whether and how many children younger
than 18 years of age live in the household. Populations of each race/ethnicity and age group at the national
and state levels were also calculated using PUMS. COVID-19 deaths for each race/ethnicity and age group
were obtained from the National Center for Health Statistics.

DEFINING CAREGIVERS

PUMS dataset was used to define caregivers. Both primary and secondary caregivers were identified. In
households that reported the presence of a child (< 18 years of age), parents were considered primary
caregivers. Other adult members of the household were considered secondary caregivers. In households
where a grandparent and a grandchild resided and no parent was present, the grandparent was considered
a primary caregiver. If a parent was present, the grandparents and other household members were
considered secondary caregivers.

DEFINING DEATH COUNTS

Total COVID-19 deaths were for the current period of pandemic (from January 1, 2020 to mid-November
2021—updated as of November 17, 2021) by state, age group and race/ethnicity as reported on a current
flow of mortality data in the National Vital Statistics System.

CALCULATION OF THE PROBABILITY (DEATH RATE) OF LOSING CAREGIVERS

Counts of COVID-19 deaths were then used to calculate the probability associated with COVID-19
mortality for each segment of the population (age group, by race/ethnicity, by state). COVID-19 death
rates were calculated by dividing the number of deaths for each segment of the population (i.e., for each
age group, by race/ethnicity, by state) by the corresponding estimated number of population (as the
weighted sample) from PUMS. People living in group settings (including prisons, student dormitories,
etc.) were excluded from the subsequent analytic PUMS dataset. For each household reporting the
presence of a child (<18 years of age), first, a total household probability of death was calculated by
summing the death rates of all caregivers. Because the death of the child excludes the child from the

HIDDEN PAIN 78
calculation of loss of caregivers and bereavement, the average mortality rate of the child in the household
was subtracted from this total household mortality rate. To further avoid overcounting the loss of
caregivers through multiple deaths, the probability of deaths of multiple caregivers in the same household
was subtracted from the total household death rate.

CALCULATION OF THE NUMBER OF COVID-19 BEREAVED CHILDREN

The number of COVID-19 bereaved children was calculated by multiplying the probability of losing
caregiver(s) in the households of children of each state, race/ethnicity, and age group by the
corresponding weighted sample size. This resulted in a child centric measure of COVID-19 bereavement,
in that bereavement was calculated in relation to the demographic attributes of the children.

LIMITATIONS

There are, of course, limitations to this study. First, there is inherent uncertainty in estimates derived
from survey data and extrapolation and though we did our best to minimize that uncertainty, it is still
present. Second, while race and ethnicity categorizations between CDC (death estimates) and the ACS
(population records) are congruent, how individuals are categorized into those races may be differ. Third,
the CDC notes that underreporting of deaths for people of Hispanic origin and those of non-Hispanic
American Indian or Alaska Native and non-Hispanic Asian or Pacific Islander race, meaning both that
these statistics should be interpreted cautiously and that our estimates of bereavement for these groups
are likely to be understated. Fourth, we use 2019 population data from the American Community Survey
Public Use Microdata Sample, as the 2020 data (which the Census Bureau will note as experimental) have
not yet been released.

HIDDEN PAIN 79
Hidden Pain
Children Who Lost a Parent or Caregiverto COVID-19
and What the NationCan Do to Help Them

DECEMBER 2021