|Year : 2022 | Volume
| Issue : 2 | Page : 101-105
Children Orphaned Due to COVID-19 Pandemic: Learning from the Past and Preparing for Their Future
Consuelo Cagande1, Raman Marwaha2, Mariam Rahmani3, Rama Rao Gogineni4
1 Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania; Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA
2 Department of Psychiatry, Case Western Reserve University, MetroHealth System, Cleveland, Ohio, USA
3 Department of Psychiatry, University of Florida, Gainesville, Florida, USA
4 Department of Psychiatry, Cooper Medical School of Rowan University, Camden, New Jersey, USA
|Date of Submission||29-Jun-2022|
|Date of Decision||29-Jun-2022|
|Date of Acceptance||30-Jun-2022|
|Date of Web Publication||22-Aug-2022|
Dr. Consuelo Cagande
Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, 3500 Civic Blvd, HUB Bldg, DCAPBS,12th floor, Philadelphia, PA 19104
Source of Support: None, Conflict of Interest: None
A worldwide spread of children orphaned due to COVID-19 was another tragedy many families and communities faced. Between March 2020 and October 2021, 5·0 million COVID-19 deaths had occurred worldwide, and roughly 5·2 million children had lost a parent or caregiver due to COVID-19-associated death. However, the great orphaning was not affecting all demographic groups equally, with different racial and ethnic groups experiencing different levels of mortality. This study further discusses the impact of the pandemic on transnational orphans in the U.S., society, development, and emotions. In addition, there were lessons learned from prior global pandemics such as the Spanish Influenza of 1918 and the HIV pandemic that left children orphaned. Therefore, there were strategies to help mitigate the impact on children orphaned due to a pandemic. They include engaging the community, developing and improving evidence-based programs, and providing a safe environment as well as protective and mental health services and trauma-informed care for children worldwide. Lessons from the past should drive the advocacy for such programs and hope for the future.
Keywords: COVID-19, orphans, pandemic
|How to cite this article:|
Cagande C, Marwaha R, Rahmani M, Gogineni RR. Children Orphaned Due to COVID-19 Pandemic: Learning from the Past and Preparing for Their Future. World Soc Psychiatry 2022;4:101-5
|How to cite this URL:|
Cagande C, Marwaha R, Rahmani M, Gogineni RR. Children Orphaned Due to COVID-19 Pandemic: Learning from the Past and Preparing for Their Future. World Soc Psychiatry [serial online] 2022 [cited 2022 Sep 27];4:101-5. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/2/101/354180
| Introduction|| |
Among the many tragedies of the COVID-19 pandemic is a worldwide spread of children orphaned. Caregiver deaths from COVID-19 amounted to millions within just 2 years. This study reviews the global magnitude of children orphaned during the pandemic, especially transnational orphans in the U.S., its social, developmental, and emotional consequences, and discusses the application to the current pandemic of lessons learned from another global pandemic, the Spanish Influenza of 1918, the HIV pandemic, and other global catastrophes that left children orphaned. Strategies are discussed to help mitigate the impact on children orphaned due to a pandemic. First, three cases in which children were orphaned due to COVID-19 were presented.
| Case|| |
This case was a 7-year-old girl of South Asian descent who lost her father to COVID-19 after he went to visit his home country due to her grandparent's sickness. Her father fell sick in his home country (India) and was hospitalized for 10 days. She was unable to talk to him when he was taken to the intensive care unit, and she kept on thinking that he would call her. He was on a ventilator for a few days and she was not able to communicate with him. During his hospital stay, she was told that he was sick and would come back to the US as soon as he gets better. When he passed away, she kept on saying “He is with grandpa and when will he come back?. After a few days, she started asking her mother “did papa leave us to be with God.” The girl kept on crying, wondering why her dad did not call her. She was scared of anyone leaving the house as she worried they would get sick and not come back. She would not let her mother leave her and started worrying, crying, and saying she had stomach pain when her mother would leave home for any errands. Her mother brought her to a primary care physician (PCP) as she was not attending school and did not want to leave the house. Her PCP referred them to see a therapist and a psychiatrist. Her mother had additional stress of the possibility of being deported as they were immigrants, and the family was dependent on her husband's worker visa status in the US. She saw a therapist who used culturally informed care to help her and her mother with the grieving process. The family used virtual technology to say their prayers and follow ceremonies important for their culture and religion. Their local community in the US helped them with providing a social support system and providing ceremonial tasks important for the family. While the 7-year-old and her family faced difficulties with loss of a parent transnationally during the pandemic, they also got help in adapting to it from their extended social networks and coming together to process collective grief as a community.
| Results|| |
Between March 2020 and October 2021, 5·0 million COVID-19 deaths had occurred worldwide, and roughly 5·2 million children had lost a parent or caregiver due to COVID-19-associated death. Unwin et al. reported that the number of children who experienced COVID-19-associated orphanhood and caregiver death over a 6-month study period (May 1, 2020, to October 31, 2021) was nearly double the rate observed in the first 14 months of the pandemic (March 1, 2020, to April 30, 2021). It is noteworthy that nearly 800,000 children have experienced the death of their mothers, and almost 2·6 million children are estimated to have experienced the death of their fathers. Thus, 3 out of 4 children affected by COVID-19-associated orphanhood lost their fathers. Of different age groups, adolescents have been more vulnerable to COVID-associated orphanhood than younger children. For example, nearly 500,000 children aged 0–4 years, >735,000 children aged 5–9 years, and >2·1 million children aged 10–17 years were estimated to be orphaned during the pandemic until October 31, 2021. There are also geographical disparities, as noted by Africa and Americas having the highest proportion of children 0–9 year old and European and Eastern Mediterranean regions having the highest proportion of children 10–17 year old affected by COVID-19 associated orphanhood. For South Africa, at least one in every age group has experienced COVID-19-associated orphanhood.
As with so many things, the great orphaning is not affecting all demographic groups equally, with different racial and ethnic groups experiencing different levels of mortality. In the US, roughly 149,300 children have been orphaned due to the COVID-19 pandemic. For every one white American child orphaned, 1.8 Hispanic American children, 2.4 Black Americans and 4.5 Native Americans and Native Alaskans were affected. Possible reasons for these racial disparities include misinformation about COVID-19 infection, disproportionate COVID-19 vaccine hesitancy, overrepresentation in the low wage, essential workforce at the front lines, higher likelihood of living in overcrowded housing, and higher number of medical comorbidities.
In addition, as the Pediatrics paper reports, in the U.S., about 4.5 million children live with a grandparent who's providing their housing, rather than with their parents, but rates of such grandparent care are twice as high among Black, Hispanic and Asian children. With COVID-19 impacting the elderly more severely than younger adults, the risk is greater that a custodial grandparent will be lost compared to a parent–and when that happens, the authors of the study wrote, “these children, functionally, face orphanhood a second time.”
Orphaned children are especially at increased risk for abuse and economic and sexual exploitation. UNICEF has found that increased mortality of adults including parents in families is resulting in increasing poverty, difficulties with childcare, lack of preventive health services, and food insecurity in children around the globe, which in turn is related to higher rates of COVID-19-related deaths.
For the last two decades, the epigenetics of childhood trauma, the process by which gene expression can be switched on or off depending on life experiences, have been studied by the Centers for Disease Control and Prevention. The activity of the genes can be profoundly affected by adverse events such as losing a caregiver, and that can mean an increased lifetime risk of all kinds of diseases, including every major cause of death in adulthood – cardiovascular disease, diabetes, cancer, chronic obstructive pulmonary disease and suicide. Furthermore, the impact of losing a parent/caregiver on a child can be traumatic enough to cause lower educational attainment, slower brain development, and a higher risk of mental health disorders and substance abuse.
During the HIV/AIDS crisis, more than 13 million children lost one or both parents. Sub-Saharan Africa had nearly 80% of these orphans. More often, foster care may be the only option within a country with a foster system that is already straining under the burden of caring for hundreds of thousands of children.
| Transnational Orphans|| |
Immigrants make up about 14% of the U.S. population, and about a quarter of all children in the U.S. have at least one parent who is an immigrant. Immigrants leave behind their extended families in their countries of origin creating transnational families. During the pandemic, many immigrants have lost family members in their home country, and they have faced additional challenges to cope with grief. Their grieving process can be impacted by not being able to go to their home country due to immigration-, financial-, health-, and pandemic-related challenges. They may experience guilt and a longer period of denial. Certain cultures also have rituals that they follow which if unable to do can interfere with bereavement. It can be painful to grieve without being able to see your family. Virtual technologies such as Zoom, WhatsApp, Viber, FaceTime, and Skype have helped transnational families keep in touch and help with sharing experiences during crises such as bereavement. Children and families not being able to physically grieve can lead to anxiety, sadness, and guilt and it may lead to unresolved grief.
| Historical Aspects of Spanish Influenza Pandemic of 1918|| |
Close to a third of the world's population became infected by the Spanish Flu and it reached epidemic proportions across the globe by October 1918. Nearly fifty million people died worldwide. In 1918, a preventive vaccine to protect against influenza was yet to be developed and there were no treatments available to treat the infected. While the flu infected people of all ages, those aged 20–39 years suffered the highest mortality rates. The deaths of these young adults not only created widows and widowers, but also “half-orphans,” and children with neither a father nor a mother. In New York City alone, the flu produced nearly 31,000 orphans in just a matter of weeks. To help with this, community members came together to care for orphans. Families had to pick up their lives following the deaths of loved ones, and the extended family played an essential role in caring for orphans. Relatives, grandparents, and extended family were primarily responsible for the well-being of their family members and frequently took in widows and children. However, there were many who had no family to turn to including the large population of immigrants. For them, adoption provided stability for some orphaned children, but there were thousands of others who lacked kind strangers to come to their aid. Some of these children especially the older ones took care of their orphaned siblings and worked hard to stay with their siblings, despite the economic hardships that this entailed.
Emotional and economic consequences for orphaned children from Spanish flu
Loss of parents at a young age had a significant impact on the emotional well-being of orphans created due to flu pandemic. Many children did not know that their mother or father or both were dead. The younger ones were reported to be calling out for their mothers in their sleep. There was also a long-term economic impact which resulted from single-parent families to orphanages trying to take care of these children.
The Spanish flu epidemic, which had a peak around fall of 1918 and largely subsided by January 1919, generated sharp predictions for long-term effects. Data from the 1960 to 1980 decennial U.S. Census indicated that cohorts in utero during the pandemic displayed reduced educational attainment, increased rates of physical disability, lower income, lower socioeconomic status, and higher transfer payments compared with other birth cohorts. These results indicate that investments in fetal health can increase human capital.
How American families emerged from the Spanish flu
The Spanish influenza pandemic of 1918 had significant effects on the American family. While it tore households apart, extended family and community members sought to recreate the stability of families by caring for widows, widowers, and their children. Relatives and community members provided crucial support structures to flu survivors, and although many consider 1918 to be a difficult time, it quickly became a year marked with generosity and love. American communities and religious organizations were united in fighting for the well-being of the families left behind. Innocent children were the most impacted victims of the flu and orphans were cared for by extended family, older siblings, orphanages, or adopted by kind strangers. Whatever fate had in store, family and community members strove to ensure that flu orphans were cared for. Although the circumstances of many must have been bleak, individual women, men, and children displayed considerable resilience and courage. The flu pandemic was a difficult time for American families, but it also helped define and characterize them as resilient as communities showed courage, strength, and endurance.
| Strategies to Mitigate Impact of Losing a Caregiver to a Pandemic|| |
As the pandemic starts to wane, more information on how to mitigate its impact on COVID-19-associated orphaned children are being published. Based on lessons learned from other pandemics, such as the Spanish flu epidemic and HIV/AIDS epidemic, evidence-based interventions and a safe and stable environment can improve outcomes for children made orphans by a pandemic. Keeping children in their families or extended families is vital and supporting the bereaved families should be a priority. Ensuring that they have continued access to social protection, counseling, and health care is very important to foster normal physical, emotional, mental, and spiritual development. In addition, keeping schools open and accessible is recommended.,
Developing programs that address adverse childhood experiences, promote resilience, and nurture relationships is critical. In terms of resilience, the National Institutes of Health recommend strengthening economic support to families, quality childcare and educational support, and evidence-based programs to improve parenting skills and family relationships. The developmental age of the child should be kept in mind when addressing the impact of the loss, including the cultural, racial, and structural disparities and inequalities.
Protective and mental health services for children are critical for orphans worldwide. Social welfare and child protection organizations should be funded, strengthened, and respected. Sustainable national social service systems, including workforce and other social service agencies, need to be strengthened to be able to ensure that orphaned and abandoned children can live in safe environments.,
The Tanzania Youth Scholars Project Case Study funded through USAID and US President's Emergency Plan for AIDS Relief Published identified seven best practices for working with this population:
- To be successful, one must address the daunting academic, financial, emotional, and social challenges that create additional barriers to success for orphans and vulnerable children
- Recognize and work to understand the different reasons students drop out, and address them in ways that respects family status, educational level, and gender
- Adopt a comprehensive approach to training, packaging career guidance, life skills, alignment of training with the job market, internships, job placement services, and entrepreneurship training
- Increase engagement by using interactive methodology by Interactive learning, group projects with simulated business
- Encouragement and basic resources to foster entrepreneurship
- Increase young people's access to services and opportunities by bringing the public and private sectors together
- Gather and examine the data to measure progress, qualitative data and remaining flexible.
Individual therapy, such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), could be an important intervention for children who present with trauma symptoms. Assessing these children will require trauma and culturally informed care such as in the case above. A study by Dorsey et al. found that TF-CBT was more effective than usual care in reducing posttraumatic stress among children who experienced parental death in 3 of 4 sites in Kenya and Tanzania. At 12-month follow-up, TF-CBT was more effective in reducing PTS only among children in rural and urban Kenya.
”The children learned that you don't lose the relationship,” Dorsey said. “You have to convert that relationship to one of memory, but it is still a relationship that can bring comfort.” In the study, guardians who were also grieving and took in an additional family member also learned coping skills for themselves and to support their orphan. In addition, Shumba and Moyo studied counseling needs of orphaned children due to HIV/AIDS in schools. Based on their findings, they recommend schools to ensure orphans receive effective counseling services in order to further prevent decline in academic performance.
It is also essential to provide community-based caregiver or family interventions to support orphaned children's mental health. A review of evaluation studies by Penner et al. found that programs undertook cultural adaptation of the intervention using community participatory methods or were locally developed. The majority of interventions targeted caregiving behavior and/or caregiver–child relationships using behavioral and cognitive behavioral strategies, or were home visiting interventions. Interventions had mixed effects on the orphan's mental health.
| Conclusion|| |
”Through pandemics and epidemics, hope stays alive” UNICEF
Growing statistics and knowledge of the impact on orphaned children due to a global pandemic are sobering. Losing a caregiver as a child is an adverse childhood experience with lifelong effects. To promote success in these children, social services and educational programs need to be comprehensive, developmentally focused and evidence based. It is important to involve and strengthen communities to help provide emotional and financial support. Lessons from the past should drive the advocacy for such programs and hope for the future.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Unwin HJ, Hillis S, Cluver L, Flaxman S, Goldman PS, Butchart A, et al.
Global, regional, and national minimum estimates of children affected by COVID-19-associated orphanhood and caregiver death, by age and family circumstance up to Oct 31, 2021: An updated modelling study. Lancet Child Adolesc Health 2022;6:249-59.
Willis DE, Andersen JA, Bryant-Moore K, Selig JP, Long CR, Felix HC, et al.
COVID-19 vaccine hesitancy: Race/ethnicity, trust, and fear. Clin Transl Sci 2021;14:2200-7.
Bibbins-Domingo K. This time must be different: Disparities during the COVID-19 pandemic. Ann Intern Med 2020;173:233-4.
Poulson M, Geary A, Annesi C, Allee L, Kenzik K, Sanchez S, et al.
National disparities in COVID-19 outcomes between black and white Americans. J Natl Med Assoc 2021;113:125-32.
Trask BS. Globalization and Families: Accelerated Systemic Social Change. New York: Springer; 2010.
Falicov CJ. Working with transnational immigrants: Expanding meanings of family, community, and culture. Fam Process 2007;46:157-71.
Bravo V. Coping with dying and deaths at home: How undocumented migrants in the United States experience the process of transnational grieving. Mortality 2016;22:33-44.
Boss P. Ambiguous Loss: Learning to Live with Unresolved Grief. Cambridge: Harvard University Press; 2000.
Almond D. Is the 1918 influenza pandemic over? Long-term effects of in uter
o influenza exposure in the post-1940 U.S. population. J Polit Econ 2006;114:4. p.672-712.
Alkhehaiwi AM. The psychology of a child who grew up in an orphanage. J Educ Psychol Sci 2018;15:157-64.
Hillis SD, Blenkinsop A, Villaveces A, Annor FB, Liburd L, Massetti GM, et al.
COVID-19-associated orphanhood and caregiver death in the United States. Pediatrics 2021;Oct 7:e2021053760.
Dorsey S, Lucid L, Martin P, King KM, O'Donnell K, Murray LK, et al.
Effectiveness of task-shifted trauma-focused cognitive behavioral therapy for children who experienced parental death and posttraumatic stress in Kenya and Tanzania: A randomized clinical trial. JAMA Psychiatry 2020;77:464-73.
Shumba J, Moyo G. Counseling needs of orphaned children: A case study of Harare metropolitan children. Mediterranean J Soc Sci 2014;5:145-56.
Penner F, Sharp C, Marais L, Shohet C, Givon D, Boivin M. Community based caregiver and family interventions to support the mental health of orphans and vulnerable children: Review and future directions. In: Tan M, editor. HIV and Childhood: Growing up Affected by HIV. New Directions for Child and Adolescent Development. Wiley Periodicals, Inc, Published online in Wilet Online Library (wileyonlinelibrary.com) DOI: 19.1992/cad.20352.