The number of children under the age of 18 who are estimated to have experienced the death of a parent or co-residing grandparent caregiver in the United States surged to nearly three million by 2021, finds a new study involving UCL researchers.
The research, published in Nature Medicine, is the first paper to examine trends in all types of orphanhood in the U.S.
The authors combined multiple datasets that included state-level population and mortality estimates by sex, age, race and ethnicity; survey estimates of family composition to determine numbers of grandparent caregivers in homes; and fertility rates from 1969 to 2021 to estimate the number of children in families by age categories.
This approach made it possible for them to estimate the incidence and prevalence of children affected by the death of a caregiver or a co-residing grandparent caregiver each year, from 2000 to 2021.
They found that, between 2000 to 2021, the number of children newly affected by all-cause orphanhood and caregiver death increased by 50%, and the total number of children living with orphanhood increased by 8%.
Adolescent children aged between 10-17 years old were disproportionately affected, with 1.7 million (5.2%) losing either a mother, father, or both parents to premature death.
Increased orphanhood risks were also observed among American Indian or Alaska Native children (6.4%) and Black children (4.7%)
Meanwhile, the researchers also observed state-level variations in orphanhood prevalence, with children in southern and eastern states disproportionately affected. The five states with the highest orphanhood burden (West Virginia, New Mexico, Mississippi, Louisiana, and Kentucky) were also the five states with the highest poverty levels.
This highlights the link between poverty and premature deaths of parents, which in turn is creating a hidden generation of orphanhood among their bereaved children.
Co-author Professor Lorraine Sherr (UCL Institute for Global Health), who is also a member of the Global Reference Group for Children in Crisis, said: "This paper will not only elevate the conversation on the hidden crises affecting children in the United States in an unprecedented way, but will provide a platform for global attention to the issue of orphanhood and the under provision for children.
"It is our clear vision that the guidance of 'prepare, prevent and protect' should be a policy call for all countries. The numbers are staggering, the burden is high, and the long-term ramifications cannot be underestimated."
Since 2020, drug overdose has been the leading cause of orphanhood incidence and prevalence, surpassing COVID-19. Orphanhood rates particularly escalated from 2020 to 2021, with the intersecting crises of the overdose epidemic and COVID-19 pandemic.
Additionally, for 48 states, fatal injuries (i.e. drug overdose, suicide, homicide), and unintentional injuries - were among the top two causes of orphanhood in 2021.
Orphanhood due to fatal injuries was higher than orphanhood due to leading chronic diseases (such as heart disease and cancers) as a cause of death in parents.
Overall, evidence shows that children who experience the loss of a caregiver have an increased risk of poverty, exploitation and sexual violence or abuse, HIV infection, mental health challenges, and severe distress. In some contexts, they also have increased vulnerability to gang involvement and violent extremism.
Given the scale of caregiver death, the researchers are now calling for comprehensive, evidence-based programmes for children experiencing orphanhood as a moral and public health imperative.
They highlight three key ways to help orphans recover and be resilient, which could also guide policies. These include:
- Preventing the death of parents and caregivers by providing timely prevention and treatment for major health issues and ensuring everyone has access to health and mental health care.
- Preparing families to offer safe and loving alternative care for children.
- Protecting children who have lost parents by offering grief and mental health counselling, and support for parenting, finances, and education.
These strategies can be adapted and prioritised based on the specific needs of children who have lost their caregivers.
Senior author, Dr Susan Hillis (Imperial College London and the US Centres for Disease Control and Prevention), said: "We estimate that one child of every 25 children in the United States has experienced death of a parent or caregiver. These children face a heightened risk of lifelong adversity, unless given appropriate support in time.
"Our findings show the urgency to invest in response plans focused on children at greatest risk and in the locations most affected. Effective policies can build on two decades of experience supporting vulnerable children through the HIV/AIDS epidemic, to offer needed support for children experiencing loss from any cause, in the U.S. We have seen that timely, responsive, and supportive intervention transforms acute and lasting threats into lifelong dividends. The right help provided over the appropriate time period can transform trajectories of despair into trajectories of hope."
Senior author, Dr Oliver Ratmann (Imperial College London) said: "Our estimates are directly based on death and birth registration data and so indicate a powerful pathway to supporting affected children and families, simply by collecting vital information on the number and ages of children left behind at every death registration.
"This could unlock immediate and comprehensive support at a critical time and put to an end the largest of all challenges: finding all the children that collectively make up this public health crisis."
Study limitations
The estimates in the study are generated by mathematical modelling and do not count actual numbers of children affected by parent or caregiver death. Most notably, the estimated number of children per death in caregiver ages is estimated by population-level fertility rates and may over- or undercount the actual number of children affected, and hence caregiver death incidence and prevalence. Additionally, limited information on the roles of co-residing grandparents supporting children may underestimate their contributions to caregiving.
