"I didn't know how to talk to the ambulance people. I kept calling Ro the 'patient.' They [the dispatcher] asked me to check his pulse, so I ran back to his room. He was sitting in his recliner, slumped over and drooling. They told me to start CPR, but he's 5' 10" and I'm 5' 2", and I couldn't get him out of the chair. All I could think to do was grab his face and scream at him not to die."

COVID-19 was rampaging through Arizona at the time. The morgues were full and bodies were being stored in refrigeration units. When the paramedics arrived, they were wearing full protective gear. To a child's sensibility, they probably resembled aliens.

"The paramedics were in there for about 10 minutes," continues Susan, hesitating now and then to choke back emotion. "The kids were still in their rooms, but they heard the machines and the screams of 'Clear!'"

"I was sitting in the rocking chair in the front room, texting friends and family about what was happening, expecting someone to come out at any moment and say, 'Everything is under control, we're taking him to so-and-so hospital.'"

Instead, the fire chief came out holding Ro's wedding ring. "He handed it to me and said, 'We lost him.'"

She remembers that a social worker who had come with a crisis team looked at her and suggested she tell her children.

"As crazy as it sounds, I didn't want to tell the kids. I wanted to protect them," Susan says. But she sat the kids together on the bunk bed and broke the news."

"I told them, 'Mommy did everything she could, but we lost Dad.' Rodrigo, my baby [age 6], got very sad and clingy. He just wanted his mommy. My middle son, Rowen [age 13], tried taking the blame, saying maybe if he had been a better son and done CPR, he could have saved him. My daughter, Roana [age 19], secluded herself away."

Susan says Ro's body remained in the bedroom for 5.5 hours while the police and coroner completed their work. At 11:45 p.m., a funeral director finally wheeled out Ro on a gurney covered by a red velvet blanket. 

"That was the last time the kids saw their father," Susan says. "There was never a funeral. We said our final goodbyes in our front room."

Indeed, losing a parent is one of the most significant experiences a child can have. But losing a parent or primary caregiver to COVID-19 can be even worse.

Two prominent psychiatrists shared their thoughts on this for this story. Asim Shah, MD, is a professor and executive vice chair of the Menninger Department of Psychiatry at Baylor College of Medicine in Houston. Warren Y.K. Ng, MD, is the president of the American Academy of Child and Adolescent Psychiatry (AACAP) and a professor of psychiatry at Columbia University in New York. Both are on the front lines of helping children who lost a parent to COVID-19. They defined six distinct challenges that must be kept in mind when counseling them.

Trauma: Shah has counseled survivors of 9/11 and Hurricanes Katrina and Harvey. He's noted that while those disasters were over in a few hours, COVID-19 has been relentless for a long time, which adds to the trauma. 

The images of people on ventilators, bodies being stored in refrigerated trailers, the daily death counts, and the general confusion about how the virus is transmitted and how to protect yourself -- especially during the pandemic's early stages -- all resulted in unprecedented levels of stress, fear, and trauma for adults, let alone children. These kids have been through the equivalent of war.

Stigma: Ng works with racially ethnic minority communities in northern Manhattan. It's a high-density population, with many families packed into high-rise apartment buildings. It's the type of living arrangement where everyone knows everyone's business.

At the height of the pandemic, Ng says, people were ostracized for having COVID. It's like they had a big red C on their door, warning neighbors to stay away.

As the pandemic progressed, the stigma grew beyond the disease itself. Anti-maskers and anti-vaxxers were considered stupid or selfish by some. If they contracted the virus, they were seen as deserving the consequences.

"I have a very close friend with two kids, ages 7 and 11, who is a nurse in Arkansas," Shah says. "She wore a mask all the time, but her husband didn't believe in masking. He believed this was all made up. Unfortunately, he got COVID and was on a ventilator for 29 days. Before dying, he admitted that he should have listened to his wife and wore a mask. He died with guilt, and he passed on that guilt to his kids."

Blame: If a child brought home the virus that eventually killed a parent or caregiver, or if he or she, like 13-year-old Rowen Lechuga, feels they could have done something to save them, that can eat away at one's mental health. The memory is a cruel and persistent reminder that you may be responsible. And that can have devastating effects.

Ng tells the story of a 9-year-old boy he treated whose father died of COVID. Both parents were in the health care field, so they didn't have the luxury of working remotely. And because of limited resources, they worked opposite shifts.

The father was sick at home while the mother was working nights. The boy was sleeping in bed with his dad when he passed away, and he didn't realize it until his mom got home the following morning. He was distressed that his father wouldn't wake up and that his mother was so overwhelmed and grief-stricken. Having to quarantine afterward compounded their situation.

"The boy became very preoccupied with wanting to join his father," Ng recalls. "He wanted to die and be asleep forever. He was at that stage in his development where he didn't quite understand what death meant or what had happened to his father, and why nobody could come visit. All this furthered his sense of aloneness, sadness, and trauma. He also had a sense of guilt that maybe he had done something wrong. All this alarmed the mother, and she brought him in for treatment. Fortunately, we were able to work through the confusion and help him understand that it wasn't his fault."

Lack of closure: At the height of the pandemic, in-person funerals and memorial services were canceled. Such rituals for honoring a life are important to the healing process. But instead of feeling the love and support of family and friends, survivors often felt abandoned.

Even goodbyes were hard to come by. If a loved one was hospitalized, they were often isolated in ICUs that didn't permit visitors or, because of being on ventilators, they were uncommunicative. If there was a chance for some final interaction, it was usually the partner who got priority. In many cases, the situation was considered too much for children to be exposed to.

"The trauma people had at that time is just unimaginable," Shah says. "Consider you've just lost a loved one: a) You cannot see them, b) You cannot go to their funeral, and c) You cannot even come close to their dead body. It was treated like a contaminated fixture. All those things combine to multiply the trauma."

Financial insecurity: Dan Treglia, PhD, an associate professor at the University of Pennsylvania in Philadelphia and a co-author of Hidden Pain, says the death of a parent or primary caregiver often has "cascading consequences" because it disproportionately affects families with less financial resources.

"The child loses not just a caregiver but a breadwinner," Treglia explains. "Suddenly, the family can no longer afford to live in the same place. Suddenly, they're moving or become homeless or food insecure. Suddenly, they no longer have health insurance. This creates all kinds of other challenges."

Ng cites a United Hospital Fund report for New York State that found that 50% of children who lost a parent or caregiver were likely to enter poverty, with 23% at risk to enter foster or kinship care. "These compounding factors add to the level of distress these kids may experience," he says.

Ongoing reminders: Although the pandemic has subsided somewhat and we know much more about the virus, COVID is still far from being out of the news, and that can be a cruel reminder for families who've lost loved ones.

"A child's home is their sanctuary," Ng says, "but for many it suddenly became unsafe. Their world was turned inside out. They thought that home and family meant safety and security, but now with COVID-19 there's this danger within."

"Even though my husband died a year and a half ago, every single day my children are hearing about what killed their dad," says Susan Lechuga, who moved to California shortly after Ro's death to be closer to family. "If he had died in a car accident, I wouldn't have to worry about turning on the TV and hearing there were 2,598 car accident deaths today. But if I turn on CNN, I can guarantee you that in 10 minutes there's going to be something about COVID."

"We have yet to be able to say this is over, the pain can now heal," she continues. "The media, politicians, and society keep throwing it in our faces every day, and we cannot step out of this cycle of grief."

Shah, who practices psychiatry in the largest outpatient network in Houston, is also frustrated.