More Than 1.4 Million US Children Have Lost a Family Member to Drug Overdose

Abstract

Objectives. To estimate children’s exposure to family overdose in the United States.

Methods. We used recent demographic kinship modeling advances and the Centers for Disease Control and Prevention’s most recent underlying cause of death estimates to model how many children aged younger than 18 years in 2019 had lost 1 or more parents, siblings, grandparents, aunts or uncles, or cousins to overdose mortality since birth. We calculated the number and proportion of children with such exposures and considered age, cohort, and gender patterning.

Results. More than 1.4 million children in the United States, mostly adolescents, experienced a family overdose death, often losing central figures like parents or grandparents. Cohort analyses suggest dramatic increases in these exposures, portending mounting prevalence.

Conclusions. Attention to the large population with lives disrupted by overdose deaths should include affected children. The long-arm consequences of the overdose crisis will continue to define the public health landscape for decades. (Am J Public Health. 2024;114(12):1394–1397. https://doi.org/10.2105/AJPH.2024.307847)

A recent AJPH study by Athey et al. shows that personal connections to overdose deaths have disrupted the lives of more than 1 in 8 adults in the United States.¹ Using survey reports, their study builds on emerging research about the secondary impacts of overdose deaths. Other surveys indicate that 13% of adults lost a loved one or close friend² and 9% lost someone in their family³ to overdose. Collectively, these studies draw attention to a neglected and vulnerable population bereaved by overdose, but they overlook an important group: children younger than 18 years old.

The prevalence of personal connections to overdose loss among children is unclear. Few surveys measure child bereavement in general, let alone children’s exposure to specific causes such as overdose. Yet there are many reasons to suspect that exposure to overdose deaths is pervasive among children. The average age of overdose death has drifted down in recent decades,⁴ putting those dying of overdose in prime family years. Postpartum overdoses are soaring,⁵ amid an exponential expansion in overdose deaths at all ages, including a 12-fold increase since 2000 among adults older than 55 years, that potentially implicates grandparental and other losses.⁶ During the same period, long-standing negative associations between family structure and substance use attenuated, also increasing children’s risk of loss.⁷ Recent modeling efforts confirm these suspicions, finding that 322 000 US children lost a coresidential parent to overdose between 2011 and 2021⁸ and 759 000 lost a parent to overdose between 1999 and 2020.⁹ Both estimates, however, are cumulated over many years and pertain to the exposure of children who were younger than 18 years at the time of loss, not all of whom remain so. Other familial exposures to overdose loss have not been examined.

Overdose loss among children is severely disruptive. Experiencing a loved one’s death profoundly influences immediate and long-term mental and physical health.¹⁰ Children are not immune to these losses; they exhibit a range of behavioral and health challenges after experiencing a family member’s death,¹¹ including elevated rates of substance use.¹² Although most child bereavement research focuses on parental death, other family deaths are also consequential, including siblings¹³ and more extended relatives like grandparents, aunts and uncles, and cousins.¹⁴ Children who lose loved ones to stigmatized causes such as overdose face unique risks.¹⁵ Given the critical implications of overdose death for children’s short- and long-term well-being, research is needed to establish the prevalence of overdose loss during this key developmental stage.

METHODS

To examine US children’s exposure to familial overdose deaths, we modeled whether US children had a relative die from drug or alcohol overdose as an underlying cause of death since birth (see Appendix, available as a supplement to the online version of this article at http://www.ajph.org). Using demographic models of kinship and bereavement and dynamic fertility and mortality data from 2000 to 2019, the most recently available years without COVID-19 disruption, we estimated children’s age-by-year exposure to overdose losses among a wide range of biological family members (parents, siblings, grandparents, aunts and uncles, and cousins). We report the prevalence of losses among US children in 2019 by taking all those younger than 18 years in 2019, weighting each single year of age group by its corresponding 2019 population size, and calculating the weighted total and percentage. Our modeling strategy capitalized on new advances in established demographic techniques, including the ability to model experiences of family death from specific causes, using time-varying demographic rates, and separately estimating losing male and female relatives, each of which is important to consider given the dramatic increases in and the gendered patterning of overdose death rates.⁴

Details on these methods, their limitations, and additional analyses are available in the online Appendix. To examine the life course timing of these losses, cohort changes in prevalence, and their gendered nature, we generated age-specific estimates for children younger than 10 years and aged 10 to 17 years, examined these patterns by birth cohort, and separately modeled the deaths of male and female relatives.

RESULTS

We estimated that more than 1.4 million children in the United States experienced at least 1 familial overdose death since birth (Table 1; Appendix Figure A). In total, our results suggest that 1.8% of children in 2019 had experienced such a death. Most strikingly, this percentage reflects approximately 408 000 children aged younger than 10 years and 1.01 million children aged 10 to 17 years. Although older children experienced overdose losses more frequently, these experiences were patterned by birth cohort, with younger cohorts experiencing much higher rates of overdose loss by each age than older cohorts did, a fact not seen for losses from other causes (Appendix Figures B and C).

TABLE 1—

Estimates of Counts and Percentages of Children Aged Younger Than 18 Years in 2019 Who Had Lost Various Relatives to Overdose Deaths During Their Lifetimes, Overall and by Age Group: United States

	Estimated No. of Children, Thousands (% of Population in Age Group)
Total US population aged < 18 y	77 295.0
Total who experienced kin loss to overdose death	1 421.8 (1.8)
Total who lost ≥ 1 of following to overdose deatha
Parents	317.2 (0.4)
Siblings	14.7 (< 0.1)
Grandparents	476.8 (0.6)
Aunts and uncles	536.0 (0.7)
Cousins	89.2 (0.1)
Total US population aged birth to 9 y	39 772.6
Total who experienced kin loss to overdose death	408.0 (1.0)
Total who lost ≥ 1 of following to overdose deatha
Parents	85.3 (0.2)
Siblings	1.3 (< 0.1)
Grandparents	164.6 (0.4)
Aunts and uncles	146.2 (0.4)
Cousins	12.6 (< 0.1)
Total US population aged 10–17 y	37 522.4
Total who experienced kin loss to overdose death	1 013.9 (2.7)
Total who lost ≥ 1 of following to overdose deatha
Parents	231.9 (0.6)
Siblings	13.4 (< 0.1)
Grandparents	312.2 (0.8)
Aunts and uncles	389.8 (1.0)
Cousins	76.6 (0.2)

Note. All relatives are biological only. Total US population in age group estimates is based on 2019 US Census population estimates.

^a Not mutually exclusive; could lose more than 1 relative of more than 1 type.

The results in Table 1 further demonstrate the wide range of family that children lose to overdose. An estimated 536 000 children (0.7% of the population younger than 18 years) experienced the overdose death of an aunt or uncle, 477 000 (0.6%) experienced the overdose death of a grandparent, and 317 000 (0.4%) experienced the overdose death of a parent, followed by fewer overdose deaths of cousins (0.1%) and siblings (< 0.1%). These patterns were similar across age groups.

Taking a gendered perspective, our estimates confirm that the deaths of male relatives drive the staggering toll of children’s overdose loss (Appendix Table A), in line with higher male overdose mortality.⁴ Among all children, 926 000 (1.2%) lost a biological father, brother, grandfather, uncle, or male cousin, compared with 503 000 (0.7%) who lost a comparable female relative. Similar male-to-female loss ratios of 2 to 2.5 are seen across both age groups (< 10 years and 10–17 years) and for each focal type of relatives, except grandparents, for whom the ratio is closer to 1.75.

DISCUSSION

Existing data sources are ill-equipped to capture the rates, structure, and experiences of overdose loss among children, leaving this population overlooked in assessments of the overdose crisis. Using recent modeling advances, we reveal the high burden that overdose deaths place on children in the United States, estimating that a staggering 1.4 million children in 2019 had experienced at least 1 family overdose death during their lifetime. Notably, these estimates pertain only to some of the most intimately related family ties—those among children’s biological grandparents, parents, aunts and uncles, siblings, and cousins. More children are presumably affected by overdose deaths among other important figures, including unexamined relatives, friends, neighbors, and others. This share would expand further if deaths before a child’s birth were considered. The rising burden of loss among children younger than 10 years is especially alarming, portending further growth in this secondary public health threat. Substantial increases in overdose death rates since 2020 further highlight the conservative nature of our estimates. Future work should examine racial, ethnic, geographic, and other disparities in these losses. Scholars also must prioritize the development of culturally sensitive interventions for children’s bereavement.

As Athey et al.¹ emphasize, greater attention is needed for the millions intimately affected by overdose deaths—and this brief report serves to remind that this population includes children. Although comparatively few children die of overdose, they are far from passed over by this crisis. The high burden of overdose loss experienced among children is only likely to grow more prevalent as a public health concern. The full consequences of the overdose crisis will continue to define public health for decades to come as these children age into adulthood.