Patricia Royalty's world turned upside down last June when her 34-year-old husband Dakota Royalty died from cirrhosis. The 36-year-old mother was left caring for the couple's five children.
"He meant a lot to the kids. He was always a really good father," Patricia said in an interview with ABC News. "When my 5-year-old went to school in January, they asked her what her new year's resolution was. She asked for her dad back."
Royalty's children are among a growing group of children who have lost a parent or sibling. A new report from Judi's House - an organization that advocates for grieving kids and families - found that one in 12 kids will lose a parent or sibling by age 18. Since the pandemic, the rate has continued to increase.
Micki Burns, a co-author of the report, said that on top of the grief, children who have lost a parent can feel isolated because it's difficult for other kids to understand grief and loss.
"Recognizing that [losing a parent or sibling] is prevalent is important," Burns said in an interview with ABC News. "It's something that we need to start to talk about more openly and more easily so that the children don't feel so isolated."
Losing a parent during childhood is an important risk factor for adult mental health problems and the issue is often overlooked, according to M. Katherine Shear, a grief expert at Columbia University.
While grief affects everyone in different ways, Shear said children are oftentimes not the focus of support from community members. She said this most likely happens because people think children are more resilient than their grieving parent.
"[Kids are then] in a situation of great emotional need with a parent who is less able to provide it due to their own intense grief," Shear said in an email to ABC News. "It's very important that clinicians learn about childhood grief, how to recognize and treat it."
The researchers behind the new report also found higher rates of childhood grief in some southern and Appalachian states. West Virginia had the highest rate, with approximately 13.3% of children experiencing grief, while Minnesota had the lowest rate. Arizona, Royalty's home state, had a rate of 8.8%.
It's unclear why certain states had lower rates, but Burns suggested the differences may depend on resource availability and state laws. She said states like West Virginia may have reduced access to health care and other resources.
Burns also emphasized that the causes of death have changed over the years. According to this year's report, the leading causes of death for parents are accidents, heart disease and cancer. Birth conditions, accidents and birth defects top the list for siblings who die.
Suicide and homicide are also among the leading causes of death. Royalty's sister, who had one child, died earlier this year from a fentanyl overdose.
Burns said she noticed a large uptick in suicide and drug overdose deaths during her career.
"That's where we really see kids coming in questioning, 'Was this because of something I did? Was this because I wasn't a good enough son or good enough sibling?'" Burns said. "I think it's alarming and it's saddening."
Shear pointed to research suggesting that negative outcomes in children, such as depression, continue to affect them for as long as seven years on average after a relative's death.
While Royalty's children are still learning to grieve their father's death, they receive emotional and social support at school. They are also finding ways to honor her late husband.
"I feel bad for kids who experience this at a young age. It's difficult for them to show emotions and open up," Royalty said. "Always remain strong. Know that your parents will be watching you regardless. Do anything and everything to make them proud of you."
Michal Ruprecht is a medical student at Wayne State University School of Medicine and a member of ABC News Medical Unit.