FARGO, N.D. - A new report confirms that vulnerable families in North Dakota are experiencing more struggles as the pandemic drags on. Households with children say housing payments and health coverage are becoming increasingly out of reach.

This week's report from the Annie E. Casey Foundation looked at all states, using weekly census survey data to get a better sense of what families are experiencing. Fifteen percent of North Dakota households said they're worried they won't be able to cover their rent or mortgage payments in the near future. One in eight households said they can't afford health insurance for their kids.

Leslie Boissiere, vice president for external affairs at the Casey Foundation, said it all adds up to an overwhelming sense of pressure.

"They're also struggling with their mental and their physical health," she said. "Twelve percent of families don't have health insurance, one in three has postponed getting needed medical care, and one in five have experienced depression since the pandemic."

The number of North Dakota households that report feeling down or depressed is one in seven. In addition to boosting mental-health services, the report recommended guaranteeing COVID-19 vaccines be available at no cost, boosting investments in education and ensuring schools are more equitably funded.

Also in North Dakota, 6% of households with children said they didn't have enough food to eat. Xanna Burg, who coordinates the Kids Count program for North and South Dakota and Montana, said that need more than likely runs deeper, since the survey data only covers short periods of time.

"So really, we think that hunger is something that families are struggling with in North Dakota," she said, "even though the snapshot of data in this report maybe indicates a lower percentage."

Burg said these problems of overall family instability stand to have long-term effects on a child's development, but she says that can be mitigated through short-term responses by policymakers, including a new COVID relief package being debated in Congress.

Roughly 200,000 children in the U.S. have lost a caregiver to COVID-19. In South Dakota, mental-health experts say these cases can have added complications as kids grieve, and a range of support is needed for a strong emotional recovery.

Nikki Eining is therapist with Avera Behavioral Health and board member for the Center for the Prevention of Child Maltreatment. She said loss of a biological parent falls under the scope of Adverse Childhood Experiences.

Eining explained it can affect the child's development, because they lost a relationship that's difficult to replace.

"I might not be receiving that nurturing piece from that caregiver anymore," said Eining, "when I've developed that bond to that caregiver as an infant or a toddler, or even an early elementary-aged youth."

With social-distancing requirements, the child may have not had a chance to say goodbye, and those rules may have kept their support system at bay during the mourning phase.

Eining said that's why it's important for adults in their lives to help build new trusted relationships that offer a sense of bonding. That involvement can come from outside the home, including neighbors, teachers and coaches.

Maureen Murray, director of mental health and prevention services with Youth and Family Services in Rapid City, said her office has responded to a handful of these cases.

She said in situations where a child has to suddenly adapt to a new environment, that can extend the grieving even longer.

"A move, a different school system, loss of friends," said Murray, "even if the surviving parent is struggling with their own grief and is not there emotionally for the child."

She said it's dangerous to assume all kids are resilient, noting some will not show how much they're struggling emotionally.

Murray said providing safe spaces for them to talk when they are ready is important, while adding therapy, such as individual sessions or grief camps can help.

The Moderna and Pfizer COVID-19 vaccines were cleared this weekend for use in children under age five by both the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC).

Parents likely have questions, and at Arkansas Children's Hospital, health professionals are gearing up to answer them.

The FDA has said both vaccines are likely to protect kids under age five against severe COVID illness, hospitalization and death. For the week ending June 9, children made up nearly 14% of reported weekly COVID cases.

Dr. Jessica Snowden, division chief for pediatric infectious disease at Arkansas Children's Hospital, thinks the expanded access could help keep cases down.

"There are a lot of kids who develop 'long COVID' syndrome that we are still trying to figure out how to treat and prevent," Snowden pointed out. "So far, the only thing we know that decreases your chance of getting that is being vaccinated. For a lot of parents, this is going to be an important step in protecting their kids as we move through the pandemic."

Parents are being advised to check with their child's pediatrician, and also to take other health precautions to prevent spreading any virus, from covering coughs and sneezes to 'masking up' if local guidelines suggest it. As of June 2, more than 400 deaths in children under age four were COVID-related, according to the CDC.

For parents deciding if the vaccine is a right move for their young children, Snowden pointed to her own experience as a parent and doctor, seeing children who have been in the Intensive Care Unit with long-term COVID symptoms.

"Particularly knowing that we don't have good treatments for this virus yet; this isn't like an ear infection, where I can give you antibiotics, and you'll get better," Snowden emphasized. "If your child gets sick, the things we can do to help them are limited. If I can help any family avoid that, vaccination is the best way to do that."

Pfizer's vaccine will be offered to children ages six months through four years, while Moderna's is for kids six months through five years of age.

North Dakota is seeing more diversity within its youth population, but researchers say they face a tougher road in securing a brighter future. A new report details these outcomes and how they were shaped.

According to Kids Count, a research arm of the Annie E. Casey Foundation, nearly one in four children in North Dakota is a person of color. However, because of discriminatory policies in such areas as housing, their families are less likely to achieve economic security.

Kids Count regional Coordinator Xanna Burg said these decisions, made decades ago, still have repercussions today.

"It made it harder for families of color to qualify for loans to purchase a home," she said, "and when we think about kind of the legacy that that racist policy had on today, we see disparities in home-ownership rates. "

North Dakota has the third-lowest rate of childhood poverty, but when measured by race, it has the highest poverty rates for Native American and Black children. The report authors recommended more energy investments in tribal areas to reduce utility costs, as well as boosting the minimum wage.

Burg acknowledged these aims might be hard with a conservative legislature, but said recent victories provide hope. She pointed to passage of a bill updating Native American history curriculum, and noted that having a more culturally relevant education helps Indigenous students succeed.

Burg said there are disparities in health outcomes as well, including access to prenatal care early in a pregnancy.

"We really see some of the lower rates for American Indian families," she said, "and when we think about some of the history, the federal government had this trust responsibility to provide health care. Unfortunately, the Indian Health Service is chronically underfunded."

The report recommended the federal government fund the Indian Health Service at the same per-person rate as Medicaid. It also called on the state to ensure all children eligible for Medicaid are enrolled. North Dakota is second-last in the nation for Medicaid participation among children, at 83%.