It Is Time to End the Debate Over School Reopening | Pediatrics | JAMA Network Open | JAMA Network
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April 29, 2021

It Is Time to End the Debate Over School Reopening

Author Affiliations
  • 1Child Health Advocacy Institute, Division of General Pediatrics and Community Health, Children’s National Hospital, Washington, DC
  • 2Seattle Children’s Research Institute, Center for Child Health, Behavior, and Development, Seattle, Washington
  • 3Editor, JAMA Pediatrics
JAMA Netw Open. 2021;4(4):e2111125. doi:10.1001/jamanetworkopen.2021.11125

The study by Raviv and colleagues1 examines the association between the COVID-19 pandemic and caregivers’ perceptions of the psychological well-being of their school-aged children. The authors partnered with Chicago Public Schools (CPS) during the summer of 2020 to design and administer an anonymous electronic survey of caregivers of CPS students. The survey assessed attitudes about returning to in-person instruction, caregiver reports of mental health concerns (eg, agitated or angry, lonely, anxious, stressed, depressed or low mood, self-harm, and thoughts of suicide) and positive adjustment characteristics (relaxed, interacts positively with siblings or family members, positive peer or social relationships, talks about plans for the future, and hopeful or positive) in their children, COVID-19 exposure and illness among family members, and the effect of COVID-19 on social determinants of health, such as employment and food access. The survey was translated into multiple languages, and responses were received from more than 32 000 caregivers reporting on behalf of more than 40 000 students in CPS, a district that serves more than 340 000 students.2 Using a retrospective pre-post design, the study found that caregivers reported an increase in child mental health concerns and a decrease in positive adjustment characteristics comparing the periods before and after the end of in-person instruction. COVID-19 exposure and social stressors were associated with increases in mental health concerns and decreases in positive adjustment characteristics.

Despite the limitations of a retrospective design relying on parental report, the study supports what has been observed in our health care centers, our emergency departments, and our inpatient units: children’s mental health has been significantly affected by school closures during the COVID-19 pandemic.3 The survey assessed the child’s experience holistically in the context of family and adult stressors, such as access to health care, employment, and food. The findings mirror what is happening in adults, who can play a critical role in buffering toxic stress for children and who are experiencing a sustained worsening in mental health symptoms during the pandemic.4

It is important to consider the context of the study by Raviv et al.1 It was conducted approximately 3 months into the pandemic, in a school district that began reopening schools for its youngest students in February and March 2021. Now, 9 months after the survey was administered, the mental health concerns and positive adjustment characteristics identified in this study have likely worsened. The COVID-19 pandemic has not affected all students and families equally; Raviv et al1 found that Black or Latinx respondents or respondents from low-earning households were more likely to report COVID-19 exposures and family impacts. Compounding this is the learning loss experienced by children owing to prolonged school closures, with students of color, students who are English language learners, and students who have disabilities among the most affected.5 We wrote last year6,7 about the disproportionate consequences of the pandemic and learning loss for children who live in poverty and that the prioritization of schooling and children’s well-being continues to be overshadowed by a focus on opening workplaces, restaurants, and other businesses as well as on the needs of adults.

One year into the pandemic, school districts continue to be mired in debate over reopening, students continue to fall further behind, and there is no clear consensus on offering summer school programs to help address the learning loss and other needs of children. The toll this will take in both the short and long term is staggering, although largely invisible at present.8

At every stage of the evolving pandemic in most communities, school reopening has been an afterthought and not a priority. The time for debating school reopening has passed. We need to focus on school re-envisioning. The disruption in learning and the consequences for children’s health means that we cannot resume school as usual. First, partnerships between the health and education sectors, such as the one that led to the development of the survey of CPS caregivers, are more important than ever to identify and address the multiple health-related needs of children and families during and after the pandemic. No longer can the health and education sectors work in siloes. Robust investment in school-based health care services can help to address the lack of access to health care families and students have faced during the pandemic as a result of loss of employer-based health insurance and the health issues, such as weight gain, exacerbation of eating disorders, depression, and anxiety, that have emerged during the pandemic. Health experts can help to train the school workforce on how to address the cognitive decline, trauma, and mental health challenges that so many students have experienced during this pandemic. Second, given the association of the pandemic with child and adult mental health, health and education systems must collaborate to provide access points to multigenerational mental health services. Third, we must focus on research to refine and improve school safety and operating protocols, to expedite contact tracing, and to shorten quarantine after an exposure to minimize loss of in-person learning time.9 Fourth, there must be transparent and honest communication between families, policy makers, and teachers’ unions regarding what constitutes acceptable risk related to school openings. It will never be zero, and that cannot be an operational principle for opening. Finally, we must address the erosion of trust in the medical, public health, and education systems experienced by families and students of color to ensure that the opportunity to safely return to school in person is available to and used by all students, especially those who have the least access to the digital learning environment.

Every district needs a plan and commitment to reopen every school, for every child, as soon as possible. Anything less is a failing grade.

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Article Information

Published: April 29, 2021. doi:10.1001/jamanetworkopen.2021.11125

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Dooley DG et al. JAMA Network Open.

Corresponding Author: Danielle G. Dooley, MD, MPhil, Child Health Advocacy Institute, Division of General Pediatrics and Community Health, Children’s National Hospital, 111 Michigan Ave NW, Washington, DC 20010 (

Conflict of Interest Disclosures: None reported.

Raviv  T, Warren  CM, Washburn  JJ,  et al.  Caregiver perceptions of children's psychological well-being during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(4):e2111103. doi:10.1001/jamanetworkopen.2021.11103Google Scholar
Chicago Public Schools. Demographics. Accessed February 28, 2021.
Li  W, Zhang  Y, Wang  J,  et al.  Association of home quarantine and mental health among teenagers in Wuhan, China, during the COVID-19 pandemic.   JAMA Pediatr. 2021;175(3):313-316. doi:10.1001/jamapediatrics.2020.5499PubMedGoogle ScholarCrossref
Czeisler  MÉ, Lane  RI, Wiley  JF, Czeisler  CA, Howard  ME, Rajaratnam  SMW.  Follow-up survey of US adult reports of mental health, substance use, and suicidal ideation during the COVID-19 pandemic, September 2020.   JAMA Netw Open. 2021;4(2):e2037665. doi:10.1001/jamanetworkopen.2020.37665PubMedGoogle Scholar
Natanson  H. Failing grades spike in Virginia’s largest school system as online learning gap emerges nationwide. Washington Post. Published November 24, 2020. Accessed February 28, 2021.
Dooley  DG, Bandealy  A, Tschudy  MM.  Low-income children and coronavirus disease 2019 (COVID-19) in the US.   JAMA Pediatr. 2020;174(10):922-923. doi:10.1001/jamapediatrics.2020.2065PubMedGoogle ScholarCrossref
Christakis  DA.  School reopening—the pandemic issue that is not getting its due.   JAMA Pediatr. 2020;174(10):928. doi:10.1001/jamapediatrics.2020.2068PubMedGoogle ScholarCrossref
Christakis  DA, Van Cleve  W, Zimmerman  FJ.  Estimation of US children’s educational attainment and years of life lost associated with primary school closures during the coronavirus disease 2019 pandemic.   JAMA Netw Open. 2020;3(11):e2028786. doi:10.1001/jamanetworkopen.2020.28786PubMedGoogle Scholar
Nelson  EJ, McKune  SL, Ryan  KA,  et al.  SARS-CoV-2 positivity on or after 9 days among quarantined student contacts of confirmed cases.   JAMA. 2021. Published online February 19, 2021. doi:10.1001/jama.2021.2392PubMedGoogle Scholar
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