Pandemic Recovery for Children—Beyond Reopening Schools

We are clinicians in busy health centers, and we are seeing the impact of school closures for in-person learning—including school disengagement, mental health challenges, unhealthy weight gain, food insecurity, immunization delay, and soaring rates of new-onset type 2 diabetes.¹ These immediate, visible consequences of school closures are harbingers of long-term outcomes, including decreased life expectancy for US schoolchildren.² Across the country, jurisdictions have eased restrictions, reopened schools, and returned to business as usual, and vaccine eligibility has expanded to include children 5 years and older. It is easy to focus primarily on these hopeful signs of progress during the pandemic, and fall back on the argument that children are resilient. However, we cannot waver in our focus on children. Children are resilient, but this resiliency requires individual support, systemic scaffolding, societal investment, and scientific research into the short-, medium-, and long-term impacts of the pandemic on children. In this issue of JAMA Pediatrics, Viner et al³ present an important international review of the impacts of school closures on the health and well-being of children during the first wave of the pandemic (February through June 2020) and urge a balance between measures to contain infectious disease and to bolster the physical and mental health of children. The findings in this study can help identify clinical practices, policy and systems interventions, and research priorities that may mitigate the harms caused by school closures.

In their research, the authors conducted a review following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to examine school closures during social lockdown and mental health, health behaviors, and child well-being during the first wave of the pandemic. Their search strategy used a machine learning approach and included both medical and educational research databases as well as consultation with experts in the field to identify any studies that may have been missed. They initially identified more than 16 000 possible studies, of which they conducted a full review of 151 and then deemed 36 of those to be relevant. They presented a narrative review that grouped studies by outcome(s) of interest and weighted studies based on type and quality. The heterogeneity of the studies precluded a meta-analysis. As a result of this approach, they were able to take a wide-ranging look at research during the initial phase of the pandemic, and ultimately report findings from 36 studies representing 11 countries. Outcome measures were mental health and well-being; child abuse notifications; sleep; health behaviors including physical activity, screen time, and diet; and overweight.

There are 2 findings in particular we feel are important to highlight. Notably, Viner et al reported that suicide rates did not increase significantly; however, they reviewed data from the first wave of the pandemic. Subsequent studies have demonstrated an increase in emergency department visits for suicide attempts and suicidal ideation among youth during the pandemic.^4,5 The toll of school closures and social isolation on children’s mental health cannot be overstated and will require both immediate- and long-term investigation and action to fully assess and address the impact.

The authors also identify studies from both the US and the UK that report a substantial decrease in child abuse notifications. This is a critical finding that signals the need, globally, to adapt child abuse notification systems to reach children in the event of future school closures or challenges. Given that education personnel account for approximately 21% of child protection referrals,⁶ school closures combined with an overall decrease in pediatric emergency department visits⁷ and primary care visits meant that surveillance systems for child protection were largely offline. This illustrates a brittle system with too few inputs, a system that needs innovation. Educators need training on identifying children at risk via virtual learning platforms.⁸ Community supports, such as home visitation programs when possible, policies that decrease economic stressors for parents, such as moratoria on evictions, and increased access to mental health supports for families are some components of a robust child protection system. As we consider system innovations, we must acknowledge the consequences of a surveillance and enforcement-based system of child protection that has disproportionately impacted children of color and families with low incomes, and strongly advocate for more funding and capacity building for supportive measures that address the underlying causes of child maltreatment without contributing to further inequities.⁹

While the authors intend to explore the impact of the pandemic on health service utilization and health conditions in a future article, the current article highlights the need for continued research into the impact of the pandemic on children’s health and well-being, as well as the development of solutions tailored to different age groups, communities, and populations. It also highlights some immediate challenges and opportunities at the clinical practice, research, and policy and systems levels. At the practice level, pediatric practices are called on to develop more intentional partnerships and engagement with schools. Pediatric clinicians this fall have faced the challenge of helping millions of families reengage with schools and are continually addressing issues such as heightened anxiety about returning to school, medical exemptions from in-person learning, safety measures in schools to prevent COVID-19 transmission, mental health challenges such as depression and eating disorders, along with updating immunizations so children can safely return to school. Opportunities include strengthening practice connections to community-based resources to support families as well as the development of clear guidance on medical exemptions from in-person learning.

At the research level, the work by Viner et al begs the question: “What is the long-term impact of a ‘lost year’ due to school closures?” Funding is needed to study these long-term impacts, including prospective cohort studies, to identify long-term effects of school closures and interventions to mitigate the impact of this and future crisis events on children. Particular attention should be paid to health disparities perpetuated or worsened by the pandemic and pandemic response with an eye toward developing recommendations for recovery, future planning, and response.

At a policy and systems level, both public and private investments will be necessary scaffolding to support children’s health and well-being. Care delivery systems that reach children in schools, especially school-based health centers and school-based mental health services, require increased investment as children return to school. Additionally, mobile health units represent a critical access point for children and families, both in terms of mounting an emergency response to a pandemic or natural disaster but also in terms of routine care such as addressing immunization delay.^10,11 Health care systems would do well to assess how they are reaching children and families where they are by using schools and mobile health units as access points. Our institution’s Mobile Medical Program, an extension of the primary care medical home model, received funding from the United Health Foundation to partner with schools, early childhood development centers, and community organizations to identify children whose access to care, including well visits, immunizations, mental health services, and asthma care, has been impacted by the pandemic. This exemplifies the cross-sector collaborations needed to support children and families beyond the pandemic. While this and many other mobile medical programs operate with critical philanthropic support, systems-level changes are needed in terms of health care financing to support these place-based care models that complement the medical home.

Lastly, school infrastructure requires major public investment to improve indoor air quality, outdoor recreation spaces, and aging physical plants. Viner et al identified decreased physical activity and increased screen time as negative health impacts for children as a result of school closures. The Infrastructure Investment and Jobs Act does not address critical investments in schools that would help to mitigate these impacts.¹² Finally, the pandemic illustrates the importance of building a robust public and community health infrastructure and workforce that is well equipped to address the social determinants of health. Policy needs to evolve to support the incorporation of community health workers into our public health workforce in order to optimize resource connections for children and families and support recovery.¹³ Policy must evolve to address the underlying social determinants of health and health disparities.¹⁴

With the rise in coronavirus variants as well as other global health issues, this is not the last time that a pandemic, epidemic, natural disaster, national emergency, or other crisis will prompt our communities to consider school closures. Let’s be sure that our response and our systems evolve to reflect the growing body of research and evidence about the harms of these closures on children’s health, well-being, and life expectancy.

Corresponding Author: Danielle G. Dooley, MD, MPhil, Child Health Advocacy Institute, Children’s National Hospital, 111 Michigan Ave NW, Washington, DC 20010 (dgdooley@childrensnational.org).

Published Online: January 18, 2022. doi:10.1001/jamapediatrics.2021.3227

Conflict of Interest Disclosures: None reported.