Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families (2023)

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Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families Tumaini Rucker Coker, Jennifer Appleton Gootman, and Emily P. Backes, Editors Committee on Addressing the Long-Term Impact of the COVID-19 Pandemic on Children and Families Board on Children, Youth, and Families Division of Behavioral and Social Sciences and Education Consensus Study Report Prepublication copy, uncorrected proofs 

NATIONAL ACADEMIES PRESS 500 Fifth Street, NW, Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and the Administration for Children and Families, a division of the U.S. Department of Health and Human Services, (#75N98021C00032) and the Robert Wood Johnson Foundation (#78561). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/26809 This publication is available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2023 by the National Academy of Sciences. National Academies of Sciences, Engineering, and Medicine and National Academies Press and the graphical logos for each are all trademarks of the National Academy of Sciences. All rights reserved. Printed in the United States of America. Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. https://doi.org/10.17226/26809. Prepublication copy, uncorrected proofs 

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. Prepublication copy, uncorrected proofs 

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. Rapid Expert Consultations published by the National Academies of Sciences, Engineering, and Medicine are authored by subject-matter experts on narrowly focused topics that can be supported by a body of evidence. The discussions contained in rapid expert consultations are considered those of the authors and do not contain policy recommendations. Rapid expert consultations are reviewed by the institution before release. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. Prepublication copy, uncorrected proofs 

COMMITTEE ON ADDRESSING THE LONG-TERM IMPACTS OF THE COVID-19 PANDEMIC ON CHILDREN AND FAMILIES TUMAINI RUCKER COKER (Chair), University of Washington, Seattle Children’s TINA L. CHENG, Cincinnati Children’s Hospital, University of Cincinnati JOSHUA GOODMAN, Boston University NIA JENEE HEARD-GARRIS, Northwestern University STEPHANIE M. JONES, Harvard University VELMA MCBRIDE MURRY, Vanderbilt University CYRIL “KENT” MCGUIRE, William and Flora Hewlett Foundation ROBERT S. PYNOOS, University of California, Los Angeles MICHELLE SARCHE, University of Colorado FLORENCIA TORCHE, Stanford University JOSEPH L. WRIGHT, University of Maryland Medical System MARCI YBARRA, University of Wisconsin Staff JENNIFER APPLETON GOOTMAN, Study Director (from March 2022) SUZANNE LEMENESTREL, Study Director (until January 2022) ADAM JONES, Research Associate SUNIA YOUNG, Senior Program Assistant (from July 2022) MARISSA GLOVER, Senior Program Assistant (until July 2022) EMILY P. BACKES, Deputy Board Director ALEJANDRA CASILLAS, National Academy of Medicine Emerging Leader in Health and Medicine Scholar Prepublication copy, uncorrected proofs v 

BOARD ON CHILDREN, YOUTH, AND FAMILIES DAVID V. BRITT (Chair), Sesame Workshop (retired) HAROLYN M. BELCHER, Kennedy Krieger Institute and Johns Hopkins University School of Medicine RICHARD F. CATALANO, JR., University of Washington School of Social Work TAMMY CHANG, University of Michigan DIMITRI A. CHRISTAKIS, Seattle Children’s Research Institute, University of Washington GREG J. DUNCAN, University of California, Irvine NANCY E. HILL, Harvard University STEPHANIE J. MONROE, Wrenwood Group JAMES M. PERRIN, Harvard Medical School and MassGeneral Hospital for Children NISHA SACHDEV, Premnas Partners, Washington, DC MARTIN TEICHER, Harvard Medical School and McLean Hospital JONATHAN TODRES, Georgia State University College of Law JOANNA L. WILLIAMS, Rutgers University Staff NATACHA BLAIN, Director EMILY P. BACKES, Deputy Director Prepublication copy, uncorrected proofs vi 

Acknowledgments An ad hoc committee of the National Academies of Sciences, Engineering, and Medicine was convened to study the consequences of and solutions to the long-term effects of COVID-19 on children living in high-risk communities. The committee was asked to focus specifically on the physical and mental health of children and their caregivers by collecting information and data from a broad set of sources, including, but not limited to, public information-gathering sessions, input from those collecting real-time data on the health and mental health effects of the virus, and reviews of the national responses of other countries that have been effective in their responses to COVID-19 for children and families. The committee thanks the sponsors of this study for their support: the Administration for Children and Families, a division of the U.S. Department of Health and Human Services, and the Robert Wood Johnson Foundation. This report would not have been possible without the contributions of many people. Special thanks go to the members of the committee, who dedicated extensive time, expertise, and energy to the drafting of the report. The committee also thanks the members of the staff of the National Academies for their significant contributions to the report: Jennifer Appleton Gootman, Emily Backes, Adam Jones, and Sunia Young, as well as Suzanne LeMenestrel and Marissa Glover, who both contributed to the early stages of working with the committee. The committee is also grateful to Javed Kahn, Pamella Atayi, and Lisa Alston for their administrative and financial assistance on this project. From the Office of Reports and Communication of the Division of Behavioral and Social Sciences and Education (DBASSE), Kirsten Sampson Snyder, Viola Horek, Douglas Sprunger, and Meredith Fender shepherded the report through the review and the production process and assisted with its communication and dissemination. Hannah Fuller and Megan Lowry, of the Office of News and Public Information and Sandra McDermin and Julie Eubank of the Office of the Congressional and Government Affairs were instrumental in the release and promotion of the report. The committee also thanks Clair Woolley of the National Academies Press and Bea Porter of DBASSE for their assistance with the production of the final report; Rebecca Morgan, in the National Academies research library, for her assistance with fact checking and literature searches; consultant Erin Hammers Forstag for her writing and editing contributions, and consultants Eugenia Grohman and Allie Boman, for their skillful and thoughtful editing. Throughout the project, Natacha Blain, director of the Board on Children, Youth, and Families, Carlotta Arthur and Patti Simon, executive director and associate executive director of the Division of Behavioral and Social Sciences and Education, and Mary Ellen O’Connell and Monica Feit, the then executive director and deputy executive director of the Division of Behavioral and Social Sciences and Education, provided valuable oversight and guidance. Many individuals volunteered significant time and effort to address and educate the committee during our information gathering sessions. Their willingness to share their perspectives, research, and personal experiences was essential to the committee’s work. We thank: David Alexander, Jenny Arwade, Raul Botello, Melissa Brymer, Emmanuel L. Chandler, Mykela Collins, Dominique Davis, Paolo DeMaria, Isra Elshafei, Mary Greiner, Jacki Haight, Leslie Helmcamp, Ebonie Hubbard, Angela Hudson , Tamara Hunter, Wendelyn Julien, Jamilah Jor’dan, Eunice Minero, Gladys Moran, Charles Macias, Micker “Mike” Richardson, Alicia Prepublication copy, uncorrected proofs vii 

Mousseau, Marquinta Thomas, Ashley Vasquez, Delia Vicente, Melissa Walls, and Keesha Woods, as well as adolescents, Jermal, Martha, Mylon, Nathaniel, Nyeja, and Zanab. We also thank the researchers who prepared commissioned papers for the committee: Amit Cohen, Sarena Goodman, Julia Greenberg, Simona Hannon, Alvaro Mezza, Misty L. Heggeness, Adam Isen, and Timothy Thomas. This consensus study report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: MELISSA BRYMER, Terrorism and Disaster Programs, University of California, Los Angeles–Duke National Center for Child Traumatic Stress VALERIE FLAHERMAN, Department of Pediatrics, University of California, San Francisco LAUREN GAYDOSH, Department of Sociology, Center on Aging and Population Sciences, The University of Texas at Austin EDMUND ‘TED’ HAMANN, Department of Teaching, Learning, and Teacher Education, University of Nebraska-Lincoln JACQUELINE JONES, Foundation for Child Development (retired) JENNIFER E. LANSFORD, Center for Child and Family Policy, Duke University KATHERINE A. MAGNUSON, Institute for Research on Poverty, University of Wisconsin–Madison MELISSA WALLS, Center for Indigenous Health, Johns Hopkins University GEORGES C. BENJAMIN, Executive Director, American Public Health Association DOUGLAS S. MASSEY, Department of Sociology, Princeton University Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by Georges C. Benjamin, American Public Health Association, and Douglas S. Massey, Princeton University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. Prepublication copy, uncorrected proofs viii 

Contents Summary, 1 1. Introduction, 12 STUDY CHARGE AND COMMITTEE APPROACH, 13 STUDY METHODS, 13 STUDY FOCUS, 15 EFFECTS OF THE PANDEMIC TO DATE, 17 ORGANIZATION OF THE REPORT, 21 ANNEX: PERSPECTIVES ON THE PANDEMIC, 22 ADOLESCENTS, 22 EARLY CHILD EDUCATORS, 24 K–12 EDUCATORS AND ADMINISTRATORS, 25 PRACTITIONERS SERVING CHILDREN INVOLVED IN THE CHILD WELFARE SYSTEM, 26 PRACTITIONERS SERVING CHILDREN INVOLVED IN THE JUVENILE JUSTICE SYSTEM, 26 NATIVE AMERICAN TRIBAL LEADERS, 27 REFERENCES, 30 2. Societal and Developmental Contexts of The Pandemic, 33 SOCIETAL CONTEXT, 33 DEVELOPMENTAL CONTEXT, 35 THEORETICAL FRAMEWORKS AND PERSPECTIVES, 37 LIFE COURSE PERSPECTIVE, 37 FRAMEWORK OF DANGER, SAFETY, AND PROTECTION, 39 PANDEMIC “SIGNATURES” AND “DOSE OF EXPOSURE” PROFILES, 40 ADVERSITIES AND RESILIENCE, 43 PREEXISTING INEQUITIES, 44 SECONDARY ADVERSITIES, 45 RESILIENCE, 46 REFERENCES, 48 3. Social, Emotional, and Behavioral Effects, 57 SHORT-TERM EFFECTS AND CONSEQUENCES, 58 SHORT-TERM SOCIAL, EMOTIONAL, AND BEHAVIORAL CONSEQUENCES, 58 DELAYS, DERAILMENTS, AND CASCADES, 59 MECHANISMS OF ACTION, 61 INTERVENTIONS AND APPROACHES, 63 EARLY CHILDHOOD INTERVENTIONS, 63 SOCIAL AND EMOTIONAL LEARNING INTERVENTIONS, 67 SCHOOL-BASED MENTAL HEALTH SUPPORTS FOR YOUTH, 68 PARENTING, FAMILY, AND COMMUNITY-BASED PREVENTIVE INTERVENTIONS, 69 Prepublication copy, uncorrected proofs ix 

CONCLUSIONS, 70 REFERENCES, 71 4. Effects and Promising Interventions in Education, 78 SCHOOLS AND EDUCATORS, 78 INITIAL EFFECTS IN K–12 EDUCATION, 78 INITIAL IMPACT ON EARLY CHILDHOOD EDUCATION, 79 THE CHALLENGE OF REOPENING CHILD CARE FACILITIES AND K–12 SCHOOLS, 80 STUDENT OUTCOMES, 84 SCHOOL ENGAGEMENT, 84 LEARNING, 90 CONCLUSIONS, 95 PROMISING EDUCATION POLICY INTERVENTIONS, 95 ADDRESSING MISSED LEARNING OPPORTUNITIES, 95 REENGAGING STUDENTS AND FAMILIES AND RESTORING ENROLLMENT, 100 STRENGTHENING THE EDUCATOR WORKFORCE, 102 PANDEMIC PROOFING SCHOOLS, 104 REFERENCES, 106 5. Health Effects, 116 PHYSICAL HEALTH, 116 OVERALL EFFECTS TO DATE, 117 LONG-TERM EFFECTS OF COVID-19 ILLNESS, 118 OVERWEIGHT AND OBESITY, 120 COVID-19 IN THE PRENATAL AND PERINATAL PERIODS, 120 ROLE OF VACCINES, 122 MENTAL HEALTH, 127 DEPRESSION AND ANXIETY, 129 SUICIDALITY AND SUICIDE, 131 POST-TRAUMATIC STRESS DISORDER, 132 SLEEP DISTURBANCE, 133 SUBSTANCE USE, 133 CHILD ABUSE, NEGLECT, AND VIOLENCE, 134 COMMUNITY VIOLENCE, 134 HOUSEHOLD VIOLENCE, 135 PANDEMIC BARRIERS TO HEALTH AND WELL-BEING, 136 FOOD INSECURITY, 136 DECREASE IN ACCESS TO CARE, 137 CHILDREN WITH SPECIAL HEALTH CARE NEEDS, 138 THE HEALTH CARE SYSTEM, 139 ACCESS TO COVERAGE, 139 STRENGTHENING THE SYSTEM FOR THE FUTURE, 143 A TIERED PUBLIC HEALTH APPROACH, 144 CONCLUSIONS, 146 Prepublication copy, uncorrected proofs x 

REFERENCES, 148 6. Effects of Economic Policies, 172 SOCIAL INSURANCE PROVISIONS, 173 UNEMPLOYMENT INSURANCE, 173 PAID SICK LEAVE AND PAID FAMILY LEAVE, 176 CASH TRANSFERS, 177 ECONOMIC IMPACT PAYMENTS, 177 CHILD TAX CREDIT, 178 EVICTION MORATORIUMS, 181 STUDENT LOAN PANDEMIC RELIEF MEASURES, 184 SAFETY NET EXPANSIONS, 186 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM, 186 PANDEMIC ELECTRONIC BENEFIT TRANSFER, 187 OTHER SAFETY NET PROVISIONS, 188 SUPPORT FOR TRIBAL NATIONS, 189 FAMILIES’ CURRENT ECONOMIC WELL-BEING, 190 IMPLEMENTATION ISSUES, 192 CONCLUSIONS, 194 REFERENCES, 196 7. Recommendations, 211 PRIORITIZE CHILDREN AND FAMILIES, 212 ADDRESS SOCIOEMOTIONAL, COGNITIVE, AND EDUCATIONAL NEEDS, 213 ENROLLMENT AND REENGAGEMENT, 215 ACADEMIC RECOVERY AND ACHIEVEMENT, 216 POSITIVE SOCIAL-EMOTIONAL DEVELOPMENT, 216 EDUCATION WORKFORCE, 217 PANDEMIC PROOFING, 218 ADDRESS PHYSICAL AND MENTAL HEALTH NEEDS, 218 ADDRESS ECONOMIC NEEDS, 219 INVEST IN FUTURE RESEARCH AND POLICY NEEDS, 221 CONCLUSION, 223 APPENDIX: Biographical Sketches of Committee Members and Staff, 224 Prepublication copy, uncorrected proofs xi 

Boxes, Figures, and Tables BOXES 1-1 Statement of Task, 13 2-1 Essential Public Health Functions, 42 2-2 Principal Regulatory Functions for Medical Products, 52 5-1 Recommendations of the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association, 128 6-1 Federal Provisions to Mitigate the Effects of the COVID-19 Pandemic, 172 FIGURES 1-1 Age adjusted risk of COVID-19 infection, hospitalization, and death in the United States as of February 1, 2022, 6 1-2 COVID-19 weekly cases in the United States per 100,000 population by race and ethnicity, April 2020 to July 2022, 7 1-3 COVID-19 weekly deaths in the United States per 100,000 population by race and ethnicity, April 2020 to May 2022, 8 2-1 Timeline of the COVID-19 pandemic and other major social events, 23 2-2 Socioecological model of development across the life course, 25 2-3 A life-course view of COVID-19 developmental effects, 27 4-1 School district strategies for delivering distance learning, by grade level and whether high or low poverty, 72 4-2 Preschool enrollment during the pandemic, by family income, 74 4-3 Absenteeism data from School Pulse panel, 77 4-4 Freshman enrollment changes by type of college and student gender and age, 79 4-5 National Assessment of Educational Progress mathematics assessment trends by state, 82 4-6 National Assessment of Educational Progress reading assessment trends by state, 83 6-1 Eviction trends, 2020, 182 6-2 Eviction trends, 2021, 183 TABLES 5-1 Selected Timeline of COVID-19 Vaccine Rollout, 124 Prepublication copy, uncorrected proofs xii 

Acronyms and Abbreviations AIR American Institutes for Research ARP American Rescue Plan PBIS Positive Behavior Interventions and Supports CAA Consolidated Appropriations Act CARES the 2020 Coronavirus Aid, Relief, and Economic Security Act CCDBG the Child Care and Development Block Grant CDC Centers of Disease Control and Prevention CHIP the Children’s Health Insurance Program CPRSAA Coronavirus Preparedness and Response Supplemental Appropriations Act CPSP Center on Poverty and Social Policy CRRSA 2020 Coronavirus Response and Relief Supplemental Appropriations CSRP Chicago School Readiness Project CTC child tax credit EITC Earned Income Tax Credit ESSA Every Student Succeeds Act ESSER Elementary and Secondary School Emergency Relief Fund FFCRA Families First Coronavirus Response Act GAO Government Accountability Office GDP gross domestic product HUD U.S. Department of Housing and Urban Development HVAC heating, ventilation, and air conditioning MIHOPE Mother and Infant Home Visiting Program Evaluation NCTSN National Child Traumatic Stress Network P-EBT SNAP Pandemic EBT PBIS Positive Behavior Interventions and Supports PTSD post traumatic stress disorder SAMHSA Substance Abuse and Mental Health Services Administration SERV Project School Emergency Response to Violence SNAP Supplemental Nutrition Assistance Program SPR Skills for Psychological Recovery TANF Temporary Assistance for Needy Families Prepublication copy, uncorrected proofs xiii 

VOYCE Voices of Youth in Chicago Education WIC the Special Supplemental Nutrition Program for Women, Infants, and Children Prepublication copy, uncorrected proofs xiv