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

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Summary In early 2023, 3 years after a pandemic was declared, the world is still dealing with COVID-19. To date it has directly been the cause of over 6.55 million deaths worldwide, 1.06 million of them in the United States alone. The indirect impact of the pandemic is much harder to quantify, and the long-term effects are unknown. What is clear, however, is that in almost every outcome—across measures of social, emotional, behavioral, educational, mental, physical, and economic health and well-being—low-income and racially and ethnically minoritized children and their families have borne, and without intervention will continue to bear, the brunt of the pandemic’s negative effects. 1 The Board on Children, Youth, and Families (BCYF) of the National Academies of Sciences, Engineering, and Medicine (the National Academies) convened an ad hoc committee with wide-ranging expertise across child mental and physical health, health disparities, economics, education, learning and development, and public policy to examine the long-term impact of the COVID-19 pandemic on the well-being of children and families, with a particular focus on addressing the challenges and obstacles that the pandemic introduced for children and families in marginalized communities. This report documents the committee’s findings, conclusions, and recommendations with respect to three broad questions included in its statement of task: 1. What was learned during the pandemic that informs approaches to policies and programs, including those affecting early childhood care and education, that are necessary to address the developmental, emotional, behavioral, and physical health needs of children in “high-risk” communities to promote child health and well-being in the long-term? 2. What was learned during the pandemic about promising practices to support parent and caregiver well-being? 3. What policies (e.g., child care, health care) and practices can work to address disparities and inequities experienced by communities of color following a pandemic? 1 The reason that these communities have borne a disproportionate share of the pandemic’s impact is rooted in structural racism, which has created long-standing and pervasive inequities in the systems and structures that are foundational to physical, mental, social, and emotional health and educational and economic well-being. These inequities have created an environment of disadvantage for children in racially and ethnically minoritized and low- income communities, which has led to their disproportionate direct and indirect burden of the COVID-19 pandemic. Prepublication copy, uncorrected proofs 1 

The committee was asked to focus on “children and families in high-risk communities.” Informed by conversations with the sponsors and data on the disproportionate impact of the COVID-19 pandemic on certain populations, the committee defined “high-risk communities” as encompassing children 2 and families who are Black, Latino, and Native American and those who have low incomes. The committee refers to these groups as low-income individuals and those who have been racially and ethnically minoritized SOCIETAL CONTEXT OF THE COVID-19 PANDEMIC Disasters or large-scale public health events like the COVID-19 pandemic can reveal preexisting vulnerabilities that are due to long-standing societal inequities: that is, the societal shock of the COVID-19 pandemic did not occur in a vacuum or a neutral environment. It emerged in the context of existing patterns of inequities and marginalization, known as structural racism, which intensified its impact for children and families who have been racially and ethnically minoritized and those with low incomes. Structural racism refers to a system in which historical and contemporary public policies, institutional practices, cultural representations, and other norms work in different, often reinforcing ways, to maintain or compound racial and socioeconomic inequalities (NASEM, 2022). The COVID-19 pandemic landed in this inequitable environment, compounding numerous preexisting inequities in social, emotional, behavioral, educational, mental, physical, and economic health and well-being. In addition, the pandemic intersected with and likely helped trigger other major social events and broader unrest, including the widespread protests for racial justice in 2020; a rise in opioid addictions and deaths; and increasing polarization, politicization, and misinformation in public discourse. Over the course of the COVID-19 pandemic, Black, Latino, and Native American people have experienced a disproportionate burden of cases, hospitalizations, and deaths in comparison with their White counterparts. Families with low incomes have also been disproportionately affected by the pandemic. Perhaps the most pronounced disparities are among bereaved children: children of racial and ethnic minorities account for 65 percent of those who have lost a primary caregiver because of COVID-19, with Native American children 4.5 times as likely as White children to have lost a parent or caregiver, Black children 2.4 times as likely, and Latino children 2.0 times as likely (Hillis et al., 2021). SHORT-TERM OUTCOMES The emergence of COVID-19 resulted in both imminent danger and an unknown threat of severe illness and death. In addition, the necessary efforts to control the pandemic and minimize infection resulted in disruption to everyday life: schools, businesses, and places of worship closed, social distancing led to social isolation, access to cultural and community supports was limited, and family routines were dramatically transformed. 2 This report generally uses the term “children” to encompass children, adolescents, and youth; however, other terms may also be used in keeping with the language used in the studies or publications being referenced. Children are primarily defined in this report as birth through age 18, with an added focus on young adults aged 18– 24 in certain situations, as when discussing matriculation to postsecondary education. Prepublication copy, uncorrected proofs 2 

In order to best understand the consequences of these short-term outcomes, the committee took a life-course perspective. That is, the full characterization of the effects of the pandemic on children and adolescents had three fundamental characteristics: it is developmental, that is, shaped by individual and societal experiences prior to the pandemic as well as the salient developmental windows and tasks at play at its onset and throughout; it is ecological, that is, situated in a sociodemographic, familial, community, societal, historical, and cultural context; and it is variable in its effects and consequences for racially and ethnically minoritized families and communities. Social, Emotional, and Behavioral Outcomes Children and adults, in one form or another, experienced some level of disruption, uncertainty, stress, and loss of connection to community during the pandemic. However, these challenges were more acute for children and families in racially and ethnically minoritized and those in low-income communities, and, to some degree, these experiences have persisted. The evidence shows: • increases in children’s dysregulated, internalizing, and externalizing behaviors and decreases in children’s adaptive behaviors and self-regulation skills; • increases among adolescents and young adults in their levels of concern about their present and future, more time spent feeling unhappy or depressed, lack of social connection, anxiety about the loss of a caregiver, and a desire for greater social and emotional support from their teachers and schools; and • increases in parents’ stress, household chaos, challenges in parents’ mental health, and parent–child conflict. Education and Learning Outcomes COVID-19 presented a major disruption to the education system, affecting early childhood programs, elementary and secondary schools, and postsecondary institutions. The most significant interruption was the closure of schools, which resulted in children’s increased anxiety, reduced social interactions and peer relationships, lost learning opportunities in a school environment, and a widening of achievement gaps. The evidence shows: • declines in early childhood program enrollments—the programs experiencing the highest enrollment losses were those serving racially and ethnically minoritized families, low-income families, and families that did not speak English at home; • for kindergarten, 9 percent fewer students enrolling in 2019–2020 than in the year before the pandemic, with larger declines in fully remote school districts, which disproportionately enrolled low-income students; • for grades 1–8, average decline of a 3 percent in enrollment; • overall, declines in enrollment in public K–12 schools in the first school year after the pandemic began, with 1.3 million fewer students than in the previous school year; • increases in chronic absenteeism, with 72 percent of public schools nationwide reporting higher chronic absenteeism rates than prepandemic; and Prepublication copy, uncorrected proofs 3 

• declines in the number of students aged 18–20 enrolling in college soon after graduating from high school, with community college enrollment for freshman declining by 20 percent. Looking at outcomes, there were declines in literacy and numeracy measures. Missed learning was greater among students without access to in-person schooling, and missed learning was particularly acute for the low-income and racially and ethnically minoritized communities. Across all measures of school engagement and learning outcomes, students appear to be worse off than they would have been absent the pandemic, and such negative outcomes are generally more acute for the low-income and racially and ethnically minoritized communities. Physical and Mental Health Outcomes Although children have had lower infection rates and lower burden of symptomatic disease than adults, there are concerning short-term findings of health outcomes of COVID-19 infection and health outcomes. The evidence shows: • increased incidence of diabetes type 1 and type 2 among children during the pandemic, which may be due to a direct effect of the infection in children, or in the case of diabetes type 2, the increase in childhood obesity during the pandemic; • an increase in maternal mortality rates, with largest increases for Black and Latina women; • increases in the proportions of children with symptoms of depression and anxiety; • an increased rate of substance overdose deaths among adolescents, a majority of which were fentanyl related, with highest rates among Native American youth; • increases in household food insecurity and childhood obesity; and • delayed preventive care and immunizations, with lower rates of both for Black and Latino children. Economic Effects In the early months of the COVID-19 pandemic families were hit with economic hardship, including job loss and food insecurity. This economic hardship disproportionately affected low-income and racially and ethnically minoritized families who were economically vulnerable prior to the pandemic. However, the unemployment rates that peaked during the pandemic’s first few months have returned to prepandemic rates, with similar trends by gender, race, and ethnicity. Similarly, food insecurity peaked at the onset of the pandemic and has since rebounded to the prepandemic level. PANDEMIC-ERA RESPONSES Throughout the pandemic, children and their families, communities, and child-serving agencies have applied great ingenuity, innovation, perseverance, and creative problem solving to enhance positive adjustments to meet the changing threats and challenges presented by the pandemic and related protective measures. Prepublication copy, uncorrected proofs 4 

Tribal communities, for example, developed successful campaigns to encourage masking, physical distancing, and eventually vaccine take-up that drew on tribal beliefs about interconnectedness, responsibility toward others, and the need to protect elders as tribal culture and knowledge bearers. Technology and social media were creatively used to maintain connections despite physical separation. While many schools were thrown by the challenges they faced, some schools thrived because they were able to quickly shift their focus to supporting student and family well-being, through activities such as distributing meals, connecting families to social services, providing technology supports (e.g., computers, tablets, hot spots) to ensure that all students could access virtual learning, and creating small cohorts or pods to mimic the social structures that are commonplace in in-person schooling. Pediatric clinicians and health care organizations quickly implemented telemedicine, even in the face of big utilization swings, higher-acuity patients, an increase in patients with behavioral and mental health crises, and later, a surge of serious respiratory illness among children that overwhelmed pediatric inpatient units and emergency departments. Recognizing a serious gap in the nation’s emergency preparedness for children and families, the Health Resources and Services Administration established and funded the Regional Pediatric Pandemic Network to help children's hospitals and their communities be ready to care for children during future disasters and public health emergencies. In response to the immediate and ongoing consequences of the COVID-19 pandemic, the federal government provided time- limited provisions through a series of laws to mitigate deleterious health and economic effects of the pandemic on households and individuals. • Under the Families First Coronavirus Response Act, states were prohibited from disenrolling Medicaid recipients during the public health emergency period, leading to increases in Medicaid and the Children’s Health Insurance Program enrollment by 27.1 percent, a total of 19.3 million people. • The Centers for Disease Control and Prevention, acting under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), imposed a temporary moratorium for evictions due to nonpayment of rent. • Under the American Rescue Plan, the Child Tax Credit (CTC) was expanded and shifted to monthly payment, resulting in a reduction of food insecurity in low-income households and reductions in household poverty. • Three rounds of federal economic stimulus payments were distributed to individuals and families, which contributed to economic stability and well-being for children and families. RECOMMENDATIONS While evidence on the long-term effects of the pandemic is still emerging, the research on past global outbreaks, epidemics, and disasters informs understanding of the effects of the COVID-19 pandemic on children and families and guides predictions about the potential long- term consequences. Two factors emerge that play a role in the long-term outcomes of a disaster event: (1) the signature of the event, that is, objective features regarding the type and magnitude of the event and (2) the “dose of exposure” for children and their families. Embedded in the Prepublication copy, uncorrected proofs 5 

signature of the COVID-19 pandemic are the major differences in dose of exposure across children and their families and communities, namely, the disproportionate burden of exposures for ethically and racially minoritized and low-income children and families. Drawing from evidence on the COVID-19 pandemic and lessons from other disaster recovery and previous public health crises, the committee’s recommendations propose a path to recover and rectify the inequities resulting from and exposed by the pandemic in four ways: 1. addressing the immediate and short-term direct and indirect effects of the pandemic on children and their families; 2. mitigating potential shifts in the life-course trajectories of children and families due to the pandemic; 3. collecting and quickly responding to comprehensive, child- and family-focused data to help understand the pandemic’s ongoing effects on children and families; and 4. preparing for the next pandemic, “pandemic-proofing.” Prioritize Children and Families Recommendation 1: The secretaries of the U.S. Department of Health and Human Services and the U.S. Department of Education, in coordination with the Domestic Policy Council, the Office of Management and Budget, states, Native American tribes, localities, and the nonprofit and private sectors, should establish a task force on addressing the effects of the COVID-19 pandemic on children and their families, with a focus on those who have experienced the greatest negative burdens of the pandemic: Black, Latino, and Native American children and families and those with low incomes. Recommendation 2: All federal and state agencies and departments involved in COVID-19 pandemic relief planning and future public health disasters should address the needs of pregnant people, and children, and low-income and racially and ethnically minoritized populations, including children and adolescents in the foster care and juvenile justice systems, in the planning and management of public health disaster relief and recovery efforts. Address Social, Emotional, and Educational Needs To address the individual and collective adversity caused by the pandemic, adequate time, attention, and resources are needed to help children process their pandemic experience; cope with uncertainty and change; rebuild social, cultural, and community connections; and readjust to group learning environments. Supporting students’ ongoing social and emotional needs will not only make it easier to address academic fallout in the long run, but also provide students with the internal resources and external support to cope with what is likely to be an indefinite period of uncertainty and change. A number of prepandemic evidence-based social, emotional, and behavioral interventions, strategies, and approaches have been shown to effectively address some of the key mechanisms that link exposure to pandemic-related disruption, stress, worry, grief, and bereavement to developmental outcomes, including early childhood interventions, social and emotional learning interventions, school-based mental health supports for youth, and community-based parenting and family preventive interventions. Prepublication copy, uncorrected proofs 6 

Given the negative educational outcomes from the pandemic, it is important to consider potential interventions to mitigate the damage. Without targeted intervention, pandemic-era disengagement and missed learning opportunities for students will have lasting damage, with an impact throughout adulthood for these children. A number of interventions can help shift students’ life courses, as well as prepare for the next pandemic: these interventions include reengaging families and students who have become disengaged from schools; compensating for missed instructional time and missed opportunities for social and emotional development; supporting positive social and emotional development and recovery; strengthening the educator workforce needed to accomplish these first three goals; and pandemic-proofing schools to minimize future disaster-related disruptions to education. Recommendation 3: The U.S. Department of Education should renew pandemic-related funding that allocates a greater proportion of funding to high-poverty schools, and funding to support early childhood education, to address enrollment and reengagement; academic recovery and achievement; recovery and optimization of positive social and emotional development; support and expansion of the education workforce; and preparation for the next pandemic, “pandemic proofing.” These investments should be made in coordination with other federal agencies, including the U.S. Department of Health and Human Services, as well as with state and local authorities and educational agencies. These investments should meet the needs of children facing the most barriers, such as children requiring special services. • Enrollment and reengagement: Continue and expand support for a variety of locally tailored strategies for enrolling and reengaging children at all levels of education, including early childhood, K–12, and college, as well as students who have special needs, with the goal of returning enrollment and attendance rates to prepandemic levels, if not higher. • Academic recovery and achievement: Allow investments in a flexible portfolio of evidence-based interventions to address the education gaps created during the pandemic, with the goals of compensating for missed learning and for returning students’ academic achievement to prepandemic grade-level expectations or better, with a particular focus on closing socioeconomic achievement gaps that widened during the pandemic. • Positive social and emotional development: Support and expand on currently used and evidence-based and promising programs and interventions that focus on the promotion of social and emotional development in children from early childhood through high school. School districts and early childhood centers will need funding to adequately address pandemic-related deficits in social and emotional development in early childhood and K–12 settings, and to provide ongoing support for optimal social and emotional development. • Education workforce: Attract, train, support, and retain an expanded educator workforce at the early childhood and K–12 levels with the goal of both strengthening the severely contracted early childhood sector and supporting the K–12 staffing needed to reengage students and restore missed learning. • Pandemic proofing: Invest in and pursue a variety of measures to prepare schools for future pandemics with the goal of reducing future schooling disruptions, specifically those that decrease the likelihood of disease spread in schools, increase the safety of Prepublication copy, uncorrected proofs 7 

in-person schooling (and communicating such risk-reduction measures to parents and teachers), and reduce the use of remote schooling. Most critically, additional funding is needed to support high-poverty schools. With the vast majority of schools serving children from low-income families already underfunded relative to schools with children from higher-income families, the initial three rounds of federal funding that schools received during the pandemic will not be sufficient to both remedy the damage that has been done and address the preexisting inequities in schools. With additional resources, schools will be better able to overcome prepandemic gaps in funding, as well as the compounded needs for educational supports that arose because of the pandemic, potentially reducing the wide funding gap in the nation’s public school systems. Address Physical and Mental Health Needs The COVID-19 pandemic has had and is continuing to have tremendous direct and indirect effects on the physical and mental health of children and families in the short term and has the potential to affect developmental trajectories for decades to come. While acute COVID- 19 illness in the child population has not been as severe as it has been for adults, children have been affected, including those experiencing hospitalizations, long COVID symptoms, and death. Children aged 0–4 and those with underlying medical conditions, in particular, have faced greater risk from more serious illness with COVID-19 infection. Surveillance of the long-term health complications from COVID-19 infection will be important as more is learned about the virus. The COVID-19 pandemic has had the greatest negative effects on the physical and mental health of children and families who were already, according to prepandemic data, facing worse health outcomes and worse access to health care. Those effects have been disproportionately borne by children who are Black, Latino, and Native American; who live in households with low incomes; and who had unmet physical and mental health problems prior to the pandemic. To address both the short- and long-term effects of the pandemic on these children, mitigate potential shifts in their life-course trajectories, and prepare for the next pandemic, efforts are needed to bolster the health care system so that all children have access to high-quality, continuous, comprehensive, and accessible physical and mental health services. Recommendation 4: The U.S. Department of Health and Human Services should strengthen and expand Medicaid coverage at the federal level so that all children and families have consistent access to high-quality, continuous, and affordable physical and mental health services. To implement this recommendation, the department can establish and enforce standards of care for the state programs for Medicaid and the Children’s Health Insurance Program that include national standards for equitable payment rates, presumptive eligibility, continuous eligibility periods, and network adequacy. Specifically, the department should implement four changes: • Increase Medicaid payment rates to be in line with Medicare rates for the same services. In the absence of federal support, states should consider strategies that allow for Medicaid parity with Medicare payment. Prepublication copy, uncorrected proofs 8 

Expand Medicaid coverage to children with presumptive eligibility for any child aged 0–18 without commercial insurance, and ensure that families have multiple entry points for coverage through linkages among social and health services. Implement continuous eligibility for children from birth until age 6. For pregnant people, provide postpartum coverage through 12 months after a child’s birth. Ensure network adequacy, with a focus on the necessary network of providers, specialty providers, and ancillary services needed for behavioral and mental health services, especially for children who have such pandemic-related or pandemic- exacerbated conditions as bereavement, prolonged grief disorder, post-traumatic stress disorder, and substance use. In addition to these actions by the U.S. Department of Health and Human Services, it will be critical for federal policy makers to pursue coverage solutions for parents with incomes below the poverty level and who live in states that have not adopted Medicaid expansion and thus are caught in the “coverage gap.” These solutions will need the partnership of Congress for new legislation to cover these individuals, or from states, to adopt expansion. Recommendation 5: The U.S Department of Health and Human Services (HHS) should increase investments in and advance policies and funding to ensure that children and families can access high-quality treatment and preventive behavioral health services in clinical settings, communities, and schools. HHS should lead and coordinate efforts to: advance and implement polices that ensure mental health parity to physical health for preventive and treatment-related behavioral health services provided in clinical settings, communities, and schools; expand Medicaid payment to be inclusive of nonmedical professionals for preventive and community-based behavioral services; and strengthen the child behavioral health workforce by increasing implementation of training programs in evidence-based mental and behavioral care, expanding opportunities for racially and ethnically minoritized individuals to enter a pathway for child behavioral health workforce participation; and expanding loan repayment programs for child behavioral health care professions. Address Economic Needs In the early months of the COVID-19 pandemic, low-income families who were economically vulnerable prior to the pandemic were particularly hit with economic hardship. Without the continuation of important federal pandemic-era provisions, and with the rising costs of essential goods, families in poverty will face a slow, difficult, and likely incomplete economic recovery. Additionally, because of widespread state-level variation in the type, amount, and duration of means-tested and social insurance provisions, the poorest families—who disproportionately live in states with the most constrained safety nets, particularly in the South and Southwest—may have severely restricted access to such provisions. In order to address these needs, efforts are necessary to incentivize safety net parity across states, ensure access to paid Prepublication copy, uncorrected proofs 9 

family and sick leave programs, and prioritize cash transfers to families to mitigate the economic effects of the pandemic. Recommendation 6: The federal government should incentivize states to expand key safety net programs, including Temporary Assistance for Needy Families, and child care subsidies. The federal government should incentivize states to expand the number of families served in these safety net programs, raise the floor benefit levels states must provide in relevant programs, and reduce administrative burdens to facilitate program participation. These improvements should be coupled with rigorous evaluations of the effects of program expansion on family socioeconomic well-being, especially in states where safety net capacities are substantially enhanced. Existing evidence on the effects of paid family leave and sick leave provisions indicate positive effects on work, especially among women, and maternal and infant health. The evidence also suggests null or minimal effects on businesses when paid family leave or paid sick leave programs are implemented. Given the evidence on the positive effects of such paid leave provisions, implementing such programs or incentivizing states to implement their own programs can provide much-needed support to all workers, particularly marginalized workers who are disproportionately less likely to have similar employer-provided benefits. Recommendation 7: The federal government should support federal paid family leave and paid sick leave programs, building on similar pandemic-era and existing state-level programs. Alternatively, the federal government should incentivize states to implement their own paid leave programs. Prior to the pandemic, the Child Tax Credit (CTC) was not available to families with earned income under $2,500; had a maximum amount of $2,000 per child;, and was not fully refundable, that is, families could not receive the full amount if they had no tax obligation or if it exceeded their income tax obligation. The American Rescue Plan (ARP) temporarily increased the CTC to $3,000 per child aged 6–17 and to $3,600 per child under age 6, removed the $2,500 earned income requirement, changed its distribution to a monthly payment rather than annual, and made it fully refundable. Evidence to date demonstrates that families used the CTC benefits to pay for essential goods, offsetting food insecurity and helping to protect housing stability. As a cash transfer program, monthly distribution of the CTC does not incur the degree of administrative burdens as other safety net programs, which often lead to delayed or no receipt of benefits. It also allows families to more efficiently allocate resources based on their individual circumstances, irrespective of state of residence. The expanded CTC ended in 2021. In addition to a permanent expansion of the CTC beyond the pandemic, the federal government and states need to consider similar cash transfers to families when any disaster occurs, whether public health, climate, or economic. Recommendation 8: The federal government should reissue and continue pandemic-era expansion of the Child Tax Credit (CTC), as well as its distribution on a monthly rather than a yearly basis. In the absence of such expansion, state governments should consider implementing their own monthly CTC payments, as well as other provisions such as the Earned Income Tax Credit. FUTURE RESEARCH AND DATA NEEDS Prepublication copy, uncorrected proofs 10 

While evidence about the short-term effects of the pandemic on children and families is emerging, the long-term impacts remain unknown. There is still much unknown about the long- term impact that the pandemic may have on children’s social, emotional, behavioral, educational, physical, mental, and economic health and well-being. In order to better understand the pandemic’s effects on life-course trajectories, significant investments to build a pandemic- focused research program and data infrastructure are needed, including coordinating data collection and conducting urgent new research. Currently funded childhood longitudinal studies can provide critical evidence of the long-term effects of the pandemic on child health and wellness outcomes throughout development, but these studies do not extend from infancy through early adulthood. Extension of current longitudinal studies that enrolled pregnant people or young infants or a large national study that spans infancy through early adulthood is needed to fully understand the long-term impact of the pandemic on children. Moreover, investments are needed to ensure that across all child- and family-related sectors (e.g., education, health, social services, juvenile justice), data are collected and used to better understand how life-course trajectories have shifted because of the pandemic. Such data collection will need to be done in a community-partnered and culturally relevant manner that allows for a comprehensive, accurate, and timely understanding of the pandemic’s effects on these families. Recommendation 9: Public and private agencies, at the federal, state, and local levels, should eliminate existing barriers to and support mechanisms for child- and family-serving systems to collaborate on the systematic linking of data on children and families, across health, education, social services, juvenile justice, child welfare systems with other federal and state administrative data, to optimize and promote advancement in services, policy, programs, and research to address the negative effects of the pandemic on child and family well-being. Recommendation 10: Relevant federal government departments and agencies should prioritize and fund rigorous research, and the infrastructure to support it, on the effects of the pandemic on children and families. Questions on COVID-19 exposure and adversity also should be incorporated into existing national studies, such as the Youth Risk Behavior Survey and the Head Start Family and Child Experiences Survey. By investing in children and families today, the nation can avoid higher overall costs to society at large, as a generation of children, despite living through the COVID-19 pandemic, grows to adulthood with health and well-being that is optimized to allow them to reach their full life potential. These investments will need to be targeted to children and families from racially and ethnically minoritized and low-income communities who bore the brunt of the pandemic on top of preexisting societal inequities. Prepublication copy, uncorrected proofs 11