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

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1. Introduction The COVID-19 pandemic 1 has had unprecedented effects on the lives of children 2 and their families, who have been confronted with innumerable challenges, including illness and death; public health safety measures, such as school closures; social isolation; financial hardship; food insecurity; deleterious mental health effects; and lack of or gaps in access to health care (Shah et al., 2020; Stern et al., 2020). At the same time, the country has experienced continued racial trauma; violence against communities of color; and protests against that violence. The far- reaching effects of the pandemic—coupled with racial trauma and violence and historic inequities rooted in structural racism—are likely to have lasting adverse effects on children’s physical, mental, and social and emotional development. During the pandemic, many children were separated from stabilizing routines, school- based mental health resources, peer interactions, and programs that typically support their well- being. While some effects of these stressors were immediate, some may not become apparent until later in their lives. Overall, the developmental trajectories of children have been disrupted, which could have long-lasting effects on educational, economic, and health outcomes (Benner & Mistry, 2020). The effects of the COVID-19 pandemic have also been felt by parents and caregivers. Parents have reported significantly higher levels of stress related to COVID-19 than nonparents; for example, more than 70 percent of parents cited remote learning for their children as a source of great stress (Margolius et al., 2020). These impacts have been felt disproportionately by children and families facing economic hardship and by people in racially and ethnically minoritized communities, and the COVID-19 pandemic has highlighted existing inequities and the challenges that are faced by those communities. Chronic exposure to poverty and prolonged periods of limited resources are additional risk factors that have been intensified by the ongoing pandemic and so have increased the risk of adverse childhood experiences. The effects of the COVID-19 pandemic on children and families may be felt for years to come: for example, research on the 1918 influenza pandemic found long-term physical and mental effects for those who were children or in utero during it (Beach et al., 2022). 1 This report uses the terms “the COVID-19 pandemic,” “the pandemic,” and “COVID-19” to refer to the global pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which began in late 2019, was declared a pandemic in March 2020, and was ongoing as of the date this report was written. 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” is 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 12 

Understanding and responding to the long-term impact of the pandemic is needed in order to support the health, development, and well-being of children, benefiting not only children and their families, but also society at large. Furthermore, these long-term effects are likely to have significant implications for low-income children and families and those from racially and ethnically minoritized communities. STUDY CHARGE AND COMMITTEE APPROACH Given this context, the Robert Wood Johnson Foundation and the U.S. Department of Health and Human Services asked the National Academies of Sciences, Engineering, and Medicine to convene an expert ad hoc committee to examine the consequences of and solutions to the long-term effects of COVID-19 on children living in high-risk communities, focusing specifically on the physical and mental health and well-being of children and their caregivers. The full statement of task for the committee is provided in Box 1-1. BOX 1-1 Statement of Task An ad hoc committee of the National Academies of Sciences, Engineering, and Medicine will conduct a study on the consequences of and solutions to the long-term effects of COVID-19 on children living in high-risk communities. The committee will focus specifically on the physical and mental health of children and their caregivers. Information and data will be collected from a broad set of sources and may include a virtual public information-gathering session, input from those collecting real-time data on the health and mental health impacts of the virus (e.g., RAPID-EC), and review of the national responses of other countries that have been effective in their response to children and families. The committee will produce an independent report aimed at health and mental health practitioners and policymakers. The committee will address issues including, but not limited to, the following: 1. What policies and programs, including those affecting early childhood care and education, 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? What was learned during the pandemic that informs these approaches? 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? [END BOX] Study Methods The Committee on Addressing the Long-Term Impacts of the COVID-19 Pandemic on Children and Families was assembled to carry out this statement of task and produce this Prepublication copy, uncorrected proofs 13 

consensus report. The committee included experts in the areas of mental and physical health, health disparities, economics, education, learning and development, and public policy. During the course of this study, the committee held three virtual and two in-person meetings and conducted additional deliberations by video conference and electronic communications. The committee began its work in the fall of 2021, just a year and a half into the pandemic. Throughout its deliberations, evidence as to the impact of the pandemic on children and families began to emerge as more and new data became available through local-, state-, and national-level studies. While the evidence continues to emerge and evolve as longitudinal data continue to be collected, the committee’s report reflects its understanding of the effects of the pandemic on children and families through early 2023. Additional information as to the long- term effects of the pandemic will continue to emerge in the years to come. To carry out its work, the committee organized a wide range of information-gathering activities. The committee conducted an extensive critical review of the existing research literature in a wide range of disciplines, including neuroscience, developmental and social psychology, child and adolescent health and medicine, economics, disasters, and education and learning. To understand the roles, structures, policies, practices, and effects of social systems, the committee also reviewed pertinent research in social and behavioral sciences and public policy. This review began with an English-language search of online databases, including ProQuest and HeinOnline. Committee members and project staff used online searches to identify additional literature and other resources. Attention was also given to consensus and position statements issued by relevant experts and professional organizations. Research reports in peer-reviewed journals of the disciplines relevant to this study received priority. The committee largely focused on U.S. studies and data as the committee’s task was to come to a set of conclusions and recommendations for children and families in the United States; we did, however, include international studies when relevant. The report also builds on recent publications of the National Academies, including Vibrant, Healthy Kids (2019b); The Promise of Adolescence (2019a); A Roadmap to Reducing Child Poverty (2019d); and Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth (2019c). In addition to deliberating on the available scientific literature and evolving information related to the COVID-19 pandemic, the committee also drew on presentations and discussions from information-gathering sessions with key groups of stakeholders: adolescents, early care and education professionals, K–12 educators and administrators, juvenile justice and child welfare professionals, and Native American tribal leaders to guide its process. While the listening sessions were not designed to be representative and do not reflect the full range of perspectives or experiences of children and families during the pandemic, they provided the committee with important contextual and key narratives for understanding the lived experience of the pandemic. During these sessions, parents, youth, caregivers, and child- and youth-serving practitioners and organization leaders discussed the effects of the pandemic and potentially promising approaches for responding to it: these discussions served as a backdrop for the committee’s review and assessment of the available empirical literature, as well as a reminder of the real-life stories and experiences behind the data. The sessions served as an important input to the committee’s deliberations and provided a context for, though not the basis of, its conclusions and recommendations. The annex to this chapter provides a summary of those sessions. The committee also commissioned three papers to further its understanding of the impact of the pandemic on the workforce, housing, and student loans. Findings from these papers Prepublication copy, uncorrected proofs 14 

informed the committee’s deliberations and are incorporated throughout the report, as appropriate: • “Parents and Jobs in the Care Economy: Before and During the First Two Years of the Pandemic,” by Misty Heggeness, covered the workforce, both parents and child- and youth-serving practitioners. • “Eviction and Children During the COVID-19 Pandemic,” by Timothy Thomas, Julia Greenberg, and Amit Cohen, covered changes in the housing sector during the pandemic that affected families. • “Implications of Student Loan COVID-19 Pandemic Relief Measures for Families with Children,” by Sarena Goodman, Simona Hannon, Adam Isen, and Alvaro Mezza, covered the economic effects of student loan debt and repayment on families during the pandemic. Study Focus Guided by its charge, the committee focused on four key domains: social, emotional, and behavioral development; education; physical and mental health; and economic policy. These areas saw the greatest disruptions in the lives of children and their families, particularly for those groups that are the focus of the committee’s charge. The committee took a developmental approach to this analysis—that is, understanding the effects of the pandemic in relation to children’s development across the life course. In undertaking its task, the committee was also asked to focus on “children and families in high-risk communities.” While all people were affected by the COVID-19 pandemic in some way, the definition of “high risk” was informed by conversations with the sponsors and data on the disproportionate impact of the COVID-19 pandemic on children and families with low incomes and Black, Latino, 3 and Native American 4 families with children. 5 In this report, these groups are referred to as “individuals who have been racially and ethnically minoritized” and “individuals who have low incomes,” rather than “high-risk individuals.” While data on case rates, hospitalizations, and deaths continue to evolve as the pandemic unfolds, and while there are other individuals outside of these groups who have faced pandemic-related challenges, these groups were disproportionately affected and the underlying structural inequities that placed people of color at increased risk at the outset of the pandemic remain. It is critical to identify and address the factors leading to disparities in these populations to prevent the further widening of disparities and to take action to ensure the health and well-being of children and families moving forward. See Chapter 2 for further discussion of the societal context and structural racism. The committee acknowledges that other ethnic and racial groups and marginalized communities may have been disproportionately affected by the pandemic, but a lack of available 3 The term “Latino” is being used in this report as an ethnonym of “Hispanic” and is referring collectively to the inhabitants of the United States who are of Spanish or Latin American ancestry. 4 The term “Native American” is being used to be inclusive of Indigenous populations in the United States, including Alaska Natives. 5 The report uses the terms “Latino,” “Black,” “White,” and “Native American” in identifying these racial and ethnic groups to the extent possible; however, it retains other terms that are used in specific data or research references, such as “African American,” “Hispanic,” and “Indigenous people,” in order to remain consistent with the research being discussed. Prepublication copy, uncorrected proofs 15 

national data on these specific communities makes it challenging to draw strong conclusions or make recommendations. In particular, there is a significant lack of national data on the impact of COVID-19 on Asian American, Native Hawaiian, and Pacific Islander communities. The available evidence suggests that these communities experienced high rates of morbidity and mortality, but more than half of the states do not report data on these populations or include the data with other racial and ethnic groups (Morey et al., 2022). When data relevant to this report on Asian American, Native Hawaiian, and Pacific Islander children and families are available and meaningful, they have been included. While many of the report’s recommendations may be applied to all children and families, the committee aimed to focus specifically on supporting those groups most affected through targeted interventions to support developmental recovery, strengthen resilience, foster preparedness for future pandemics, build a community-engaged data infrastructure to better understand the needs of the most affected communities, and address the underlying societal inequities that exacerbated the harms of the pandemic. Although the primary focus of this study is the pandemic’s effects on children and their families, the committee also examined several contextual elements that co-occurred with the pandemic, including anti-Black rhetoric and violence, the economic recession triggered by the pandemic, and the sudden dependence on technology-mediated interactions. The committee acknowledges that, given the scope of this study and the time allotted for the committee to produce its report, important topics related to children and families and the pandemic were necessarily left out. For example, this report does not examine in depth how the pandemic affected youth involved in the child welfare or juvenile justice system. It also does not cover the pandemic’s effects on children with disabilities and their families, including their ability to access clinical service and treatment needs, home caregiving, and mental health treatment, although these are critically important areas of study. It does not look in depth at the effects of the pandemic on specific populations within the primary focus, such as children and adolescents who identify as LGBTQ+. And as noted above, it also focuses primarily on U.S.- based data and evidence. Several previous National Academies activities have examined some of these issues in greater depth (see, e.g., the National Academies of Sciences, Engineering, and Medicine, 2021a,b,c, 2022a,b). The committee was tasked with looking at what was learned during the pandemic and identifying promising practices to support child, parent, and caregiver well-being. Three years into the COVID-19 pandemic, the scientific community has amassed a great deal of information about the virus and its transmission, as well as the immediate responses, such as school closures and social distancing, on children and families. However, the pandemic remains dynamic, with the emergence of new waves and variants; long-term effects continuing to unfold; and shifting responses at the local, state, tribal, and national levels. With this in mind, the committee reviewed and assessed available data and literature on promising approaches and practices. Many approaches and practices show promise, but they will require further testing and evaluation to fully understand their mechanisms and their potential for implementation and sustainability. In addition, the committee also relied on evidence for prepandemic interventions; because the pandemic’s initial impact was so tightly related to systemic inequities in opportunity and resources for low-income and racially and ethnically minoritized populations, interventions in this area are relevant. Prepublication copy, uncorrected proofs 16 

EFFECTS OF THE PANDEMIC TO DATE As of January 2023, COVID-19 had resulted in 101 million confirmed cases in the United States and the deaths of over one million people. 6 Black, Latino, and Native American people had experienced a disproportionate burden of the COVID-19 cases and deaths relative to their White counterparts (see Ndugga et al., 2021). As shown in Figure 1-1, Latino, Black, and Native American people have been about twice as likely to die from COVID-19 as White people, and Latino and Native American people have been one-and-a-half times more likely to contract COVID-19 than White people. The figure also shows large disparities in COVID-19 hospitalizations for Black, Latino, and Native American people in comparison with White people. The higher rates of infection among low-income and racially and ethnically minoritized families likely reflect increased exposure risk due to working, living, and transportation conditions; these populations are more likely to work in jobs that cannot be done remotely, live in larger households, and rely on public transportation (Lopez et al., 2021). In addition, the prevalence of comorbidities, such as diabetes, hypertension, and obesity, are higher among low- income and racially and ethnically minoritized populations; these conditions can make COVID- 19 infection more serious and more likely to result in hospitalization or death (Lopez et al., 2021). FIGURE 1-1 Age-adjusted risk of COVID-19 infection, hospitalization, and death in the United States as of February 1, 2022. NOTE: Persons of Hispanic origin may be of any race but are categorized as Hispanic; other groups are non-Hispanic. SOURCE: Data from Faherty et al. (2022) and Centers of Disease Control and Prevention (2022). Analyses of weekly data on COVID-19 infections and deaths show that disparities in infections and deaths have both widened and narrowed over the course of the pandemic: see 6 Confirmed cases are likely to be an underestimate of the total number of people with the disease. Early in the pandemic, testing was not readily available. As testing expanding and at-home tests became more common, reporting of results became less consistent because individuals are not required to report their results to public health agencies (see the National Academies, 2020, 2022). Prepublication copy, uncorrected proofs 17 

Figures 1-2 and 1-3. These analyses are based on case and death rates that have not been adjusted for age, meaning they are likely underestimates of racial disparities, particularly for deaths, since the White population tends to be older and COVID-19 death rates have been higher among older individuals. During periods in which the virus has surged, disparities have generally widened, while they have narrowed when overall infection rates fell (Kaiser Family Foundation, 2022). FIGURE 1-2 COVID-19 weekly cases in the United States per 100,000 population by race and ethnicity, April 2020 to July 2022. NOTES: Data for August 7, 2021, were excluded because they reflect a large data influx for which clinical dates were not available. U.S. territories are included in the case counts. AIAN refers to American Indian/Alaska Native. SOURCE: Hill and Artiga (2022), Kaiser Family Foundation, using data from the Centers for Disease Control and Prevention: https://covid.cdc.gov/covid-data- tracker/#demographicsovertime Prepublication copy, uncorrected proofs 18 

FIGURE 1-3 COVID-19 weekly deaths in the United States per 100,000 population by race and ethnicity, April 2020 to May 2022. NOTES: U.S. territories are included in the death counts. AIAN refers to American Indian or Alaska Native. SOURCE: Hill & Artiga (2022), Kaiser Family Foundation, using data from the Centers for Disease Control and Prevention: https://covid.cdc.gov/covid-data- tracker/#demographicsovertime While the rates of severe illness and death among children have been relatively low in comparison with those for adults, the impact of the pandemic on young people has still been significant. Around 15 million children in the United States have tested positive for COVID-19 since the pandemic began, and this may be a substantial undercount (American Academy of Pediatrics, 2022). Thousands of children with COVID-19 have been hospitalized, and more than 1,400 have died (National Center for Health Statistics, 2022). Multisystem inflammatory syndrome in children (MIS-C), a rare but serious condition associated with COVID-19, had affected nearly 9,000 children and adolescents as of August 2022. 7 “Long COVID,” in which symptoms persist or recur after the acute phase of the illness, seems to be less prevalent among children than among adults. However, given the sheer number of infections, the number of children experiencing long COVID may be substantial (the National Academies, 2022c); the full impact of long COVID may not be known for many years (Buonsenso, 2021). In addition to their health challenges, children have also faced the loss of family members and caregivers. As of September 2022, it was estimated that more than 265,000 children in the United States had lost a parent, custodial grandparent, or grandparent caregiver because of COVID-19 (Hillis et al., 2021). 8 The burden of this loss was disproportionately borne by communities of color, with Black, Latino, and Native American children experiencing the loss of a caregiver at rates significantly higher than White children: as of mid-2021, the death of a caregiver had affected one in 753 White children, one in 412 Latino children, one in 310 Black 7 See https://covid.cdc.gov/covid-data-tracker/#mis-national-surveillance 8 See https://imperialcollegelondon.github.io/orphanhood_calculator/#/country/United%20States%20of%20America Prepublication copy, uncorrected proofs 19 

children, and one in 168 Native American children (Hillis et al., 2021). The stress and uncertainty around becoming infected and the fear of losing loved ones has weighed heavily on children and adolescents (Fitzgerald, 2021). Overlapping respiratory illnesses (respiratory syncytial virus [RSV], influenza, and COVID-19) also emerged as an acute concern for children in fall 2022 and was continuing into winter 2022–2023 (Agathis et al., 2023). In addition to these direct effects of COVID-19, children and adolescents have also dealt with major disruptions to their social and educational lives. The severity of the virus and the widespread risk of hospitalization and death, especially before the development of effective vaccines, prompted a wide-scale public health response and mitigation measures across the globe. After COVID-19 was declared a global pandemic and a national emergency in March 2020, travel restrictions and lockdowns were implemented, and schools began to close and shift to distance learning. Ohio was the first state to announce a statewide closure of schools on March 12; within one day, 15 other states had followed. 9 By March 25, 2020, all public school buildings in the United States had closed their doors, which affected about 50 million students. Many child care facilities around the country also closed in the spring of 2020, due to government restrictions, health concerns, and decreased demand for in-person care (Lee & Parolin, 2021). At the same time that schools and child care providers were adapting to COVID-19, employers and employees also were faced with difficult choices. Some employees transitioned to working from home and some lost their jobs, while essential workers—such as those working in health care, infrastructure, or critical retail jobs—remained on the front lines. Many parents were simultaneously coping with caring for young children and supervising remote learning for older children while working from home, out of work, or working in stressful and high-risk jobs. Although these aspects of the pandemic affected nearly all families, some were more affected than others. Women were more likely than men to lose their jobs or to be forced to leave their jobs because of a lack of child care (Heggeness & Fields, 2020; Heggeness, 2022; S. Census Bureau, 2022). Some families—particularly those with low incomes, those living in rural areas, and families of color—could not fully participate in remote learning for many reasons, including lack of appropriate high-quality technology, lack of reliable internet connection, and limited English proficiency (U.S. Department of Education, 2021). Black, Latino, and Native American workers faced multiple challenges related to unemployment: they were less likely to be able to work from home, they were more likely to lose their jobs, and they were more likely to work in public-facing jobs that put them at risk of infection (Dubay et al., 2020; EPI, 2020). In addition to the variable impact of the pandemic on different populations, the response to COVID-19 differed significantly across the United States. Most states issued “stay-at-home” orders in March or April of 2020, although some rural states held off or adopted less strict measures (Mervosh et al., 2020). Policies regarding face coverings also varied by state, with some states requiring people to wear masks indoors or when unable to socially distance, and other states taking the opposite approach of actually prohibiting local municipalities or schools from mandating masks (Hubbard, 2022). While all public schools closed in spring 2020, schools diverged in their approaches for the 2020–2021 school year. Some states required remote or hybrid education, some left the decision to local school districts, some permitted in-person school if certain requirements were met, and some required full-time in-person learning. For See https://ballotpedia.org/School_responses_to_the_coronavirus_(COVID- 9 19)_pandemic_during_the_2019-2020_academic_year#Timeline Prepublication copy, uncorrected proofs 20 

example, schools in New York could remain open with a certain test positivity rate, while Arkansas required districts to offer in-person learning and also prohibited districts from requiring masks (EdWeek, 2021). The trajectory of the pandemic since 2020 has been uneven and unpredictable, complicating public health efforts and compounding the effects on children and their families. As vaccines became available in early 2021, there were hopes that the end of the pandemic was in sight (Stein, 2021). However, just as the United States was reporting a record low number of deaths and had achieved a rate of 70 percent of eligible people vaccinated, the Delta variant gained a foothold (American Journal of Managed Care, 2021). Hospitalization and death rates spiked, including among children (American Journal of Managed Care, 2021). Several months later, in January 2022, case rates rose far above previous levels because of the extremely contagious Omicron variant. Schools and child care facilities struggled to stay open in the face of teacher and staff absences, and many working parents found themselves again juggling work and child care (Green, 2022; Querolo, 2022). While adults had access to vaccines during this period, adolescents only became eligible for vaccination in spring 2021, and vaccines for children aged 5–11 did not begin until November 2021. The youngest children—those aged six months to five years—did not become eligible for vaccination until June 2022. As of the publication of this report, the pandemic has touched four academic years, and the effects on child care and education programs has been substantial. Many early childhood education programs that closed in the spring of 2020 have remained closed or have been forced to raise prices or cut services (Lee & Parolin, 2021). A survey in early 2022 found that more than 25 percent of families with young children had not been able to access child care in the previous month. At the same time, some caregivers were forced to take unpaid leave, cut work hours, or leave their jobs (Census, 2022). As described in more detail in Chapter 4, many elementary, middle, and high school students experienced up to a year and a half of remote or hybrid school, and the 2021–2022 school year was further interrupted by local Omicron outbreaks, resulting in closures and quarantine and isolation requirements. Sports, camps, and other organized activities for children abruptly stopped in the spring of 2020 and have haltingly reopened with reduced capacity, masking, and social distancing requirements, along with interrupted seasons. As with other aspects of the pandemic, these effects have been disproportionately borne by low-income and racially and ethnically minoritized children and families. For example, after the initial widespread school closures in spring 2020, continued remote learning was more common in schools that served low-income and racially and ethnically minoritized children than those that served other children (Lee & Parolin, 2021). These school closures in some cases contributed to reduced access to such supports as food assistance, mental health services, and intervention for abuse or homelessness (Hoffman & Miller, 2020). Black and Latino families were more likely to experience child care closures throughout the pandemic than White families; lack of child care is associated with reduced employment and increased stress for parents (Lee & Parolin, 2021). ORGANIZATION OF THE REPORT Following this introductory chapter, Chapter 2 describes the societal and developmental contexts of the pandemic. Chapter 3 details the social, emotional, and behavioral effects, and interventions to help address these effects. Chapter 4 describes challenges in learning and education and describes promising interventions to address the academic and other losses resulting from the pandemic. Chapter 5 details the evidence of the health effects of the pandemic Prepublication copy, uncorrected proofs 21 

on children and families and assesses programs and policies to address the physical and mental health needs of children and families. Chapter 6 discusses how children and families are faring economically from the pandemic and the evidence of effectiveness of economic policies adopted to mitigate the effects of the pandemic. Finally, Chapter 7 offers the committee’s recommendations for addressing the long-term effects of the COVID-19 pandemic. The appendix provides biographical sketches of committee members and staff. ANNEX PERSPECTIVES ON THE PANDEMIC As noted above, the committee’s information gathering included listening sessions to understand experiences of the pandemic among adolescents, parents, early child care and education professionals, K–12 educators and administrators, juvenile justice and child welfare professionals, and Native Americans. Two of these listening sessions were conducted during open public meetings and four were done in private with a group of committee members. While these listening sessions were not designed to be representative and do not reflect the full range of perspectives or experiences of children and families during the pandemic, they provided important context for understanding the lived experience of the pandemic. During these sessions, parents, youth, caregivers, and child- and youth-serving practitioners and organization leaders discussed effects of the pandemic and potentially promising approaches for responding to the pandemic; these discussions served as a backdrop for the committee’s review and assessment of the available empirical literature, as well as a reminder of the real-life stories and experiences behind the data. The sessions served as an important input to the committee’s deliberations and provided a context for, though not the basis of, its conclusions and recommendations. Adolescents Voices of Youth in Chicago Education (VOYCE), a youth-organizing alliance led by students of color from across Chicago, works to redefine what safety means in schools and communities and advance a vision for healing-centered schools and communities through the use of restorative justice. VOYCE youth members discussed with a group of committee members the greatest challenges they faced during this pandemic, what supports were the most helpful for themselves and their families, and what they think is needed moving forward to address the effects of the pandemic. The youth discussed experiencing depression, anxiety, grief, and loss. They experienced grief over the loss of family and community members. They were anxious about parents and other family members who lost work and the resulting economic stress. With everything, it piled up even more on me and I got stressed. It got to the point where I wasn’t able to sleep properly anymore or eat properly anymore, and I did gain a lot of anxiety and depression. My mom lost her business. Financially, that put her 10 steps back. We were trying to maintain everything but the bills just kept piling up. Prepublication copy, uncorrected proofs 22 

Food prices went up, rent, everything went up. That was a big struggle that we had because I always had thoughts, “What if we’re gonna go homeless?” There was a point in my life where I actually thought we were gonna go homeless and we didn’t know if we were gonna get food the next day, if we were even going to have our place. Wi-Fi support for people and families on government programs was helpful but didn’t start happening ’til mid-pandemic, so I was kinda stuck without Wi-Fi or any connectivity towards my teachers. Participants expressed experiencing a loss of routine, which affected their learning and social engagement. They lost motivation and the ability to focus on schoolwork and learning during virtual school. They became socially isolated and withdrawn. I lost a lot of motivation for school. I was at home and virtual, and there were a lot of distractions. I had a really terrible experience with virtual. I wasn’t doing good in my studies or anything at all. People were scared. No one was out of the house. They would rarely go out. The only time they would go out is if they need anything urgent or if they need to go to the grocery store to get supplies. Participants expressed experiencing feeling isolated. They noted that they lacked the emotional support that they had previously had at school through relationships with counselors and engagement in extracurricular activities. They expressed a need for additional mental health resources and a more robust social and emotional safety net at school. To make things better for me and my family and other young people affected by the pandemic, the government [should] promote mental health resources—a lot of teenagers are struggling mentally and a lot of people don’t know it. It’s something that needs to be addressed not later, but now. Participants pointed to afterschool programs and job opportunities as helpful in establishing routines and supporting their physical and mental health, but noted that these opportunities are limited in many communities. [During the pandemic] my coach was motivating me to go to the gym. She was giving me private lessons and I was just so grateful for that because we built a bond and she was like my second mom. . . . When I had that I fell back into my routine. [To make things better for me and my family and other young people affected by the pandemic, the government should provide] more jobs and afterschool Prepublication copy, uncorrected proofs 23 

activities for youth—it helps them physically and mentally. . . . It helps distract them. Early Childhood Educators A group of parents, Early Head Start program home visitors, home-based child care providers, center-based child care providers, and Early Head Start/Head Start educators and administrators from California shared their perspectives with the committee on the pandemic’s impact on the children and families they serve. They also discussed what they need both immediately and long term to mitigate the negative effects of the pandemic on the health and well-being of the children and families and child care professionals caring for these children. Participants expressed experiencing additional stress in their own families and those they served, particularly ones that were already stressed by financial, social, or other challenges. They noted that children often bring that stress to the classroom, and early childhood educators are often called upon to support the whole family. The general stress of the pandemic on families and on providers—a lot of families experienced death during the pandemic or they had COVID themselves. They may have been dealing with different things in the household. That isolation that happened, some families were already in volatile situations and were dealing with domestic violence in their homes and different issues in those homes, and those issues ended up being exacerbated by being at home for all that time, unsure or certain what the future would be. We’re seeing those effects on children and on the classroom. We need to look at the mental health of the entire family. Children are taking in [the] stress [of the whole family], and even if they aren’t seeing domestic violence, it can be something as small as mom is stressed out and hollering at the child and now that child is taking in that stress. Addressing the entire family and providing mental health supports for the entire family [and] for providers also is so important. Participants noted that early childhood professionals need training that extends beyond academic teaching to meet additional needs of children experiencing increasing anxiety as a result of the pandemic. [It is very] important to have . . . training on trauma-informed care, dealing with stress, dealing with burnout, dealing with caregiver fatigue. [Professional] training [is] really valuable to [child care workers] to bring that information to the classroom and implement some of those too and make sure they were managing their stress levels too. Participants also stressed that, from their perspective, there is a need for more preventive health care and mental health services, particularly to address child stress and anxiety. Prepublication copy, uncorrected proofs 24 

[We need more] programs for preventive health care. . . . If a child comes to my program with a level of stress, always worried over something— “Who is going to pick me up? “How am I going home?” “Is my dad coming?”—I would like to have a policy where there is more preventive health care. This can turn into something like depression or something more serious. K–12 Educators and Administrators Participants in this public information-gathering session included an early childhood teacher from Atlanta, Georgia, the CEO of the National Association of State Boards of Education, and a high school teacher from Detroit, Michigan. Participants reflected that teachers and school administrators had little or no preparation for the level of disruption they faced. Schools and districts had routines in the context of their normal course of business that they were used to and of course, a wrench was thrown into those works—not a slight disruption but a major shift. Even though there had been a push to have emergency plans in place, in most cases, those plans around disease outbreaks were superficial and not focused on anything we wound up experiencing. Administrators were instead whipsawed into a more reactive mode, concerned with [such problems as] “How do we get kids food?” “How do we get computers into the hands of kids?” “How do we facilitate broadband access?” Teachers and administrators wound up having to deal with quarantining, contact tracing, and a myriad of things they had no experience with, all while learning to transition to a remote learning environment along with their students. Participants noted changes in social interactions among their students during the pandemic. Interactions have been over Instagram, Twitter, or TikTok, and so getting back into in- person learning once schools decided to reopen, students needed to relearn how to talk to each other face to face. Whether they were having conflicts or navigating relationships outside of the class, students struggled to navigate social situations. Students were also exposed to difficult situations at home, from adults’ stress about finances or illnesses in the family, to older siblings struggling to navigate learning alongside them. They often carried that stress back to school, requiring teachers to create space for difficult conversations in addition to their lesson plans. In addition, technology and social media exposed kids to new behaviors and new ideas that they carried to school that often lacked context and needed explaining, especially in the early childhood space when “iPad parenting” was the norm. Prepublication copy, uncorrected proofs 25 

Participants also said that students felt the impact of the pandemic beyond academic outcomes, such as the loss of social events like school dances and extracurricular activities. High school students have been trying to adjust to virtual learning, but it has been hard because they’re teenagers and they looked forward to things like Homecoming, which didn’t happen because of COVID regulations, or spending time talking with friends in the hallway between classes. There has been this huge loss of social and emotional development that is a core part of the normal high school experience that they’ve missed because of the pandemic. More and more of the focus has been on teaching students about how to be in school again—simple things like raising hands when asking questions rather than shouting out answers or letting fellow students talk without interrupting them—all things that students have struggled with since returning to in-person instruction. Homeroom class became more about providing social and emotional learning and development with students because they needed a space where they could receive the mental health support. One strategy that we found effective was creating small cohorts of students in our homeroom classes where they could practice interacting with each other again. Practitioners Serving Children Involved in the Child Welfare System Health care professionals serving children involved in the child welfare system in Cincinnati shared insights with the committee on the impact of the pandemic on the children involved with this system. Participants stated that the pandemic revealed existing, systemic issues faced by children in the child welfare system. Given all that we know now about the correlation between foster care and homelessness and the truly jarring rate at which young people age out of the foster care system and immediately fall into homelessness, it’s really time to revisit our approach to supporting youth who exit the system by prioritizing prevention of homelessness with federal- and state-level policy changes, and, importantly, allocations of resources to meet the need. I often refer to COVID as the “great revealer” because it really revealed the vast inequities that exist in this country. It also exacerbated existing issues and that is true with children in the child welfare system and trauma being chief among those issues. Practitioners Serving Children Involved in the Juvenile Justice System Individuals working in the juvenile justice system in Los Angeles County shared insights with the committee on the impact of the pandemic on children involved in the juvenile justice system. Participants noted that staffing shortages resulted in decreased educational opportunities Prepublication copy, uncorrected proofs 26 

and social isolation for children in the juvenile justice system. They also observed increased anxiety and depression among they youth they worked with. There were no longer teachers coming in to teach the students in the justice system, and then also at that point in the beginning of the pandemic, they were not even doing it virtually, so they were providing packets for the youth to do while in their rooms. So the education was not as robust as it should have been during that time frame. The youth were quarantined longer than they should have been because the staffing wasn’t available. [There was] additional stress from the suspension of family visits. An increase in the sense of isolation and increased mental health issues were [the] number one impact seen in incarcerated youth, often due to long-term and consecutive quarantine as units rotated in and out as cases of infection were detected. Participants noted that delays in court proceedings occurred during the pandemic, with direct effect on children in the juvenile justice system. Our court was delayed—we had a significant backlog, literally for years. What that meant was that permanency for children in care was delayed [such as adoption and legal guardianship]. What was most troubling and problematic was that children remained in foster care for periods that were longer than necessary for their safety. Participants also noted that for some children in care, the pandemic resulted in positive outcomes and provided new ways to improve processes in the future. One of the greatest impacts of the pandemic has been further reduction in the number of youth incarceration since incarceration itself causes such a tremendous health impact for short-term and long-term experiences for youth. The virtual court for the older kids was a huge success and something that I hope the county continues. . . . It can help parents be able to not miss all day of work and kids not miss all day of school and attend a hearing that they maybe don’t need to be physically present for. Native American Tribal Leaders Participants in this public information-gathering session included the director of early childhood education and for the Port Gamble S’Klallam tribe, the director of the National American Indian and Alaska Native Head Start Collaboration Office, the vice president of the Oglala Sioux tribe, and the director of the Center for American Indian Health at Johns Hopkins. Participants expressed concerns that deaths among the elderly in tribal communities may have a significant impact on the passing down of cultural traditions. Prepublication copy, uncorrected proofs 27 

Our elderly have a unique knowledge of the language and of tribal traditions. When we lose elders, we can’t get that knowledge back. Losing them is devastating to our communities and changes how we are as a people. Which is why our communities took this pandemic seriously from the very beginning—to try to protect as many as we can. The losses we have suffered are not just a loss of life or something that put us behind a few years—they are a deep cultural wound. In South Dakota, babies that were born before the pandemic often had over 50 relatives waiting to greet them when they were born. But, during the pandemic, these children and their parents often had to go it alone without the direct support of their extended families and their communities. There was often a lot of anxiety after bringing babies home without access to this support. For members of the Port Gamble S’Klallam tribe, participation in fishing traditions was derailed. While resources were put in place to support and sustain their families, children who would normally learn these traditional fishing practices were unable to be involved in these practices in order to protect their health. The trauma associated with the high death rates among all tribal members are added to the historical trauma already faced by our communities. Participants noted that prepandemic, tribal communities struggled to receive federal support. The pandemic exacerbated these issues. What do we do when that money is gone? We had some money from the federal government to help with funding health care, utilities, schools, food, etc., but the pandemic will continue to cost money even after that funding has dried up. The effects will still be here and we need to be able support our communities. The pandemic has happened on top of all the issues that were already there in terms of how we receive support from the federal government. Participants also shared their experiences of the resilience of their communities. They noted positive instances of leadership and innovation in tribal communities’ handling of the pandemic. From early on, our community was very committed to testing, mask-wearing, and distancing measures in order to protect children and the elderly. We had the most vaccinated people of any ethnicity in the United States. We had to protect our people. While the rest of the people outside [our] community behaved like nothing was going on, we were providing monetary incentives to get our community members vaccinated. Tribal leaders operated emergency centers to provide testing and to distribute shots when they became available. Leaders got the first vaccines to show that they were safe and effective for their communities. Prepublication copy, uncorrected proofs 28 

There was a general communal orientation to the pandemic that was often missing from the national narrative regarding protective measures. Finding ways to connect to families safely, either by reconnecting to nature with exercise, or outdoor community- based activities, the central mentality often prioritized taking care of each other with an understanding that the individual thrived only when the community did. Prepublication copy, uncorrected proofs 29 

REFERENCES Agathis, N. T., Patel, K., Milucky, J., Taylor, C. A., Whitaker, M., Pham, H., Anglin, O., Chai, S. J., Alden, N. B., Anderson, J. E. J., Weigel, A., Kim, S., Lynfield, R., Smelser, C., Muse, A., Popham, K., Billing, L. M., Sutton, M., Talbot, H. K., George, A., McMorrow, M., Havers, F. P., & CDC COVID-NET Surveillance Team. (2023). Codetections of other respiratory viruses among children hospitalized with COVID-19. Pediatrics, 151(2), e2022059037. https://doi.org/10.1542/peds.2022-059037 American Academy of Pediatrics. (2022). Children and COVID-19: State-level data. Report. https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19- infections/children-and-covid-19-state-level-data-report American Journal of Managed Care. (2021). A timeline of Covid-19 vaccine developments for the second half of 2021. American Journal of Managed Care. https://www.ajmc.com/view/a-timeline-of-covid-19-vaccine-developments-for-the- second-half-of-2021 Beach, B., Clay, K., & Saavedra, M. (2022). The 1918 influenza pandemic and its lessons for COVID-19. Journal of Economic Literature, 60(1), 41–84. https://www.nber.org/system/files/working_papers/w27673/w27673.pdf Benner, A. D., & Mistry, R. S. (2020). Child development during the COVID-19 pandemic through a life course theory lens. Child Development Perspectives, 14(4), 236–243. https://doi.org/10.1111/cdep.12387 Buonsenso, D., Munblit, D., De Rose, C., Sinatti, D., Ricchiuto, A., Carfi, A., & Valentini, P. (2021). Preliminary evidence on long COVID in children. Acta paediatrica. 110(7), 2208–2211. https://doi.org/10.1111/apa.15870 Centers for Disease Control and Prevention. (2022). Risk for COVID-19 infection, hospitalization, and death by race/ethnicity data as of February 1, 2022. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations- discovery/hospitalization-death-by-race-ethnicity.html Dubay, L., Aarons, J., Brown, K. S., & Kenney, G. M. (2020). How risk of exposure to the coronavirus at work varies by race and ethnicity and how to protect the health and well- being of workers and their families. Urban Institute. https://www.urban.org/research/publication/how-risk-exposure-coronavirus-work-varies- race-and-ethnicity-and-how-protect-health-and-well-being-workers-and-their-families EdWeek. (2021). Map: Where were schools required to be open for the 2020-21 school year? https://www.edweek.org/leadership/map-where-are-schools-closed/2020/07 Faherty, L. J., Ringel, J. S., Kranz, A. M., Baker, L., Phillips, B., Williams, M. V., Perez, L., Schulson, L. B., Timmins, G., Gittens, A. D., Gandhi, P., Howell, K. & Adekunle, T. (2022). Putting equity first in COVID-19 vaccination. RAND Corporation. https://www.rand.org/pubs/research_briefs/RBA1627-2.html Fitzgerald, D. A., Nunn, K., & Isaacs, D. (2021). What we have learnt about trauma, loss and grief for children in response to COVID-19. Paediatric respiratory reviews, 39, 16–21. https://doi.org/10.1016/j.prrv.2021.05.009 Green, A. (2022, January 15). Omicron has closed classrooms for 1 in 3 Portland area students, upending kids’ and working parents’ lives. The Oregonian/OregonLive. https://www.oregonlive.com/news/2022/01/omicron-has-closed-classrooms-for-1-in-3- portland-area-students-upending-kids-and-working-parents-lives.html Prepublication copy, uncorrected proofs 30 

Heggeness, M. L. (2022). Parents in the care economy: Before and during the first two years of the pandemic. Heggeness, M. L. & Fields, J. M. (2020). Working moms bear brunt of home schooling while working during COVID-19. https://www.census.gov/library/stories/2020/08/parents- juggle-work-and-child-care-during-pandemic.html Hill, L., & Artiga, S. (2022). COVID-19 cases and deaths by race/ethnicity: Current data and changes over time. Kaiser Family Foundation. https://www.kff.org/coronavirus-covid- 19/issue-brief/covid-19-cases-and-deaths-by-race-ethnicity-current-data-and-changes- over-time Hillis, S. D., Blenkinsop, A., Villaveces, A., Annor, F., Liburd, L., Massetti, G., Demissie, Z., Mercy, J., Nelson, C., Cluver, L., Flaxman, S., Sherr, L., Donnelly, C., Ratmann, O., & Unwin, J. (2021). COVID-19–associated orphanhood and caregiver death in the United States. Pediatrics, 148(6). Hoffman, J. A. & Miller, E. A. (2020). Addressing the consequences of school closure due to COVID-19 on children's physical and mental well-being. World Medical & Health policy, 12(3), 300–310. https://doi.org/10.1002/wmh3.365 Lee, E. K., & Parolin, Z. (2021). The care burden during COVID-19: A national database of child care closures in the United States. Socius, 7. https://doi.org/10.1177/23780231211032028 Lopez L., Hart, L.H., Katz, M.H. (2021). Racial and ethnic health disparities related to COVID- 19. JAMA, 325(8), 719–720. https://doi:10.1001/jama.2020.26443 Margolius, M., Doyle Lynch, A., Pufall Jones, E., & Hynes, M. (2020). The state of young people during COVID-19: Findings from a nationally representative survey of high school youth. Americas Promise Alliance. https://www.americaspromise.org/resource/state-young-people-during-covid-19 Mervosh, S., Lu, D., & Swales, V. (2020, April 20). See which states and cities have told residents to stay at home. The New York Times. https://www.nytimes.com/interactive/2020/us/coronavirus-stay-at-home-order.html Morey, B. N., Chang, R., Thomas, K., Tulua, A., Penaia, C., Tran, V., Pierson, N., Greer, J., Bydalek, M., & Ponce, N. (2022). No equity without data equity: Data reporting gaps for Native Hawaiians and Pacific Islanders as structural racism. Journal of Health Politics, Policy and Law, 47(2), 159–200. https://pubmed.ncbi.nlm.nih.gov/34522960 National Academies of Sciences, Engineering, and Medicine. (2019a). The promise of adolescence: Realizing opportunity for all youth. The National Academies Press. https://doi.org/10.17226/25388 ———. (2019b). Vibrant and healthy kids: Aligning science, practice, and policy to advance health equity. The National Academies Press. https://doi.org/10.17226/25466 ———. (2019c). Fostering healthy mental, emotional, and behavioral development in children and youth: A national agenda. The National Academies Press. https://doi.org/10.17226/25201 ———. (2019d). Roadmap to reducing child poverty. The National Academies Press. https://doi.org/10.17226/25246 ———. (2020). Evaluating data types: a guide for decision makers using data to understand the extent and spread of COVID-19. The National Academies Press. https://nap.nationalacademies.org/read/26578/chapter/1 Prepublication copy, uncorrected proofs 31 

———. (2021a). Back in School: Addressing the well-being of students in the wake of COVID- 19: Proceedings of a workshop—In brief. The National Academies Press. https://doi.org/10.17226/26296 ———. (2021b). Promoting the health and well-being of children in immigrant families: Proceedings of a workshop—In brief. The National Academies Press. https://doi.org/10.17226/26263 ———. (2021c). Contact tracing and the challenges of health equity in vulnerable Latino and Native American communities: Proceedings of a workshop—In brief. The National Academies Press. https://doi.org/10.17226/26174 ———. (2022a). COVID-19 vaccines: Studying historical successes (and failures) for equity- centered approaches to vaccinating Indigenous communities, undocumented immigrants, and communities of color: Proceedings of a Workshop—In brief. The National Academies Press. https://doi.org/10.17226/26622 ———. (2022b). Supporting children with disabilities: Lessons from the pandemic: Proceedings of a workshop. The National Academies Press. ———. (2022c). Long COVID: Examining long-term health effects of COVID-19 and implications for the Social Security Administration: Proceedings of a workshop. The National Academies Press. https://doi.org/10.17226/26619 ———. (2022d). Evaluating COVID-19-related surveillance measures for decision-making. The National Academies Press. National Center for Health Statistics. (2022). Provisional COVID-19 deaths: Focus on ages 0-18 years. Accessed September 30, 2022. https://data.cdc.gov/d/nr4s-juj3. Ndugga, N., iPham, O., Hill, L., Artiga, S., Alam, R., & Parker, N. (2021). Latest data on COVID-19 vaccinations race/ethnicity. Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19- vaccinations-by-race-ethnicity/ Querolo, N. (2022, January 10). Record wave of U.S. Omicron school closures is set to abate. Bloomberg, https://www.bloomberg.com/news/articles/2022-01-10/record-wave-of-u-s- omicron-school-closures-is-set-to-abate Shah, K., Mann, S., Singh, R., Bangar, R., & Kulkarni, R. (2020). Impact of COVID-19 on the mental health of children and adolescents. Cureus, 12(8), e10051. https://doi.org/10.7759/cureus.10051 Stein, R. (2021, April 30). U.S. vaccinations may be reaching a tipping point in fight against virus, experts say. National Public Radio. https://www.npr.org/sections/health- shots/2021/04/30/992448089/u-s-vaccinations-may-be-reaching-a-tipping-point-to-stop- the-virus-experts-say Stern, M., Wagner, M. H., & Thompson, L. A. (2020). Current and COVID-19 challenges with childhood and adolescent sleep. JAMA Pediatrics, 174(11), 1124. https://doi.org/10.1001/jamapediatrics.2020.2784 U.S. Census Bureau. (2022). Childcare arrangements in the last 4 weeks for children under 5 years old. https://www2.census.gov/programs- surveys/demo/tables/hhp/2022/wk42/educ1_week42.xlsx U.S. Department of Education. (2021). Supporting students during the COVID-19 pandemic: Maximizing in-person learning and implementing effective practices for students in quarantine and isolation. https://www.ed.gov/coronavirus/supporting-students-during- covid-19-pandemic Prepublication copy, uncorrected proofs 32