2
Societal and Developmental Contexts of the Pandemic
This chapter first describes the societal context in which the pandemic erupted. It then describes the developmental context for children. With this background, the committee details three frameworks that provide a foundation for the discussion of effects throughout the report, particularly in Chapter 3: the life-course perspective; the framework of danger, safety, and protection; and pandemic “signatures” and “dose of exposure.” The final section of the chapter discusses adversities and resilience in the context of those frameworks.
SOCIETAL CONTEXT
The societal shock of the COVID-19 pandemic did not occur in a vacuum. It came in the context of existing patterns of inequities and marginalization, known as structural racism, which intensified the pandemic’s impact for low-income and racially and ethnically minoritized children and their families. 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 inequalities (the National Academies of Sciences, Engineering, and Medicine [the National Academies], 2022). Thus, structural racism is more than mere patterns (disparities) or treatment (discrimination), but encompasses rules, routines, and assumptions of U.S. law, institutions, norms, ideologies, policies, and technologies that create disadvantages and advantages for people and groups based on how they are racialized in society.
Social organization (in neighborhoods, families, or markets, for example) and institutions are often patterned in a way that is harmful to racialized groups, even in the absence of individual-level racism. The COVID-19 pandemic landed in this inequitable environment, compounding numerous preexisting inequities in social, economic, education, and health access and outcomes. In addition, the pandemic occurred at the time of and intersected with other major social events, 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: see Figure 2-1.
The relationships between these intersecting events are not entirely clear. For example, drug overdose deaths rose significantly as the pandemic emerged (Macmadu et al., 2021; Brener et al., 2022). Researchers have hypothesized that social distancing and stay-at-home orders could have contributed to this rise because of increased social isolation, diminished social support, and an increase in the use of drugs while alone (Bonn et al., 2020; Stephenson, 2020; Tyndall, 2020; Wakeman et al., 2020; Linas et al., 2021); however, the evidence is sparse to support any specific mechanism for the association.
The impact of the virus itself has also been exacerbated by preexisting disparities and conditions. As detailed in Chapter 1, rates of illness and death related to COVID-19 are substantially higher in certain populations, particularly communities of color. There are numerous potential factors that have contributed to these disparities in outcomes, including lack of access to health care, difficulty in social distancing because of employment demands or dense housing, cultural or linguistic barriers, lack of trust between communities and the health system, and racism (Centers for Disease Control and Prevention [CDC], 2022). Racism and discrimination played a role both in the disparate rates of COVID-19 in certain communities and in disparities in access to resources, such as vaccines. Systemic racism, experiences of discrimination, and social inequality are pervasive in the environments in which Black, Latino, and Native American families raise their children. These realities present unique threats that caregivers have to navigate to keep their children safe (Gaylord-Harden et al., 2018). These threats to safety have been compounded by the COVID-19 pandemic.
The word “syndemic” has been used to describe the biological and social interactions between conditions and states that “increase a person’s susceptibility to harm or worsen their health outcomes” (Horton, 2020, p. 874). Instead of considering COVID-19 solely a biological phenomenon, a syndemic approach requires looking at the broader socioeconomic conditions and structures that both affect and are affected by the virus. The syndemic nature of COVID-19 is demonstrated by the fact that it has disproportionately affected communities that experience discrimination and
NOTES: CARES Act, Coronavirus Aid, Relief, and Economic Security Act; CDC, Centers for Disease Control and Prevention; WHO, World Health Organization.
SOURCE: Data from The New York Times (https://www.nytimes.com/article/coronavirus-timeline.html), Nguyen et al. (2022), and the Centers for Disease Control and Prevention (https://www.cdc.gov/museum/timeline/covid19.html).
racism; lack of access to resources; and structural inequities in education, health care, and other areas aspects of daily life.
While most individuals and communities were negatively affected in some way by the pandemic, some families were able to leverage their resources to mitigate the pandemic’s effects. For example, families with resources may have been able to hire tutors or create education pods while schools were closed. Children in these leveraged families had the opportunity to maintain or advance their learning, while children in families with fewer resources are more likely to have experienced learning loss. These types of advantages to some families and disadvantages to others can also affect health outcomes: for example, advantaged families may be able to better access vaccines or may have been able to stay home from work to reduce exposure.
A theory known as fundamental cause suggests that inequalities in health persist over time because socioeconomic advantages can be mobilized to avoid the risk of disease and to minimize consequences once disease occurs; these advantages include both financial resources and social connections (Link & Phelan, 1995; Phelan et al., 2004; Freese & Lutfey, 2011; Clouston & Link, 2021). The fundamental cause theory predicts that socioeconomic position is more salient when the factors affecting health are preventable and so can be addressed by the use of available resources (Phelan et al., 2004; Clouston & Link, 2021).
Even in the absence of inequalities in infection risk or severity, disparities in the effects of infection could occur because of differences in access to and treatment by the health care system. As documented by research in medical sociology, advantaged populations are more likely to benefit from health-enhancing innovations (Chang & Lauderdale, 2009) and to receive more attention from health care providers (Van Ryn & Burke, 2000; Lutfey & Freese, 2005; Hernandez, 2013). Observed patterns of stratification in rates of COVID-19 infection are consistent with the predictions of fundamental cause theory. Risk reduction strategies, such as working from home and wearing masks, were more likely to be adopted by socioeconomically advantaged groups (Wright et al., 2020; Papageorge et al., 2021). At the same time, low-income and racially and ethnically minoritized persons were more likely to be exposed to risks, such as living in crowded conditions, holding jobs that could not be performed remotely, and working in public-facing occupations (Dorn et al., 2020; Webb Hooper et al., 2020; García et al., 2022).
DEVELOPMENTAL CONTEXT
To fully appreciate the potential effects of the COVID-19 pandemic, it is important to recognize the developmental stages across the life course and
how these stages are affected by such factors as structural inequities and racism, social determinants of health, family and social connections, and individual social and biological mechanisms. A previous National Academies (2019) report, Vibrant and Healthy Kids, provides a conceptual model for understanding development in context across life stages: see Figure 2-2. The committee used this model to examine and explain the intersectional nature of the pandemic’s effects, illustrating the ways in which the pandemic is occurring in the context of existing structures and patterns of inequities.
The diagram’s nested circles illustrate the complex sociocultural environment that shapes development at the individual level. Individual social and biological mechanisms and culture operate and interact within and across the three levels. Structural inequities operate at the outermost level, the socioeconomic and political drivers. Structural inequities are deeply embedded in policies, laws, governance, and culture; they result in the differential distribution of power and resources across individual and group characteristics (including race, ethnicity, sex, gender identity, class, sexual orientation, and gender expression).
The next level, second from the outermost circle, represents social, economic, cultural, and environmental states (i.e., the social determinants
SOURCE: The National Academies (2019, Figure S-1).
of health). In the model, these interdependent factors are grouped into three domains—healthy living conditions, health care system, and early care and education.
The next level, the third circle from the outermost ring, represents the factors that most directly and proximally shape children’s daily experiences, routine patterns, and access to resources: family cohesion, social connections, and caregiver well-being. Developmental risk and protective factors can be transferred intergenerationally, which makes parents and other family and community caregivers a central focus of understanding the effects of the pandemic on children and their families.1 Parental well-being is a critical determinant of children’s health and developmental outcomes: what happens to parents before, during, and after pregnancy has major implications for their children (Center on the Developing Child, 2009; Goodman & Garber, 2017; the National Academies, 2019). Moreover, there is clear scientific evidence that the presence of safe, stable, and nurturing relationships is critical to healthy development and can buffer the mechanisms of adversity and support positive trajectories (National Scientific Council on the Developing Child, 2004; Bronfenbrenner & Morris, 2006; Luthar, 2006; Masten, 2014; Bornstein & Leventhal, 2015; the National Academies, 2019; CDC, 2021).
In sum, long-term psychological, behavioral, and physical health is shaped by biological and environmental factors and social context and their interactions before conception and throughout the life course. This understanding of the ways in which the COVID-19 pandemic has the potential to shape developmental trajectories will be important for designing interventions at the practice, policy, and systems levels to mitigate the effects of the pandemic and help all children and families have the opportunity to develop positive life trajectories.
THEORETICAL FRAMEWORKS AND PERSPECTIVES
As noted above, the report is grounded in several theoretical frameworks and perspectives. This section details those frameworks: the life-course perspective; the framework of danger, safety, and protection; and pandemic “signatures” and “dose of exposure.”
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1 For example, historical trauma is often used to refer to the experiences of Native Americans—cumulative emotional and psychological wounding that is passed from one generation to the next in response to the loss of lives and culture. Psychological consequences of historical trauma may contribute to health disparities. John-Henderson and Ginty (2020) found that greater historical trauma preceding the pandemic predicted greater increases in psychological stress, and levels of social support interacted with historical trauma to predict changes in psychological stress. The authors concluded that historical trauma may contribute to mental health disparities, through heightened psychological stress responses to life stressors. They also note that social support appears to moderate this relationship.
Life-Course Perspective
A life-course perspective on the COVID-19 pandemic, when coupled with several core principles from decades of research and practice in human development, offers a useful foundation for understanding the pandemic’s effects and the interventions necessary to mitigate those effects (e.g., Settersten et al., 2020). Briefly, the life-course perspective (e.g., Elder & Giele, 2009) situates human development in individual, societal, and global historical contexts. This perspective is premised on the idea that the impact of specific events and experiences on developmental outcomes can only be understood within sociocultural, geographic, and historical contexts and that individual outcomes and pathways represent the sum of experiences in contexts, over time, and across generations. Underscoring the idea noted above that risk and protective factors can be transferred intergenerationally and that parents and other family and community caregivers are central to understanding the effects of the pandemic on children and their families, a key tenet of the life-course perspective includes the notion of linked lives. Linked lives refers to the idea that, across generations and within important relationships, developmental trajectories intersect to influence outcomes (e.g., Elder et al., 2003).
Figure 2-3 depicts the life-course perspective relevant to this volume in 20-year age cohorts oriented around January 2020 (the rough initial onset of the COVID-19 pandemic), anchored in birth years beginning in 2000. The figure focuses on the individual level, where time is represented by ages, life stages, and ecologically salient developmental tasks (e.g., the start of elementary school or high school).
The left side of the figure shows the 20 years before January 2020, and the right side represents the next 20 years. Each bar running up to, beyond, or spanning January 2020 represents a 20-year period consistent with this report’s focus on the first 20 years of development. Running vertically along the red line in the middle are the ages of children in January 2020. Along the horizontal axis on the left side are a few selected major historical events of the last 20 years (e.g., 9/11; the Ferguson protests, which spurred the Black Lives Matter movement; the onset of the Great Recession); on the right side, arrayed vertically, are illustrative stage-salient developmental events aligned with children’s ages at the onset of the pandemic.
Consistent with the life-course perspective, taken together the elements in this figure indicate that a full characterization of the effects of the pandemic on children is both historical and developmental—that is, shaped by individual and societal experiences before the pandemic, as well as by the salient developmental windows and tasks at play at its onset and throughout—and ecological—that is, situated in a sociodemographic, familial, community, societal, and cultural context.
NOTE: See Figure 2-1 (above) for a detailed view of cross-cutting events from January 2020 through February 2022.
In concrete terms, this means, for example, that the behavioral and educational effects of school disruptions for a child just beginning formal schooling (which in some regions of the United States meant missing the full first year of school) is quite different from the effects for a child beginning the 4th grade who already mastered school routines, early reading, and other key skills. Similarly, the effects for a child whose family is economically vulnerable and has already been subject to economic instability (e.g., whose early life was shaped by the Great Recession) is quite different from that of a child whose family has had financial security and stability over a long period. Just as the effects of the pandemic need to be understood with the time, history, and ecological lenses of a life-course perspective, so, too, do the relevant interventions and strategies intended to mitigate those effects need to be designed with that understanding.
Applying the life-course perspective to the task of capturing and understanding the impacts of the pandemic suggests that the most effective interventions are likely to be those that focus on relevant developmental tasks, stretch key developmental windows, and are ecologically embedded and relevant to individual and group experiences over time (the National Academies, 2019). Such interventions also need to consider the historical background and current social and community dynamics (Sameroff & Fiese, 2000; Dishion & Stormshak, 2007; Tricket, 2019). Another critical aspect of building effective interventions is considering how individuals make meaning of what has happened with the past and the future in mind, or as Settersten and colleagues (2020) describe it, their “subjective standpoints: that is, how people anticipate or project their lives looking forward, and how they review, interpret, and evaluate their lives in the present and looking backward” (p. 3). To that end, this committee conducted several listening sessions during its work and the experiences of the participants in those helped the committee’s understanding of its work (see “Annex” in Chapter 1).
Framework of Danger, Safety, and Protection
A starting place for considering the developmental consequences of the COVID-19 pandemic, including social, emotional, and behavioral wellbeing, is a framework of danger, safety, and protection, which is often used in literature on disasters (see, e.g., Masten & Osofsky, 2010; King et al., 2012; Masten & Narayan, 2012). This framework recognizes that individuals experience not only specific mental health conditions such as anxiety or depression, but also a wide range of psychological, behavioral, developmental, and societal responses to danger.
Beginning in 2013, the American Psychiatric Association2 categorized
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2Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR).
trauma and stress-related disorders separately from anxiety disorders, based on scientific and clinical evidence of the etiological role of the experience of life threat. The developmental considerations specifically recognize the critical role of exposure to life threat or injury of primary caretakers for children. In addition, there is an understanding that danger, safety, and protection are central concerns of children and families and that confrontation with danger and life threat can generate a wide range of psychological, behavioral, and developmental responses.3 This framework also underscores the interconnectedness of a caregiving adult’s fear and worry with their provision of (and the effectiveness of) personal, familial, community, and societal protective measures that shape children’s developmental trajectories.
The nation’s entire society has confronted imminent danger during the COVID-19 pandemic with widespread exposure of children to life threat, severe illness, and death among family members. The literature on past pandemics, epidemics, disasters, war, terrorism, and large-scale mass violence events helps to understand the impact of the COVID-19 pandemic on children and their families to date and also helps to make predictions about potential long-term consequences.4 This literature details the features of events that contribute to long-term physical and mental health effects and that shape the course of recovery. The emerging literature on the current pandemic highlights some aspects of impact and recovery that are similar to prior pandemics; features that are unique to the current pandemic; and domains of effects, course, and recovery that are shared with other such events (Goenjian et al., 2022).
Pandemic “Signatures” and “Dose of Exposure” Profiles
From the vast literature on disasters, two major operative factors invariably emerge that play a role in the long-term outcomes of a disaster event: (1) the signature of the event; and (2) the dose of exposure for a child and their family. The signature of the event includes objective features regarding the type and magnitude of the event, including a compilation of the dangers; the extent of destruction, morbidity, and mortality; the nature and extent of immediate psychological consequences; the impact on infrastructure, resource loss, and economic disruption; and the impact on the workforce, community leadership, family structure and functioning, and developmental opportunities or achievements. These factors may be more
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3 See National Child Traumatic Stress Network: https://www.nctsn.org/resources/12-core-concepts-concepts-understanding-traumatic-stress-responses-children-and-families
4 We note that the research summarized here necessarily covers only what is available and is consequently geographically bounded and limited to certain populations. While this information is certainly relevant to current circumstances and there are core lessons to draw from it, caution should be exercised in generalizing to all places and experiences.
easily defined for a destructive natural disaster event than for a years-long pandemic, though they are relevant to both.
A central lesson from the disaster literature is the organizing principle of the concept of “dose of exposure.” From a comprehensive review of the psychosocial consequences of disasters, Norris and Elrod (2006) concluded that the effects of disasters are “quite serious and enduring.” Overall, they found that 11 percent of disaster populations had a minimal or transient impairment, 51 percent had a moderate impairment, 21 percent had a severe impairment, and 18 percent had a very severe impairment: moreover, the greater the magnitude of the disaster,5 defined by the extent of destruction and rates of morbidity and mortality, the greater the severity of reactions and length of impairment. The child disaster literature confirms this dose of exposure predictive model. For example, a meta-analytic examination of disasters and children’s outcomes confirmed that the magnitude, as measured by death toll and severity of disaster experience, is associated with adverse long-term consequences (Furr et al., 2010). The magnitude and mortality of the COVID-19 pandemic exceeds even that of large-scale natural disasters, with more than 5 million deaths globally and more than 1 million deaths in the United States. Given what is known from large-scale dose-of-exposure disaster studies, such as Hurricane Katrina (Galea et al., 2007; Osofsky et al., 2009),6 the magnitude and unique signature of COVID-19 portends the risk of extensive mental health consequences for children and their families. Long-term prospective child mental health disaster studies of children exposed to the catastrophic 1988 Spitak earthquake in Armenia have indicated that these consequences can extend for decades, and they include adverse physical health and developmental outcomes (Goenjian et al., 2021; Pynoos, 2022).
A current Yehuda Science Foundation COVID-19 study conducted in three waves over 2 years with interviews of 6,000 adults has suggested that mental health consequences are primarily found among adults with the most direct exposures (e.g., an individual or family member with COVID-19 illness and hospitalization or COVID-19-related death). Overall, community rates of infection and death were far less consequential (Thompson et al., 2022). There are no parallel studies of the consequences of the pandemic for children, but similar findings have been reported among children exposed to a prolonged war, where direct exposure to life threats, witnessing threats, or
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5 The type of disasters studied ranged from widespread to contained, natural to human caused, no injuries or deaths to multiple injuries and deaths, single component to multiple components (e.g., hurricane and flood), single event to one in a series of events, and short-term to long-term response engagements (Norris & Elrod, 2006).
6 Research by Osofsky and colleagues (2009), for example, found that variables, including separation from a caregiver and evacuating to a shelter, were associated with post-traumatic stress symptoms in 7- to 19-year-old students 2 years after Hurricane Katrina.
injury to a family member and war-related losses were more predictive of long-term post-traumatic stress disorder (PTSD) and comorbid depression than general conditions of warfare, such as besieged cities or villages and war-related relocation (Layne et al., 2010). In the context of the COVID-19 pandemic, dose of exposure encompasses illness and death of caregivers, but additional trauma—including potential experiences of abuse in the home (Krause et al., 2022) or increased experiences of perceived racism, bullying, and hate violence (Mpofu et al., 2022), among others—may also be involved.
Longitudinal studies of mental health after disasters have shown that across regions and populations of children, dose of exposure can explain differences in the prevalence of PTSD, depression, and separation anxiety in the first 3 years after the event (Pynoos et al., 1993; Hoven et al., 2005; Ularntinon, 2008; Osofsky et al., 2009), with sustained differences measurable over the next 25 years (Goenjian et al., 2021). Embedded in the signature of the COVID-19 pandemic are the substantiated major differences in dose of exposure among people and communities and major disparities in exposures among diverse populations that have recurred across the different phases of the pandemic—particularly those who are the focus of this report. Based on studies of war, it is known that exposure to injury of close family members predicts child developmental problems, and since racial and economic disparities predict exposure to injury of close family members, it is highly likely that the long-term effects on development would be more pronounced among children in racially and minoritized communities. Children have also had experiences of intercurrent danger, trauma, and loss, including child abuse, witnessing of interpersonal violence, racism, bullying, and deaths of family members from other causes (Krause et al., 2022; Mpofu et al., 2022). These exposures need their own directed attention and are also known to increase the severity and course of response after disasters across exposure cohorts.
Analogous to the evidence that children who are injured in disasters, war, or mass violence are particularly at risk for long-term mental health consequences (Ularntinon et al., 2008), children hospitalized for COVID-19, especially those who required intensive care, may also be at additional psychological risk, as well as a potentially larger group who may develop “long COVID” (related conditions requiring more sustained medical and rehabilitative services). The Omicron variant phase resulted in substantial increases in short-term hospitalizations among young children for severe upper respiratory distress (Deville et al., 2023), which carries additional developmental risk. Immunocompromised and immunosuppressed children are another category of at-risk children, especially if they have required a COVID-19-related hospitalization.
Another key source of stress during the pandemic has been worrying
about the illness or subsequent death of a loved one; this intense source of stress can reverberate among family members, peer groups, and close-knit communities. Cultural considerations can be profound, such as worrying about the loss of community elders who are culture and language bearers in Native American communities (see Chapter 1). Worrying about a significant other can generate long-lasting traumatic stress reactions in situations of danger, as documented among college students exposed to a mass violent event on campus (Hughes et al., 2011) and among elementary school students after a sniper attack on their playground (Pynoos & Nader, 1988). In addition, worrying about infecting a significant other, or becoming infected through contact with a significant other, has been a major feature of the COVID-19 pandemic. Early on, this worry separated generations within families and communities, reducing or eliminating for a period of time affectionate interchanges; family gatherings; and community, cultural, and religious gatherings.
The effects of the COVID-19 pandemic on first responders—and the expanded definition of who is a first responder—are also notable. The existing disaster literature focuses on first responders who are emergency care personnel, but literature related to the pandemic expands that focus to both emergency care personnel and health care personnel (e.g., Wu et al., 2009). The pandemic also broadened the definition of “essential workers,” who put their own lives at risk by simply continuing to work in prevaccination circumstances in which they were not adequately protected. These include essential workers outside of health care who often had no employer-provided resources for protection but had frequent exposure to the public without the ability to be socially distanced, such as bus drivers, grocery store workers, and nursing home workers. Perspectives from adolescents captured during the committee’s listening sessions (see the “Annex” in Chapter 1) reflected concerns about family members or friends who were essential workers contracting the virus, consistent with qualitative analysis of adolescent perspectives conducted at the beginning of the pandemic (Scott et al., 2021).
The professional plight of health care workers during the COVID-19 pandemic has generated efforts to provide systematic support (Miotto et al., 2020; Frank et al., 2021; Song et al., 2021). Health care workers were among those professionals first worried about infecting family members, while their family members endured intense worry about them. One international COVID-19 study has documented the increased rate of traumatic stress reactions among worried children of health care providers (Sayed et al., 2021). Broad and tailored support is likely to similarly benefit essential workers outside of health care.
The literature on first responders has consistently recorded the serious mental health, career, and interpersonal outcomes of their exposure, and,
concomitantly, the strain on family life and function, as well as secondary mental health and developmental risks for their children (Duarte et al., 2006; May et al., 2021; Cox et al., 2022). In situations of danger, studies of disaster and terrorism indicate that children’s worry about a significant other, along with a safety-motivated desire for proximity, can lead to the onset and persistence of separation anxiety, even among adolescents, for whom it would be unexpected (Hoven et al., 2004). Children’s experience with danger and worry can thus significantly alter developmental trajectories.
Pregnant people are another category of concern. After 9/11, for example, psychological stress during pregnancy was reported to affect intrauterine fetal growth (Brown, 2020). In addition, longitudinal studies after the Three Mile Island Nuclear Plant accident (Bromet et al., 1990) indicated that mothers’ worries about radiation effects on their young children had long-term adverse effects on the mothers’ mental health and carried a developmental risk: for example, risk of excessive anxiety traits among that cohort of children. Studies of women who were pregnant on 9/11 and subsequently experienced PTSD indicated that this intergenerational effect could extend to the neurobiology of the offspring, who exhibit reduced cortisol levels and increased distress responses when shown novel stimuli (Yehuda et al., 2005, 2009). For this reason, studies designed to document the life-course development of the cohort of infants born during the COVID-19 pandemic are warranted.
In the United States, the COVID-19 pandemic has been most marked by a public health disaster measured in loss of life. By June 2021 it was estimated that 140,000 American children (approximately 1 in every 500 children) had lost a parent or caregiver because of the pandemic (Hillis et al., 2021); by October 2021 that number had climbed to 170,000, and by September 2022 it was more than 265,000 (Hillis et al., 2022).7 Perhaps the most pronounced dose-of-exposure disparities from the pandemic are among racially and ethnically minoritized children. According to the same study, racially and ethnically minoritized children account for 65 percent of those who have lost a primary caregiver because of COVID-19, with American Indian and Alaska Native children 4.5 times as likely as White children to have lost a parent or caregiver, Black children 2.4 times as likely, and Hispanic children almost two times as likely (Hillis et al., 2021).
Prior studies of disasters, wars, and other catastrophic violence events describe the enduring distress and impairment for children that results from such traumatic deaths of family and close friends (Layne et al., 2010). Recent clinical and population studies have documented the developmental
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7 See https://imperialcollegelondon.github.io/orphanhood_calculator/#/country/United%20States%20of%20America
hazards of childhood bereavement, including premature school withdrawal, diminished educational aspirations, reduced academic attainment (Burrell et al., 2020; Oosterhoff et al., 2018), and hesitancy to marry during the transition to adulthood (Brent et al., 2012). A Covid Collaborative report has called attention to the potential bereavement-related risk for children as a result of the COVID 19 pandemic (Hillis et al., 2022; Treglia et al., 2022). After a thorough scientific review by the American Psychiatric Association, the decision noted above to include children in the diagnosis category of prolonged grief disorder highlights the risk of a grief-related condition occurring among these children, including prolonged grief symptoms; developmental disturbances; and chronic impairments in school, family, and peer domains.
ADVERSITIES AND RESILIENCE
Recent research documents that some communities and individuals have faced more adversities because of the effects of the COVID-19 pandemic than others. For example, in the Centers for Disease Control and Prevention’s nationally representative Adolescent Behaviors and Experiences Survey (January–June 2021), students (grades 9–12) who identified as gay, lesbian, or bisexual were more likely than students who identified as heterosexual to report that since the beginning of the pandemic they experienced emotional abuse (74% and 50%, respectively) and physical abuse (20% and 10%, respectively) by a parent or other adult in the home (Krause et al., 2022). Some of these adversities are based on the dose of exposure: for example, families who experienced high exposure to COVID risk and stress due to their employment, housing, and community may experience more severe social, emotional, and behavioral effects than families not so exposed.
Other adversities reflect preexisting inequities and structural inequalities. As noted above, people who live in segregated racial and ethnic minority communities because of racism and discrimination in the housing sector are often the same people who are more likely to work on the front lines and in public-facing jobs (Li & Yuan, 2022). Both of these factors have been linked to higher rates of COVID-19 infection and death. At the same time, however, many people in communities that face many adversities also possess a high degree of resilience. The rest of this section describes preexisting inequities that may increase the impact of the pandemic and the community characteristics and resilience that can mitigate some of this impact.
Preexisting Inequities
Disasters and large-scale public health crises reveal preexisting ecological vulnerabilities that often are due to long-standing societal inequities: for example, substandard construction of homes in Spitak, Armenia, which experienced a devastating earthquake in 1988,8 or flooding of low-lying, lower-income neighborhoods due to failing dikes in New Orleans during Hurricane Katrina in 2005 (Zoraster, 2010). The COVID-19 virus has remained most virulent, not only among the elderly, but also among individuals of all ages with underlying medical conditions and in communities experiencing health disparities. Those disparities reflect several factors, including social determinants of health; structural resource deficiencies due to long-standing inequities and racism; and, in the case of Indigenous communities, failure of the United States to uphold its obligations to tribal nations. Children in families and communities disproportionately affected by the pandemic (i.e., that experienced a greater dose of exposure) are, as a result, at risk for a host of developmental consequences, including risks to their social, emotional, behavioral, physical, mental, and economic health and well-being.
In terms of mental health, the pandemic is superimposed on an existing mental health crisis for children (U.S. Surgeon General, 2021). A consistent finding in the disaster literature relevant to the current pandemic is that preexisting mental health conditions are selectively exacerbated in the aftermath of a disaster (La Greca et al., 1998; Asarnow et al., 1999) and selectively contribute to the severity and persistence of PTSD reactions. A study of New York City schools after 9/11, for example, revealed a significant reservoir of prior trauma and loss among students in addition to their current 9/11 exposure, including PTSD and other related symptoms (Hoven et al., 2005). Disaster-related mental health services, including the post-9/11 Child and Adolescent Treatments and Service Project (CATS Consortium, 2007), have included this broader trauma and loss exposure profiling in mental health recovery efforts. It will be important to explore similar issues about the long-term interactive consequence of prior trauma and loss exposure to pandemic exposure in post-COVID-19 mental health programming, including mental health screening, for children.
The pandemic has had devastating effects on many parents and caregivers. The effects of economic stress, due to job loss or income uncertainty, has led to increased parental and caregiver stress, mental health problems, and increased family conflict, which in turn has led to compromised, harsh, and abusive parenting and partner discord (Brooks et al., 2020; Krause et
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8 The 1988 Spitak earthquake occurred on December 7 with a surface wave magnitude of 6.8. It is estimated that between 25,000 and 50,000 people were killed with up to 130,000 were injured.
al., 2022). The shelter-at-home policies resulted in reduced access to support systems that could have otherwise abated the challenges associated with pandemic-related economic and other stresses. Without access to support systems, there were immediate and long-term adverse consequences for many parents and caregivers (He et al., 2021) as families experienced seclusion and social isolation from family and friends. Studies have indicated that enhancing social connectedness among children may mitigate mental health problems (Jones et al., 2022).
In addition, COVID-19-related bereavement has been occurring in the context of an opioid epidemic that has resulted in enormously uneven deep pockets of parent, caregiver, and sibling loss across the United States. The opioid epidemic appears to be continuing and perhaps worsening, now interlocked with economic, family, and community stresses resulting from the COVID-19 pandemic (National Institute on Drug Abuse, 2022). Moreover, these COVID-19-related losses are also layered on communities, particularly minoritized communized, with disproportionate rates of early and sudden death. Bereaved children from these communities are therefore contending with multiple deaths over time, a known enhancer for grief-related impairment (Kaplow et al., 2020).
Secondary Adversities
A major influence on the course of recovery after disasters and war is consistently found to be the extent, severity, and multitude of secondary adversities, such as ongoing economic uncertainty and turbulence, in otherwise predictable systems, including educational, community, political, health, and mental health systems. The challenges can deplete the coping resources of adults, children, and families. They can prolong the course of trauma-related conditions, signal the onset of demoralization and diminished motivation, result in secondary mental health problems (e.g., depression, substance abuse), and disturb developmental trajectories.
Ongoing life disruptions carry additional risks for child psychopathology (Comer et al., 2010). A consistent feature of child exposure during the pandemic has been through sustained and widespread use of social media and viewing of traditional media coverage. Prior disaster, war, epidemic, terrorism, and mass violence studies, along with current COVID-19 studies, indicate the extent to which engagement in media can exacerbate physical and psychological consequences (Pfefferbaum et al., 2003, 2014; Thompson et al., 2017, 2019; Krause et al., 2022; Marciano et al., 2022). Although children’s digital media use can have positive effects—for example, benefiting social connectedness (Jones et al., 2022; Marciano et al., 2022)—a recent study found a link between adolescent mobile phone addiction during the COVID-19 pandemic and subsequent suicide risk (Li
et al., 2022). Misinformation campaigns have potentially added to the toll of media exposure.
In contrast to disasters, where, for example, secondary adversities may be the result of widespread physical destruction, secondary adversities in pandemics are caused by the very societal protective efforts implemented to mitigate the evolving nature of the pandemic. These adversities require a massive investment of societal resources (e.g., for vaccine development, production, and distribution) and require protective policies to interrupt transmission (e.g., lockdowns, physical distancing) that alter the operation of child care, schools, businesses, and health and mental health care services; hamper interpersonal, cultural, and spiritual and religious connections; change parenting and family functioning; and impose restrictive hygienic practices. Over time, they contribute to major societal disruption in many domains.
The United States instituted many policies and committed significant resources to mitigate these secondary consequences. However, there are significant societal disparities in resource availability over time and in different communities. During a pandemic, the federal, state, and local governments may successfully implement such programs as the Child Tax Credit and emergency cash assistance to protect against increased rates of poverty (Tipping Point Community, 2021) or renter protection to prevent evictions. However, longitudinal disaster studies suggest that when these mitigation investments are reduced or discontinued, there is the risk of a delayed set of adversities that may extend or worsen the developmental consequences for children and families. After discontinuation of supplemental school services, for example, disaster studies have documented delayed academic and behavioral impairment among primary school students (Gibbs et al., 2019), sometimes after a “honeymoon” first year (Shaw et al., 1996).
The disaster literature also describes the added burden on communities contending with cumulative disasters and historical trauma, where existing inequities served as a multiplier effect for COVID-19. For example, many southern and midwestern areas experienced flooding, which intensified the threats, dangers, and vulnerabilities posed by the pandemic in communities where lives were already disrupted. Foxworth and colleagues (2021) examined community-level factors associated with COVID-19 rates in tribal areas and found that factors such as availability of household plumbing was associated with higher COVID-19 infection rates among tribal members. In another study, Native Hawaiians and Pacific Islanders in Hawaii were found to have rates of COVID-19 infection that were higher than the statewide mean infection rate (Hollis et al., 2021; Quint et al., 2021).
Historical trauma and stress have been particularly salient for Native American communities that have long suffered a disproportionate burden of disease morbidity and mortality (Walls & Whitbeck, 2011; Hill et al.,
2021; Kruse et al., 2022) due to the introduction of diseases and implementation of medical practices to diminish or eradicate their numbers (Zubrow, 1990; Patterson & Runge, 2002; Alvarez, 2014) and the underfunding of the health care to which they are entitled by treaties (Doshi et al., 2020). COVID-19 exacerbated these historical inequities, resulting in disproportionate rates of COVID-19 infection (Hatcher et al., 2020; Leggat-Barr et al., 2021; Yellow Horse et al., 2022), hospitalizations (Ward et al., 2022), and deaths (Arrazola et al., 2020; Acosta et al., 2021; Leggat-Barr et al., 2021), despite the fact that Native Americans have had one of the highest shares of vaccination rates in the country (Carroll et al., 2021; Crepelle, 2021; Silberner, 2021). In the committee’s listening session on perspectives from Native American communities, participants shared that the COVID-19-related deaths among tribal elders were especially significant considering the language and teachings that were lost with them (see “Annex” in Chapter 1).
Resilience
Throughout the many phases of the pandemic, children, youth, parents, families, communities, and agencies have applied great ingenuity, innovation, perseverance, and creative problem-solving to enhance positive adjustments to meet the changing environment of the evolving pandemic threat and the challenges presented by the protective measures. The innovation and resilience that are necessary to withstand and recover from disasters, such as the pandemic, are present in many communities and are being used to mitigate some of the pandemic’s effects. Resilience, however, cannot be a solution to inequity. It is not a substitute for structural responses that address underlying and persistent inequities that exacerbate, and were exacerbated by, the pandemic.
Tribal communities, for example, developed successful ad campaigns to encourage masking; physical distancing; and, when vaccines became available, vaccination that drew on tribal beliefs about people’s interconnectedness, responsibility toward others, and the need to protect elders as tribal culture and knowledge bearers (Hill et al., 2021). Technology and social media were also used to maintain connections despite physical separation—for example, the use of Facebook for the “Social Distance Pow-wow” group (Chan, 2020), Head Start programs that provided virtual home visits to families (Gonzalez et al., 2021), and the rapid adaptation of a children’s book to provide strengths-based and culturally grounded public health education and mental health coping resources for young children (Burleson, 2021).
Consistent with the life-course perspective used in this report, prepandemic experiences of communities, families, and individuals are critical
to developing skills of resilience and ultimately to recovery. For example, Murry and colleagues (2022) demonstrated how caregiving practices in African American families can buffer children from the negative consequences of discrimination and racism, with lasting effects observed over the life course. Children who experienced discrimination during middle childhood learned strategies to manage similar situations as they transitioned into adolescence. These stress-management skills served a protective function, reducing patterns of depressive symptomology during critical developmental periods. Family environments characterized as warm, supportive, and attentive were also protective, demonstrating downstream effects on children’s capacity to regulate emotion as they transitioned from middle childhood to early adolescence. An integrative model (Murry et al., 2018) characterizes these protective processes as “ordinary magic” (Masten, 2015) that reflect how the cultural strengths (e.g., positive racial socialization, support from extended kin) of African American families enable them to navigate and overcome adversity and raise healthy children.
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