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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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5

Health Effects

The COVID-19 pandemic has been a generation-shaping event. It has had tremendous direct and indirect effects on the physical and mental health of children, adolescents, and their families in the short term, and it will continue to affect children’s development and well-being for decades to come. Evidence on the effectiveness of interventions to buffer those effects is coming to light as the pandemic evolves, largely based on prepandemic supports for children and families who are at higher risk of poor health due to structural racism, poverty, and limited opportunities. Children and families in racially and ethnically minoritized groups and those in underserved and marginalized communities have been disproportionately affected by COVID-19 because of the direct and indirect effects of the infection and the public health preventive measures, which reflect gaps in societal safety nets for these children and families (Cheng et al., 2020).

While there are no modern experiences of the same scale and scope as the COVID-19 pandemic, there have been more limited disease outbreaks and epidemics that can inform understanding of how the pandemic may affect the physical and mental health of children, as well as their development, life opportunities, and overall life-course trajectory (Stevenson et al., 2009; Eccleston, 2011; Sprang & Silman, 2013; Jacobs & Harville, 2015; Fong & Iarocci, 2020; Kelly, 2020; Merrill et al., 2021). For example, reviews from previous infectious disease outbreaks and epidemics (e.g., SARS, H1N1, Ebola) have described how social isolation and quarantining can lead to higher levels of anxiety, post-traumatic stress disorder (PTSD), and stress in children (Meherali et al., 2021). Research has also demonstrated that low-income families experience more direct trauma but have fewer

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
×

resources and less support during times of disaster, which worsens the effects of disasters for these families (Adams & Adams, 1984; Zahran et al., 2009; Schumacher et al., 2010; Weitzman & Behrman, 2016; Parkinson, 2019; Campbell, 2020).

The first two sections of this chapter review the impact of the COVID-19 pandemic on children’s physical and mental health. The third section examines pandemic barriers to well-being and the effect of the pandemic on preventive care, routine vaccinations, and care for other conditions. The fourth section looks at the health system’s response to the pandemic. The final section presents the committee’s conclusions.

PHYSICAL HEALTH

Overall Effects to Date

As of January 11, 2023, children aged 0–18 represent an estimated 17.2 percent of COVID-19 cases in the United States, and less than 0.5 percent of U.S. COVID-19 deaths (Centers for Disease Control and Prevention [CDC], 2022c). From the start of the pandemic, children have had lower infection rates and a lower burden of symptomatic COVID-19 illness than adults. The reasons for this difference are not completely understood; they may reflect the expression of the upper airway angiotensin-converting enzyme 2 (ACE2), a receptor for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) spike protein, which increases with age (Yonker et al., 2020). Other hypotheses for the difference include children’s stronger immune response to the virus, cross-immunity from exposure to other coronaviruses, and lower seroconversion in children with some viral variants (Loske et al., 2022; Monto et al., 2020; Toh et al., 2022b; Yang et al., 2021). Prevalence of asymptomatic or mild, moderate, or severe infection in children has been difficult to estimate because most studies have small cohorts; lack standardized capture of symptoms; vary in follow-up, age group, time period of study; and have selection, nonresponse, misclassification, and recall biases.

Rates of COVID-19 infection-induced (not vaccine-induced) seropositivity has been one method to estimate incidence of infection. The February 2022 Nationwide Antibody Seroprevalence Survey provides an estimate of a 57.5 percent seroprevalence in the U.S. population: this is the estimated proportion of all individuals with at least one resolving or past COVID-19 infection (whether symptomatic or asymptomatic). It does not include people who have been vaccinated but never infected. These data indicate that children aged 0–17 have a higher burden of infection (74.6%), than any other age group, including those aged 18–49 (63.7%), 50–64 (49.8%), and 65 and older (33.2%). However, the high rate for children may reflect

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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the proportion of the adult population vaccinated and the delay in vaccine availability for children (Clarke et al., 2022).

COVID-19 testing data reported by health departments from 44 states to the Centers for Disease Control and Prevention (CDC) for March 1–December 12, 2020, provided understanding of the variation in COVID-19 outcomes by age (Leidman et al., 2021). Among children less than 18 years old with positive tests during that first 10 months of the pandemic (before vaccination was available), 2.3 percent were hospitalized, and 0.1 percent died. These percentages compare with a hospitalization rate of 16.6 percent and a death rate of 8.6 percent among adults aged 25 and older with a positive COVID test (Leidman et al., 2021).

Incidence rates and clinical outcomes also have varied depending on the SARS-CoV-2 variant. One cohort study in children younger than 5 for 4 months prior to the availability of vaccines (September 1, 2021–January 31, 2022) found that the incidence of infection with Omicron variant was 6–8 times that of the Delta variant, but that severe clinical outcomes were more frequent with the Delta variant (Wang et al., 2022). Although acute COVID-19 illness for children has not been as prevalent as it has been for adults, it has affected children. The most common symptoms in children are fever and cough; other symptoms include sore throat; rhinorrhea; headache; fatigue; shortness of breath; and gastrointestinal upset, including nausea, vomiting, and diarrhea (CDC, 2023; Wang et al., 2022). During high levels of Omicron variant transmission, case studies reported an increase in croup in spite of a decline of other respiratory viruses known to cause croup (Brewster, 2022; Sharma, 2022).

Over three-quarters of COVID-19-related hospitalizations of children aged 0–17 were among children younger than 4 or older than 12 (Siegel et al., 2021; Wiltz et al., 2022). Black, Latino, and Native American children have experienced higher rates of COVID-19 infections, hospitalizations, and deaths than White children (Kim et al., 2020; Wiltz et al., 2022; Woodruff et al., 2022). As the pandemic has evolved, treatment has improved with the use of antivirals and monoclonal antibodies, but individuals from racially and ethnically minoritized communities have been less likely to receive these treatments (Wiltz et al., 2022). There is a lack of scientific data: as of December 2022, the National Institutes of Health (NIH) reported that “currently, no results from pediatric clinical trials that evaluated the treatment of COVID-19 have been published” (NIH, 2022).

The most common predisposing risk factors for children with more serious illnesses include those with underlying medical conditions, obesity, chronic lung disease, and prematurity (Kim et al., 2020; Wiltz et al., 2022). Children with obesity have accounted for a majority of hospitalizations in older children, and they required higher levels of care and longer lengths of stay than nonobese children (Wiltz et al., 2022).

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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One complication of COVID-19 infection that has specifically affected children is multisystem inflammatory syndrome (MIS-C). MIS-C is a rare but serious condition that was identified early in the pandemic and is characterized by fever, rash, gastrointestinal symptoms, conjunctivitis, cardiac dysfunction, or shock. It is thought to be a hyperinflammatory condition associated with antecedent SARS-CoV-2 infection, which is presenting as a postinfectious immunologic disorder. The pathophysiology and long-term outcomes are not well understood, but vaccination with two doses of mRNA1 vaccine is highly effective in preventing MIS-C in children aged 12–18 (Zambrano et al., 2022).

In a cross-sectional study covering almost 9 months (February 1–October 20, 2022) across 31 states of all hospitalized patients younger than 21 years with COVID-19 and MIS-C, there were 23,686 children with COVID-19 without MIS-C and 4,107 children with COVID-19 and MIS-C (Encinosa, 2022). There were approximately 17 MIS-C hospitalizations for every 100 COVID-19 hospitalizations. Rates of MIS-C hospitalization were higher among Black children, and Black children had higher relative risks than White children for poor MIS-C outcomes (Encinosa, 2022).

Long-Term Effects of COVID-19 Illness

Surveillance of the long-term complications from COVID-19 will be important as more is learned about the virus. Longitudinal population-based studies are needed to assess outcomes (Munblit et al., 2021), including long COVID, a syndrome with symptoms that include fatigue, brain fog, cough, throat pain, gastrointestinal discomfort, and sensory symptoms (among others) that persist weeks to months after the primary infection (Zimmerman et al., 2021; Berg et al., 2022; Izquierdo-Pujol et al., 2022; Lopez-Leon et al., 2022; Thallapureddy et al., 2022; Wulf Hanson et al., 2022). Estimates of prevalence of long COVID (also called post-COVID-19 condition, post-acute sequelae of COVID-19, or chronic COVID syndrome) vary because of differing definitions, and little is known about the prevalence for children (Zimmerman et al., 2022). One prospective testing and questionnaire study found that among 1,813 children diagnosed with COVID-19 infection, 4.5 percent had symptoms for longer than 4 weeks, with 3 percent having symptoms for longer than 12 weeks. Unvaccinated children were three times more likely to have symptoms for longer times; the most common symptoms were fatigue, headaches, fevers and chills, cough and congestion, and loss of taste (Messiah et al., 2022).

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1 mRNA vaccines use a copy of a molecule called messenger RNA to produce an immune response; it is the technology of the Pfizer-BioNTech and Moderna vaccines. The Janssen (Johnson & Johnson) vaccine uses a different technology.

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
×

The long-term effects of COVID-19 illness are still a nascent area of study with concern about whether some long-term effects are related to COVID-19 infection itself or to the consequences of pandemic control (e.g., limited access to care, decreased physical activity, stress). Early in the pandemic there were academic medical centers and registries reporting an increase in children with diabetic ketoacidosis (DKA) at diagnosis and some noting an increase in the case rate of type 1 diabetes (Beliard et al., 2020; Kamrath et al., 2020; Baechle et al., 2022; Birkabaek et al., 2022; Gottesman et al., 2022). A meta-analysis of 20 studies that estimated the risk of DKA among pediatric patients with type 1 diabetes during the COVID-19 pandemic compared with the prepandemic risk found that the cumulative risks of DKA and severe DKA were 35 percent and 76 percent higher, respectively, during the pandemic. The cumulative risk of DKA among patients with newly diagnosed type 1 diabetes showed a 44 percent increased risk during the pandemic (Alfayez et al., 2022).

An analysis of two large U.S. health claims databases also showed an increased risk for diabetes and DKA among children (Barrett et al., 2022). In this retrospective cohort study, children with COVID-19 infection were more likely to receive a new diabetes (type 1 or type 2) diagnosis up to 30 days after infection in comparison with children without COVID-19 and children with prepandemic acute respiratory infections. Non-SARS-CoV-2 acute respiratory infection was not associated with an increased risk for diabetes. Furthermore, Barrett and colleagues (2022) found that for the period from March 1, 2020, to June 28, 2021, the diabetes incidence was 316 per 100,000 person-years in children with COVID-19. In comparison, the incidence for children without COVID-19 was 118 per 100,000 person-years; the incidence for children with acute respiratory infections was 126 per 100,000 person-years; and the incidence for children without acute respiratory infection was 125 per 100,000 person-years.

The pandemic has been associated with an increase in obesity and youth-onset type 2 diabetes (Magge, 2022; Schmitt et al., 2022; Capra et al., 2023). A recent review of 6 studies from around the world suggest that during the COVID-19 pandemic there has been an increase in the onset rate of type 2 diabetes and DKA, and youths with type 2 diabetes had delayed referrals to hospitals in comparison with previous years (Capra et al., 2023).

While there is some evidence suggesting that COVID-19 may trigger the onset of type 1 or type 2 diabetes, the potential pathophysiology is still being explored. It has been hypothesized that SARS-CoV-2 can be an environmental trigger for diabetes with direct cytotoxic effect on beta-cells in individuals with high genetic risk and preexisting beta-cell autoimmunity (Capra et al., 2023). Pathology studies have found that organ involvement of SARS coronavirus correlate with organ expression of ACE2. The

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
×

localization of ACE2 expression in the endocrine part of the pancreas suggests that SARS coronavirus enters islet cells using ACE2 as its receptor and damages islets, causing acute diabetes (Yang et al., 2010).

Whether an increase in the frequency and severity of diabetes in children is caused by COVID-19 infection or is associated with environmental changes and stressors during the pandemic is unclear and requires further study. A global registry2 has been initiated to learn more about this potential connection. Studies are also being conducted to examine clusters of hepatitis among children and whether and how these may be associated with COVID-19 infection (Antala et al., 2022; Cooper et al., 2022). These potential longer-term impacts of COVID-19 highlight the need for the prevention of COVID-19 infection, as well as investments in research to illuminate the relationship between COVID-19 and other illnesses.

Overweight and Obesity

Lockdowns, school closures, and the cancellation of sports and recreational activities during the early part of the pandemic reduced the opportunities for children to be physically active (Dunton et al., 2020; Stockwell et al., 2021; Neville et al., 2022). The reduction in activity, along with increased stress, disrupted routines, and less opportunity for proper nutrition have led to weight gain among children and adolescents (Pietrobelli et al., 2020). Childhood weight gain and obesity were already a major concern before the pandemic, and there is strong evidence that COVID-19 has exacerbated the problem. A large, longitudinal cohort of children aged 2–19 found sharp increases in body mass index (BMI) throughout the pandemic, with younger school-aged children and overweight or obese children experiencing the largest increases. Research found that, in this cohort, 19.3 percent of children had obesity in August 2019, compared with 22.4 percent in August 2020. The rate of BMI increases approximately doubled in comparison with prepandemic rates (Lange et al., 2021). A recent Kaiser Permanente study of children and adolescents aged 5–17 years in Southern California also found increased obesity prevalence and significant weight gain during the pandemic (Woolford et al., 2021).

Childhood overweight and obesity can lead to health issues during childhood, including diabetes, cardiovascular problems, hypertension, and psychosocial issues, and they can also lead to excess morbidity and mortality during adulthood (Balasundaram & Krishna, 2022). Given that the pandemic exacerbated the already high rates of overweight and obesity in children, policies and programs will be important to address this issue (Jenco, 2021).

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2 See https://covidiab.e-dendrite.com/

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
×

COVID-19 in the Prenatal and Perinatal Periods

Evidence shows that COVID-19 infection during pregnancy is associated with adverse outcomes for both mothers and newborns (Kotlar et al., 2021). However, the potential long-term effects of maternal COVID-19 infection in the prenatal and perinatal periods are not yet known.

Maternal Outcomes

In the United States, the maternal mortality rate has increased 33 percent during the pandemic, from 18.8 per 100,000 live births prepandemic to 25.1 after March 2020, with larger increases for Black and Latina women than for White women (Thoma & Declercq, 2022). This increase is likely driven by both direct and indirect consequences of the pandemic. The direct impact of COVID-19 infection during pregnancy is well documented: pregnant women infected with COVID-19 have a higher risk of preeclampsia, intensive care unit hospitalization, and death than both noninfected pregnant women and nonpregnant women of reproductive age (Allotey et al., 2020; Joseph et al., 2021; Joseph et al., 2021; MyClymont et al., 2022). Pregnant women with more severe COVID-19 symptoms are more likely to experience severe consequences than women with milder symptoms (Vouga et al., 2021; Wei et al., 2021). The risk of severe COVID-19 disease in pregnancy varies across the population: it is higher for some groups, including women with preexisting comorbidities, high BMI, low education; women living in disadvantaged neighborhoods; and women who are members of racially and ethnically minoritized groups (Joseph et al., 2020; Sakowicz et al., 2020; Ames et al., 2021; Prasannan et al., 2021).

Fetal and Infant Outcomes

A large number of studies have documented an association between COVID-19 infection during women’s pregnancies and adverse health outcomes for their babies, including preterm births and hospitalization in a neonatal intensive care unit (Allotey et al., 2020; Chamseddine et al., 2020; Karasek et al., 2021; MyClymont et al., 2022). Although there is some evidence that the risk of adverse outcomes depends on disease severity (Wei et al., 2021; Newton et al., 2022), some studies have failed to find significant effects of maternal infection on birth outcomes (Flaherman et al., 2021; Piekos et al., 2022). The mixed findings are likely related to the small and selected samples considered in some studies, variation in disease severity across populations, and incomplete information about maternal infection during pregnancy.

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
×

It is important to note that most current research measures COVID-19 infection in the third trimester, with limited evidence on the consequences of infection across all trimesters of gestation. In addition to the direct effects of COVID-19 infection on fetal and infant health, the pandemic may affect health through other pathways, including economic disruptions; changes in pregnant women’s and new mothers’ eating, sleeping, working, and commuting patterns; stress and anxiety; access to medical care; and other population-level factors.

COVID-19 infection rates are low in babies born to mothers with infections, signaling a very low risk of vertical in utero transmission, and harm from vertical transmission has not been demonstrated (Allotey et al., 2022). Some studies suggest that infants born during the pandemic show differences in neurodevelopment, although the possible mechanisms for these effects are not clear (Edlow et al., 2022; Shuffrey et al., 2022). There is an urgent need for long-term monitoring and evaluation of children born during the pandemic: specifically, pediatric cohorts are needed to understand the long-term physical and mental health effects of COVID-19 during childhood.

Surprisingly, during the early months of the pandemic, population-level measures of infant health—including preterm births and low birth-weights—appear to have improved in the United States and other wealthy countries (Berghella et al., 2020; Gemmill et al., 2022). Researchers have speculated that this positive effect may have been due to the benefits of staying at home and reduced pollution due to shelter-at-home measures. However, these beneficial population-level changes appear to have lasted only for a few months. By early 2021, rates of preterm birth and low birth-weight had generally returned to their prepandemic levels. In addition, these trends mask substantial socioeconomic heterogeneity. In some areas, the early positive changes in birth outcomes were experienced by non-Hispanic White and Hispanic mothers and did not extend to non-Hispanic Black or Native American mothers (Hwang et al., 2022). A study of preterm births trends in California showed marked disparities by maternal education: the early-pandemic improvement in preterm birth mostly was seen in highly educated mothers; increases in preterm birth during the rise in infections in the winter of 2021 primarily affected persons with low education (Torche and Nobles, 2022).

While the short-term effects of the pandemic on maternal and infant health care are under investigation, there is also need for research on the potential long-term effects of COVID-19 on children and women people. The “fetal origins hypothesis” posits that insults that occur during key periods of fetal development can generate a wide set of effects observed later in life (Barker, 1995). A large body of evidence shows that exposure to health

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
×

shocks in utero or during childhood may have long-term consequences in terms of health, human capital formation, and labor market outcomes.

For example, following the 1918 influenza pandemic, Garthwaite (2008) demonstrated significant increases in heart disease, diabetes, and kidney disease in fetuses exposed in utero compared with the general population. Other life-course studies found effects on educational, economic, and health outcomes of those exposed in utero and even on their children and grandchildren (Almond & Mazumder, 2005; Cook et al., 2019; McCarthy et al., 2021), although there is some concern about selection bias of those exposed to that pandemic (Beach et al., 2022). The 1918 flu pandemic differed from the COVID-19 pandemic in many aspects—including the kind of viral pathogen, the most marginalized populations at the time of each pandemic, and medical technologies—but the evidence of long-term effects of this shock emphasizes the need to track the outcomes of cohorts of children that have been exposed in utero and during early childhood.

Role of Vaccines

Although safe and effective vaccines were available for adults less than a year after the COVID-19 pandemic was declared, vaccines were not quickly available for children, particularly the youngest children, and clear vaccine recommendations for pregnant people were not available at the same time. Initial rollouts in late 2020 and early 2021 were focused on elderly Americans and workers at highest risk of exposure; the general population gained access in spring 2021. Vaccination was authorized for adolescents aged 12–15 in May 2021 and for children aged 5–11 in October 2021. There was no vaccine authorized for children aged 6 months to 5 years until June 2022, more than 2 years after the outbreak of the pandemic.

Pregnant people were technically eligible for COVID-19 vaccination when vaccines were made available to all adults, but no pregnant people were included in the vaccine trials, and the emergency use authorization noted that “there are currently insufficient data to make conclusions about the safety of the vaccine in subpopulations such as . . . pregnant and lactating individuals” (Food and Drug Administration, 2020). While experts stated that there was no reason to expect that vaccines would have adverse effects on pregnant women or their children (Wamsley, 2020), many pregnant women were hesitant about COVID-19 vaccination (Simmons et al., 2022), leading to low vaccination rates, which prompted recommendations for vaccination for pregnant women by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine in July 2021 (American College of Obstetricians and Gynecologists, 2021). The following month, CDC released safety data and published a study

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
×

that found that the COVID-19 mRNA vaccine was not associated with increased risk of spontaneous abortion and concluded the vaccines were safe in preconception and during pregnancy (Zauche, 2021). CDC also released a statement to assure the public that COVID-19 vaccines were safe for pregnant and breastfeeding women, and in September 2021, issued an urgent health advisory to increase vaccination rates among pregnant women (CDC, 2022d).

Vaccines for Children

For children, vaccination can reduce the risk of getting infected with COVID-19 and of developing serious illnesses or complications, such as MIS-C and long COVID (CDC, 2022a,b). Despite these benefits, rates of immunization among children remain relatively low, particularly among younger children (Ndugga et al., 2021). CDC estimates that, as of January 2023, 11 percent of children (1.9 million) aged six months to four years had received at least one dose of the COVID-19 vaccine; 32 percent (9.1 million) of children aged 5–11 had completed the two-dose series; and 58 percent (15.2 million) of those aged 12–17 had completed the two-dose series. The variation by state is wide: for those receiving at least one dose, the rates ranged from 2 to 40 percent for children aged six months to four years, from 17 to 78 percent of those aged 5–11, and from 40 to 100 percent of those aged 12–17. In total, an estimated 43 percent of U.S. children (30.7 million) had received at least one dose of the COVID-19 vaccine by January 2023 (American Academy of Pediatrics [AAP], 2023).3

These estimates for vaccination should be interpreted within the timeline of the vaccine rollout for children and adolescents: see Table 5-1. For example, these numbers may be more reflective of vaccine availability or access rather than vaccine hesitancy or lack of confidence in the vaccine, as the Food and Drug Administration (FDA) expanded the emergency use authorization of the Pfizer-BioNTech COVID-19 vaccine for adolescents aged 12–15 in May 2021. Three months later, FDA approved the first COVID-19 vaccine for adolescents 16 years of age and older, no longer requiring the emergency use authorization. FDA gave only emergency use authorization for Pfizer-BioNTech COVID-19 vaccine for children aged 5–11 in October 2021 and then in June 2022 for children aged six months to four years.

Vaccination rates are generally low among U.S. children under 18 years of age, and CDC survey data indicate generally similar vaccination rates among children by race and ethnicity, with the exception that rates are

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3 See also CDC Tracker: https://covid.cdc.gov/covid-data-tracker/#vaccination-demographics-trends

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
×

TABLE 5-1 Selected Timeline of COVID-19 Vaccine Rollout

Date Event and Related Notes
Feb 1 2020 The Centers for Disease Control and Prevention (CDC; Jan 30) and the World Health Organization (Feb 1) declare a public health emergency due to COVID-19
Feb 3 2020 CDC posts the 2020 recommended immunization schedules (not related to COVID-19) for children and adolescents
Dec 11 2020 The Food and Drug Administration (FDA) issues emergency use authorization (EUA) for Pfizer-BioNTech COVID-19 vaccine
Dec 13 2020 CDC publishes interim recommendations of its Advisory Committee on Immunization Practices (ACIP) for the use of Pfizer-BioNTech COVID-19 vaccine
Dec 18 2020 FDA issues EUA for Moderna COVID-19 vaccine
Dec 20 2020 CDC publishes ACIP interim recommendations for the use of Moderna COVID-19 vaccine
Feb 12 2021 CDC posts the 2021 recommended immunization schedules for children and adolescents
Feb 27 2021 FDA issues EUA for Janssen (Johnson & Johnson) COVID-19 vaccine
March 2 2021 CDC publishes ACIP interim recommendations for the use of Janssen (Johnson & Johnson) COVID-19 vaccine
April 13 2021 CDC and FDA recommend a temporary pause in the use of Janssen (Johnson & Johnson) COVID-19 vaccine
April 23 2021 CDC and FDA lift the pause in the use of Janssen (Johnson & Johnson) COVID-19 vaccine
April 27 2021 CDC updates the ACIP recommendations for the use of Janssen (Johnson & Johnson) COVID-19 vaccine because of reports of thrombosis with thrombocytopenia syndrome among recipients
May 10 2021 FDA expands EUA of Pfizer-BioNTech COVID-19 vaccine for adolescents aged 12–15
May 14 2021 CDC publishes ACIP interim recommendations for the use of Pfizer-BioNTech COVID-19 vaccine for adolescents aged 12–15
June 25 2021 FDA revises EUA Pfizer and Moderna patient and provider fact sheets regarding concern for increased risks of myocarditis and pericarditis associated with their vaccines
July 6 2021 CDC updates the ACIP recommendations after reports of myocarditis
Aug 23 2021 FDA approves Pfizer-BioNTech vaccine for youths and adults 16 and older (the EUA remains in effect for those 12 years of age and older and for the third dose for immunocompromised individuals 12 years of age and older)
Sep 22 2021 FDA authorizes booster dose for Pfizer-BioNTech vaccine for people aged 65 years and older and for those at high risk of severe COVID-19 aged 18–64.
Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
×
Date Event and Related Notes
Oct 20 2021 FDA amends EUAs of all COVID-19 vaccines, allows for booster doses, and mix and match of doses for those eligible
Oct 29 2021 FDA authorizes EUA for Pfizer-BioNTech vaccine for children aged 5–11
Nov 5 2021 CDC publishes ACIP interim recommendations for the use of Pfizer-BioNTech vaccine for children aged 5–11 years old
Nov 29 2021 CDC recommends COVID-19 boosters for all those 18 years and older
Dec 9 2021 FDA and CDC issue Pfizer-BioNTech booster recommendations for adolescents aged 16–17
Jan 4 2022 CDC recommends Pfizer-BioNTech booster 5 months after completing primary series
Feb 18 2022 CDC releases 2022 recommended immunization schedules for children and adolescents
May 17 2022 FDA amends EUA and expands eligibility for Pfizer-BioNTech vaccine booster dose for children aged 5–11
June 17 2022 FDA amends Pfizer-BioNTech and Moderna EUA to include use of the vaccine in children aged 6 months through 4 years
June 24 2022 CDC endorses ACIP recommendations of Moderna vaccine for use in those aged 6–17
Aug 31 2022 FDA amended EUAs of Moderna and Pfizer BioNTech vaccines to authorize bivalent formulations to use as a single booster dose (2 months following primary or booster vaccination)
Oct 12 2022 CDC recommends expanding use of bivalent Pfizer-BioNTech and Moderna vaccines for children aged 5–11
Dec 8 2022 FDA authorizes updated/bivalent COVID-19 booster for children aged 6 months and older

SOURCE: Data from https://www.immunize.org/timeline

substantially higher among Asian children. Among all children aged 5–17, survey data indicate that vaccine coverage with at least one dose was 73.4 percent among Asian children, 49.0 percent among Latino children, 45.0 percent among White children, and 44.7 percent among Black children (Valier et al., 2022).

CDC survey data also suggest that the rates of full vaccination are significantly lower for children living in rural areas (20.5%) than for children living in suburban (37.6%) and urban (33.1%) areas (CDC, 2021b). Poverty level is also associated with the likelihood of full vaccination: children living below the poverty line (24.7%) and children in households making less than $75,000 (27.2%) are significantly less likely to be fully

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
×

vaccinated than children living in households with an annual income of at least $75,000 (41.5%). The political leaning of the county in which a child resides is one of the strongest indicators of vaccination status: children in Democrat-leaning counties are nearly twice as likely (43.1%) to be vaccinated as children in Republican-leaning counties (22.2%). Unsurprisingly, the children of parents who are very hesitant about childhood vaccines in general are far less likely (9.4%) to be fully vaccinated than the children of parents who are not at all hesitant (39.9%; Alfierei et al., 2021; Goulding et al., 2022; Santibanez et al., 2022).

A July 2022 survey of parents of young children found that the top reasons for vaccine hesitancy were the newness of the vaccine, not enough testing or research, worries about side effects, safety concerns, and not being worried about COVID-19 infection (Kaiser Family Foundation [KFF], 2022b). Parents of unvaccinated children who were reluctant to get their child vaccinated were less likely to report that they were concerned about their children getting the COVID-19 illness (20.8%) than the parents of vaccinated children (59.8%). They were also less likely to consider the vaccine important (24.3%) than the parents of vaccinated children (97.1%), and less likely to state that a provider recommended the COVID-19 vaccine (17.0%) than the parents of vaccinated children (62.7%) (Santibanez et al., 2022). COVID-19 vaccine confidence has also been challenged by reports of rare myocarditis among some children, particularly males and adolescents. However, the risk of myocarditis from primary COVID-19 is much higher than the risk of myocarditis attributed to the vaccine, and the benefits of vaccination far outweigh the risks (Bozkurt et al., 2021; Kamat & Hotez, 2021).

Tribal nations have been among the most effective communities at vaccine distributions (Crepelle, 2021; Foxworth et al., 2021). The success of tribal communities’ vaccination rates has been attributed to swift action by the Indian Health Service on vaccine distribution to relevant communities, culturally responsive vaccination messaging, and collaborations with state governments and nonprofits that serve Native, Indigenous, and tribal communities (Foxworth et al., 2021). Other effective strategies were found in the Hopi tribe’s approach to COVID-19, including early efforts to implement contact tracing, collaboration with other health providers, and culturally attuned public health messaging on masking and social distancing (Humeyestewa et al., 2021).

Vaccination During Pregnancy: Effectiveness and Uptake

Since September 2021, CDC, as well as other national medical and health organizations, has recommended that pregnant women receive COVID-19 vaccination to prevent maternal and infant morbidity and mortality (CDC, 2022d). Studies have found that completion of a two-dose mRNA

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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COVID-19 vaccination series during pregnancy was safe (Bookstein Peretz et al., 2021) and could help prevent COVID-19 hospitalization among infants up to 6 months old (Halasa et al., 2022; Lipkind et al., 2022). Evidence shows that COVID-19 vaccines are highly effective during pregnancy, inducing an immune response comparable to that in nonpregnant women (Gray et al., 2021) and substantially reducing the risk of infection, symptomatic infection, and hospitalization (Dagan et al., 2021; Goldshtein et al., 2021). COVID-19 vaccination during pregnancy also appears to protect newborns: vaccine-induced antibodies have been found in umbilical cord blood and in breast milk among vaccinated pregnant and lactating women (Collier et al., 2021; Kelly et al., 2021; Perl et al., 2021), and cohort studies suggest a lower risk of COVID-19 infection among infants during their first four months of life (Carlsen et al., 2022).

Despite the widespread availability of vaccines and information about their safety, vaccination confidence and uptake among pregnant women have been lower than for nonpregnant women of reproductive age (Townsel et al., 2021). Multiple studies have found that the main reason pregnant women have avoided vaccination during pregnancy was a concern about adverse consequences for the fetus (Hsu et al., 2021; Firouzbakht et al., 2022; Bianchi et al., 2022). Vaccine confidence was particularly low among pregnant women who are Black or Latino, those without a college education, and those who live in rural areas (Battarbee, 2021; Hsu et al., 2021; Townsel et al., 2021).

Several contextual factors have also contributed to low vaccine confidence among pregnant women, including initially unclear vaccine recommendations for them; widespread misinformation; and disinformation spread through social networks, the media, and even health care providers (Hsu et al., 2021; Sparks et al., 2022). For people from racially and ethnically minoritized groups, a troubled history of abuses by biomedical researchers has only added to vaccine concerns (Hsu et al., 2021). A May 2022 survey found that misinformation about the COVID-19 vaccine during pregnancy was widespread and that belief and uncertainty about this misinformation was common (Sparks et al., 2022). Nearly a quarter of women who were pregnant or planning to become pregnant believed that pregnant women should not receive the COVID-19 vaccine, and nearly three-quarters of this group had heard pregnancy-related misinformation about the vaccine and either believed it or were unsure if it is true.

As of September 2022, women of childbearing age had been eligible for COVID-19 vaccination for around 18 months. As a result, most women are now fully vaccinated before they become pregnant. As of January 7, 2023, 71.8 percent of pregnant women aged 18–49 had completed the primary COVID-19 vaccine series before or during pregnancy, though vaccination

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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coverage was lower for Black women (58.4%) than for Asian women (89.7%), Latina women (71.1%), and White women (68.7%).4

MENTAL HEALTH

Even before the COVID-19 pandemic began, the mental health backdrop for U.S. children and adolescents was a challenge, with mental health disorders the leading cause of morbidity and poor health outcomes among these groups. Moreover, those outcomes likely have ramifications for the life-course development of children and adolescents. National data from 2018–2019 estimated that 22 percent of children aged 3–18 had a mental, emotional, developmental, or behavioral disorder (Perou et al., 2013; Bitsko et al., 2022; CDC, 2022e), with many of these young people moving through pivotal developmental milestones without appropriate treatment. For example, in 2016, of the 7.7 million children with a treatable mental health disorder (highest prevalence being depression or anxiety), about half did not receive adequate treatment (Whitney & Peterson, 2019).

Rates of depression, anxiety, and suicidality had increased among young people in the decade prior to the pandemic. High school students reporting persistent feelings of sadness or hopelessness increased by 40 percent from 2009 to 2019, and those with suicidal planning increased by 44 percent (CDC, 2020). Psychiatric visits to emergency departments for depression, anxiety, and behavioral challenges increased by 28 percent among children during this time (Kalb et al., 2019). Although some of these increases may be due to young people feeling more open about discussing mental health, experts have hypothesized that these trends are related to the growing use of social media, increasing academic demands, barriers to mental health treatments, alcohol and drug use, family financial crises, income inequality, and experiences of discrimination and racism. These factors all worsened or were increasingly visible during the COVID-19 pandemic. This increased need for behavioral health among low-income and racially and ethnically minoritized children cannot be met with the current workforce shortage of child behavioral health providers (American Association of Child and Adolescent Psychiatry, 2018; Health Resources and Services Administration, 2022), particularly those participating in Medicaid (Wen et al., 2019). Sustainable models for both preventive and treatment-focused behavioral health in schools and community settings, and through integrated behavioral health within primary care, will be critical to meet the needs of children and families (AAP, 2021; Office of the Surgeon General, 2021).

The report Advisory on Protecting Youth Mental Health (Office of the Surgeon General, 2021) outlined the prepandemic crisis of youth mental

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4 Data from https://covid.cdc.gov/covid-data-tracker/#vaccinations-pregnant-women

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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health and the pandemic’s substantive disruptions in access to school, health, recreational, and social services for children and families; reduced opportunities for social interactions and community-based activities; and increased household stressors of income loss, food insecurity, and housing stability. These challenges, combined with the known negative effects of quarantine and social isolation, particularly affected already marginalized children and their families (Fong & Iarocci, 2020; Merrill et al., 2021). Studies have found that risk factors for an increase in mental health symptoms during the pandemic included being a member of a racially or ethnically minoritized group (Xiao et al., 2022); having more adverse childhood experiences (Henderson et al., 2020; Hawrilenko et al., 2021; Hernandez, 2021; Stinson et al., 2021); and experiencing traumas, such as losing a family member or caregiver to COVID-19 (Office of the Surgeon General, 2021). Furthermore, children with previous mental health conditions, those with special educational needs, and those with neurodevelopmental disorders were at an increased risk for lockdown-related mental health effects (Bentenuto et al., 2020; Nonweiler et al., 2020; Waite et al., 2021).

Prior to the release of the 2021 Surgeon General’s advisory, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association recognized the pandemic’s impact on the existing mental health crisis and its outsized impact on communities of color; they declared a national state of emergency in children’s mental health and offered recommendations for addressing the crisis (see Box 5-1).

These recommendations, as well as those from the Office of the Surgeon General (2021) and the COVID Collaborative (Treglia et al., 2021), have not yet been fully implemented by federal agencies and departments, but there is ample evidence of their necessity from the burden of behavioral health problems in children and adolescents as a result of the pandemic. Additionally, President Biden’s Memorandum on Addressing the Long-Term Effects of COVID-195 focused on coordination of a government-wide response directed by the secretary of health and human services, for individuals “experiencing mental and behavioral health challenges related to COVID-19 pandemic,” in addition to those with long COVID and those with loss of a loved one from COVID. Despite this emphasis on the importance and urgency of a coordinated and robust federal response to the mental and behavioral health needs of children and families, children and their parents lack accessible and affordable mental health prevention and treatment services, and health systems and schools lack the funding and personnel to provide them.

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5 See https://www.whitehouse.gov/briefing-room/presidential-actions/2022/04/05/memorandum-on-addressing-the-long-term-effects-of-covid-19

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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The remainder of this section examines specific mental health symptoms and conditions that have been highlighted or exacerbated by the COVID-19 pandemic. These include depression, suicidality, anxiety, PTSD, sleep disturbance, and substance use. These mental health symptoms and conditions are rooted in the substantial traumas and loss experienced by children, which have been more prevalent or more magnified among children from historically underserved communities.

Depression and Anxiety

During the COVID-19 pandemic, children were confronted with continual reminders of illness and potential death; experiences of fear and perceived threat; economic and social instability; and physical and social distancing from loved ones, friends, school, and communities, putting them at increased risk of experiencing symptoms of depression and anxiety. Symptoms of anxiety in children include excessive worrying, insomnia, irritability, and decreased concentration, while symptoms of depression can include excessive sadness, guilt, hopelessness, fatigue, suicidal ideation, and changes in sleep and appetite. Anxiety disorders and depressive disorders are defined by these excessive symptoms, prolonged duration, and functional impairment (American Psychiatric Association, 2013). Depression and anxiety are two of the most common mental health disorders in children (Bisko et al., 2022).

The dangers and responses associated with the pandemic may exacerbate catastrophic concerns of children with a propensity for anxious reactions or preexisting anxiety disorder, as has been documented in prior disaster studies (Asarnow et al., 1999). Youth concerns over potential developmental lost opportunities and challenges to anticipated late adolescent and early adulthood life trajectory expectations can be a source of demoralization and depressive symptoms (Dohrenwend et al., 1980). Although anxious or depressive symptoms have been reported to be widespread during the COVID-19 pandemic, to the degree to which these have resulted in the onset of anxiety or depressive disorders is unclear.

Data for 2016–2019 from the National Survey of Children’s Health show a prepandemic increase in the prevalence of parent-reported diagnoses of anxiety for children aged 3–17 from 7.1 percent in 2016 to 9.0 percent in 2019, and of depression from 3.1 percent in 2016 to 3.9 percent in 2019 (Lebrun-Harris et al., 2022). However, the survey for 2019–2020 did not show increased prevalence of these diagnoses. In the National Health Interview Survey, parents were asked how often their child “seems very anxious, nervous, or worried” and how often they “seem very sad or depressed”: the number of parents reporting a frequency of daily or weekly symptoms, rather than monthly or less frequently, increased from 14.4 percent on the

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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January–February 2020 survey to 16.7 percent on the March–December 2020 survey (Zablotsky et al., 2022).

Other data from children seen in hospital emergency departments showed that the proportion of visits for mental health concerns (defined as a hospital visit with a mental health diagnosis in the electronic health record) increased significantly during the early part of the pandemic, from 4 percent prepandemic to 5.7 percent, and that these children were also more likely to require hospital admission (Krass et al., 2021).

Other studies have documented high rates of symptoms of depression and anxiety among children and adolescents, particularly during the early part of the pandemic. A systematic review estimated a pooled prevalence of 25.2 percent for depressive symptoms and 20.5 percent for anxiety symptoms among children (Cheah et al., 2020; McGuine et al., 2020; Glynn et al., 2021; Luthar et al., 2021; Murata et al., 2021; Racine et al., 2021). For the global study, four databases were searched (PsycInfo, Embase, MED-LINE, and Cochrane Central Register of Controlled Trials) from January 1, 2020, to February 16, 2021, and unpublished studies were searched in PsycArXiv on March 8, 2021, for studies reporting on child/adolescent depression and anxiety symptoms. The pooled prevalence for the five U.S.-specific studies was 21 percent for anxiety symptoms (confidence interval of 14% to 30%) and 28 percent for depression symptoms (confidence interval of 19% to 41%)—higher rates than expected based on national data for prevalence. Other studies, not included in this systematic review, have also reported increases in the burden of depressive symptoms among youth (Hannan et al., 2021; Mayne et al., 2021; Rogers and Ockey, 2021). An examination of electronic health record data from a large pediatric primary care network in the greater Philadelphia, Pennsylvania, area found that among youth aged 12–21 who completed a depression screen (Patient Health Questionnaire-Modified for Teens [PHQ-9-M]) at a primary care visit in June–December 2019, 5.0 percent screened positive for moderate to severe symptoms of depression prepandemic; in the early part of the pandemic, June–December 2020, 6.2 percent screened positive (Mayne et al., 2021). However, in a second analysis later in the pandemic (June 2021–May 2022), this increase risk of positive depression screening was not found (Hannan et al., 2022).

Other studies using convenience samples have found that rates of symptoms may be higher in some populations, particularly those recruited through social media. Among 4,909 children recruited through social media to report mental health symptoms between April and July 2020, 55 percent reported severe symptoms of depression, and 48 percent reported anxiety symptoms (Murata et al., 2021). Social media recruitment presents clear and substantial limitations in terms of a more biased sample, particularly as social media use itself is associated with mental health

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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symptoms, especially among adolescents. However, this finding may also be informative of child populations at greater risk. In another study of adolescents recruited through social media, 36.7 percent of 13,000 athletes (aged 13–19) self-reported moderate to severe anxiety symptoms (43.7% for girls and 28.2% for boys), and 39.5 percent self-reported moderate to severe depression symptoms (43.7% for girls and for 28.2% for boys) (McGuine et al., 2020).

Studies indicating large increases in anxiety and depression symptoms during the pandemic used more biased samples (e.g., social media recruitment, emergency department visits), used symptom reports instead of reported diagnoses, and lacked an appropriate comparison group. Despite these limitations, it seems clear that early in the pandemic children and adolescents often experienced more symptoms of both depression and anxiety than would have been expected from data in the prepandemic period. However, the increase of symptoms found among population-based samples of children was somewhat modest, and seemed, later in the pandemic, to return to prepandemic levels.

Suicidality and Suicide

It is not clear whether rates of suicidality and suicide attempts have increased because of the pandemic. In a nationally representative survey of U.S. adults in June 2020, young people aged 18–24 had the highest rates of reporting “seriously considering suicide in the past 30 days” among all adults aged 18 and older: their rate was 25.5 percent, significantly higher than the 10.7 percent across the total adult sample and the 16.0 percent for adults aged 25–44 (Czeisler et al., 2020).

Some studies have used emergency department data to examine potential increased suicide risk. One study (Hill et al., 2021) found increased reported suicide ideation among adolescents in routine emergency department suicide risk screening during March and July 2020 compared with March and July 2019, as well as increased reports of suicide attempts during March, April, and July 2020 compared with the corresponding months in prepandemic years. This increase was not seen, however in all months. The sharp drop in the overall number of emergency department visits may have altered the people who were seen, representing a population with greater clinical need.

Data on suicide risk screening among those patients seen in primary care settings may give a less biased sample than those seen in emergency departments. Two different studies examining suicidality on suicide risk screenings among primary care patients found a modest but significant increase in the rate of suicidality (from 6.1% to 7.1% and from 11.1% to 12.2%, respectively) between 2019 and 2020 (Curtin & Hedegaard, 2021; Mayne et al., 2021; Lantos et al., 2022).

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Data on suicide deaths during the pandemic indicate a decrease among adults, but one study (Charpignon et al., 2022) examining suicide death rate in 14 states found an increase in the proportion that were among children and adolescents aged 10–19 (5.9% of all suicides from 2015 to 2019 and 6.5% in 2020).

Post-Traumatic Stress Disorder

PTSD is a serious mental health condition with significant emotional, cognitive, behavioral, biological, and developmental consequences. The underlying symptom structure of PTSD rests on a consolidation and persistence of the experience of danger and irreversible moments of experiencing or witnessing harm. The ecology of the danger and the recovery environment shape the profile of PTSD and courses of recovery. The COVID-19 pandemic incorporates both the experience of prolonged and changing circumstances of danger and actual experiences of traumatic features of direct exposure to COVID-19 illness among family members and friends.

Reports from other countries provided some early indications of symptom profile and course that may be expected among children in the United States. For example, a 2021 study in Saudi Arabia found that being quarantined or separated from quarantined family members, worrying about the welfare of a family member working in a high-risk environment for COVID-19 exposure, or experiencing the death of a family member due to COVID-19 were associated with the onset and severity of child PTSD symptoms (Sayed et al., 2021). Prior studies within the United States indicate the expected concordance of parent and child traumatic stress reactions. A 2012 study of families who were quarantined because of H1N1 showed high rates of parent PTSD and parent-reported PTSD among their children, with rates upwards of 25–30 percent (Sprang & Silman, 2013). This finding indicates negative effects of disease containment experiences on family life: PTSD symptoms can reverberate among family members, especially as family members can serve as renewed reminders to each other (Pynoos et al., 2004).

Children and adolescents who have required hospitalization and intensive care from COVID-19 infection are at heightened risk of developing the full spectrum of PTSD symptoms, which has previously been shown to occur in children treated for injuries and severe physical illness (Saxe et al., 2003). At one point in the pandemic, 20 percent of hospitalized patients required intensive care, which can not only lead to physical, cognitive, and psychiatric symptoms among survivors, but also increase psychological burden, such as PTSD, among family members (Azoulay et al., 2022). The fear and emotional intensity of witnessing a family member go into respiratory distress can also be a strong antecedent to PTSD intrusive and arousal

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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symptoms. In addition, the level of media exposure after catastrophic large-scale events (Pfefferbaum et al., 2001; Pfefferebaum & North, 2013) has been shown to contribute to PTSD-related disturbances. Even without direct experience of their family members’ illness, children’s viewing of explicit images (e.g., overcrowded emergency departments, intubated patients, and patients talking about end-of-life issues) may potentially contribute to intrusive imagery and PTSD symptoms.

The most powerful impact of PTSD will likely be among bereaved children who will be contending with the combined force of PTSD and grief reactions. As discussed in above chapters, communities that have experienced disproportionate rates of COVID-19 morbidity and mortality are the same communities that have previously experienced disproportionate rates of early, sudden, and multiple deaths, as well as disproportionate rates of trauma and other victimizations (Douglas et al., 2021). At the same time, the current ecology of danger for youth influences the COVID-19 psychological recovery environment, including concerns over neighborhood safety and dangers they, their families, and peers face from discrimination and stigmatization.

Many children are experiencing the danger and consequences of the pandemic with a vulnerability due to preexisting PTSD and its shaping of their social and biological development. Interpersonal trauma during childhood can delay the maturation of brain circuits governing emotional regulation (Keding et al., 2021), and PTSD can dampen children’s positive affect, which has been reported to be important to adolescent management of stress during the pandemic (Deng et al., 2021). It will be important for school and clinical programs to pay special attention to the added emotional challenges from COVID-19 danger, trauma, and grief reactions among already marginalized children.

Bereavement and Prolonged Grief Disorder

As discussed above and in Chapter 1, the COVID-19 pandemic has led to loss of a parent or caregiver for over 265,000 children, and racially and ethnically minoritized children were disproportionately impacted by this loss and related grief. For most, the grief reactions, while profound, diminish in strength and frequency gradually over time. There is a subset of children, however, with grief reactions that remain severe, extended, and accompanied by significant impairment in several domains of daily life. They will suffer from Prolonged Grief Disorder (PGD); it is estimated that as many as 10 percent of bereaved adults after one year will have PGD, and among bereaved youth the rate is estimated as high as 18 percent (Kaplow et al., 2018).

Youth with PGD may experience multidimensional, severe grief reactions that are often developmentally based. Separation distress may be

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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predominant in younger children, whereas disruption in social identity (e.g., confusion about purpose in life) and risk for co-morbid depression are more manifest in the grief profile of older children and adolescents (Hill et al., 2019). Adolescents can give up on developmental aspirations (It’s not worth trying if their parent/caregiver can’t be here), engage in more risky behaviors (So what if I get hurt or die), or feel their future is ruined (Layne et al., 2008). Older children and adolescents may exhibit severe distress over feeling that they will share a similar fate as the deceased, or feeling profound loneliness that can be intensified by keeping grief private, sometimes over not wanting to add to the distress of a grieving caregiver or to avoid presumed stigma from peers. Concerns over stigma associated with COVID-19 deaths may amplify this loneliness and reduce opportunities for family, peer, and religious support.

The most persistent and debilitating courses of recovery have been seen among adolescents who have PTSD and symptoms of PGD (Layne et al., 2017; Glad et al., 2022), requiring proper identification and often more extended, intensive therapeutic intervention (Layne et al., 2008). Bereavement-related depression in adolescence carries its own independent risks, for not only suicidal behavior but also major functional impairment. In addition, PGD, PTSD, and depression carry added risk of substance abuse and developmental derailment. The Covid Collaborative has recommended a coordinated strategy to comprehensively identify, properly evaluate, and appropriately provide services to children who have lost a parent or caretaking guardian to COVID-19 (Treglia et al., 2021); this includes a tiered public health approach described at the end of this chapter.6

Sleep Disturbance

Sleep disturbances are ubiquitous in situations of ongoing danger. Danger- and trauma-related sleep disturbances are among the most insidious of PTSD symptoms for children and adolescents. PTSD-related sleep problems include alterations in the sleep cycle that lead children to wake up feeling “unrested.” Although sleep disturbance may be easily overlooked, it is highly related to learning difficulties and daytime irritability (Keeshin et al., 2019), adversely affecting children’s families, peers, and school behavior. Many worries related to COVID-19 may affect the sleep of children and adolescents, from concerns over parental employment and financial loss to concerns over their own health, losses in education, and peer relationships. Sleep disturbances have been reported as one of the most prevalent and

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6 This section was added since the prepublication release of the report. It had been inadvertently omitted in that version.

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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debilitating features of the pandemic. A January 2022 Gallup survey found that over 60 percent of young adults reported trouble sleeping and that these disturbances were having a major impact on their moods (Casper-Gallup, 2022). Although there were positive uses of social media during the pandemic (e.g., to counter loneliness and improve social connectedness), social media use has been associated with adverse mental health consequences and impaired sleep quality among children; sleep disturbances can further contribute to negative mental health outcomes (Alonzo et al., 2021; Marciano et al., 2022).

Substance Use

At the onset of the pandemic, adolescent substance use either remained stable or in some cases declined in comparison with prepandemic rates. In a survey of youth (Monitoring the Future, 2022), self-reported rates of annual illicit drug use among 8th, 10th, and 12th graders were somewhat stable between 2019 (27.7% prevalence) and 2020 (27.3%), but decreased drastically in 2021 (19.9%). This pattern was seen both for illicit drugs other than marijuana (9.0%, 9.2%, 5.6%, respectively, for the 3 years), and for marijuana alone (25.2%, 24.6%, 17.9%, respectively). The declines in substance use among youth during these years may have been related to sheltering at home and school closures, which curtailed youths’ access to substances. While most schools reopened in 2021, it may be that these same youth did not return to substance use, which may also have affected use among new youth who moved into these age categories during the pandemic.

There is evidence from one study of young people (aged 13–24) that vaping use decreased during the pandemic: among 2,167 youth vaping-product users, those under 21 reported quitting or decreasing their use during the pandemic (Gaiha et al., 2020).

In a June 2020 nationally representative U.S. survey, researchers found that 13.3 percent of adults reported that they “started or increased substance use to cope with pandemic related stress or emotions”; the increase among the 18–24 age group was the highest among all adults, with 24.7 percent of young adults reporting increased substance use (Czeisler et al., 2020, p. 1). This study did not include children younger than 18. It is possible that the rate of substance use increased among young adults who were able to access substances, while sheltering at home and school closures may have substantially decreased younger adolescents’ access to substances.

Despite the decrease in reported substance use among young people, overdose deaths increased dramatically during the pandemic. One study (Friedman et al., 2022), which analyzed CDC data on all U.S. deaths in which drug overdose was listed as the cause of death, found that the rate

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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of overdose deaths among adolescents aged 14–18 ranged between 2.40 and 2.36 per 100,000 in the 10 years prior to the pandemic; in 2020 and 2021 the rate increased dramatically, to 4.57 in 2020 and to 5.49 in 2021. American Indian and Alaska Native adolescents had by far the highest rate of overdose deaths, at a rate of 11.79 per 100,000 in 2020 and 2021. The percentage change in adolescents was much greater than the increase in drug overdose deaths among adults. The huge majority (64%) of the overdose deaths in adolescents were fentanyl related. Deaths related to alcohol increased by 25 percent between 2019 and 2020; the increase was highest (29.8%) for young people aged 16–20 (White et al., 2022).

CHILD ABUSE, NEGLECT, AND VIOLENCE

A significant concern of the COVID-19 pandemic has been the increased risk of harm to children, especially in households in which the stress of the pandemic—due to job loss or other social and economic stresses, or children isolated with no other supports—compounded susceptibility to abuse and violence, both in the community and at home. The Child-Help National Child Abuse Hotline experienced a 20 percent increase in reports fielded in the first months of the pandemic, compared with the same period in the prior year (Abrams et al., 2022). Similarly, an international study conducted by UNICEF noted a dramatic increase in child helpline contacts during the first 6 months of the pandemic across several countries (Petrowski et al., 2021). While not all of the child helpline calls were directly related to child harm, these data represent an important signal for the potential of increased child abuse given the numerous risk factors at play during the pandemic. At the same time, however, CDC reported a 53 percent decrease in emergency department visits related to child abuse, though this decrease was in the context of a 72 percent overall decrease in pediatric emergency department visits (Swedo et al., 2020).

Community Violence

Implementation of public health mitigation strategies in response to the COVID-19 pandemic has had a dramatic effect on how violence, especially community violence, has been experienced across the United States. Consequences of social restrictions and shelter-at-home orders have been critically examined and posited as factors driving an uptick in penetrating injuries (e.g., gunshots, explosive devices, stab wounds) for both adults and children, as reported primarily through emergency department and trauma center registries. It is less clear what effects these restrictions have had on other forms of victimization, largely because of reporting and data collection challenges. In 2020, firearm injuries were the leading cause of death

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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for children and youth aged 0–24 years in the United States (Lee et al., 2022). There has been a dramatic and sustained increase in firearm-related violence reported by trauma centers serving communities in all regions of the country (Hatchimonji et al., 2020; Klutts et al., 2022; Pino et al., 2022) and in a nationwide cross-sectional study (Sun et al., 2022). A pediatric trauma single-center analysis revealed a 51.5 percent increase in firearm injuries during the first two years of the pandemic compared with the 5-year prepandemic period (Bernardin et al., 2022). Analysis of national data has found that gun violence rates were 30 percent higher in the first 12 months of the pandemic than in the same period from the prior year (Ssentongo et al., 2021), though the number of homicides declined by 2 percent in the first half of 2022 compared with the first half of 2021 (Council on Criminal Justice, 2023). There has also been a month-over-month escalating increase in child-involved shooting incidents, particularly in incidents with child self-inflicted injuries and children being injured by an adult (Donnelly et al., 2022).

The reasons for this increase in penetrating trauma are multifactorial; however, access to a firearm appears to be a major contributor. National firearm sales and firearm-related incidents have increased together (Khubchandani & Price, 2020; Donnelly et al., 2021; Schleimer et al., 2021a). Moreover, 40 percent of first-time, pandemic-related gun owners kept at least one firearm at home unlocked and loaded—a well-known risk factor in child-involved shootings (Dowd & Sege, 2012; Lyons et al., 2021). It also appears, at least from trauma center data, that the gun violence surge is far more dramatic in terms of interpersonal morbidity and mortality than it is for domestic or self-directed injury (Yeates et al., 2021).

Investigators from the Violence Prevention Research Center at the University of California, Davis, examined several factors related to crime and violence since the pandemic began. Their findings highlight that the degree of poor adherence to local physical distancing guidelines was associated with the rate of rise for firearm violence and assault. In other words, the increase in shootings, both lethal and nonlethal, was greatest in cities where there was less compliance with physical distancing (Schleimer et al., 2021b). Another study found that the sharp rise in unemployment during the pandemic was associated with increases in firearm violence and homicide (Schleimer et al., 2022). The same research team confirmed what has been laid bare since the onset of the pandemic: that communities beset with existing marginalization and economic segregation have seen these disparities become even further exacerbated. Historically, rates of interpersonal violence at the community level have disproportionately affected underserved racially and ethnically minoritized populations. Endemic rates of violence, characterized by firearm injuries, aggravated assault, and homicide, apparently rose as a direct consequence of the systemic inequities and structural conditions amplified by the pandemic.

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Household Violence

Comprehensive reporting on all forms of domestic violence during the pandemic has been less robust than the community violence reporting, which largely relies on trauma registries. Most of the characterization of intimate partner violence has come from reporting in the lay press or police records (Ragavan et al., 2020). Early analyses of municipal reporting from Los Angeles and Indianapolis showed an increase in intimate partner violence incidents in the period immediately following the declaration of social restrictions in response to the pandemic, compared with the period immediately prior to the restrictions (Mohler et al., 2020). An analysis of the effects of stay-at-home orders and intimate partner violence in Chicago found an increase in domestic violence–related calls for service, but official reports by police officers and arrests for domestic violence crimes fell by 6.8 percent and 26.4 percent, respectively (Bullinger et al., 2021). Secondary data from a large urban hospital similarly showed an increase in intimate partner violence referrals after the start of the pandemic, despite a shift away from face-to-face care (Rahman et al., 2022).

It is important to note that intimate partner violence and child abuse often co-occur given the increased risk for maltreatment when children are isolated at home (Humphreys et al., 2020). In 30–60 percent of families in which either child maltreatment or intimate partner violence is occurring the other form of violence is also occurring (Thackeray et al., 2010). Data from a level-one trauma center showed that, while rates of violence against women during the pandemic have been similar to prepandemic levels, the probability of a penetrating mechanism of injury (i.e., stabbing or shooting) was five times higher (Tracy et al., 2022). This observation is consistent with the overall trauma registry literature nationally, documenting an increase in firearm-related violence since the start of the pandemic.

PANDEMIC BARRIERS TO HEALTH AND WELL-BEING

In addition to the direct effects that the pandemic has had on children’s physical health, mental health, and exposure to violence, the pandemic and related public health measures have also created or exacerbated barriers to children’s health and well-being. These barriers include accessing healthy or sufficient food and fewer opportunities for physical activity, which, combined with other factors, have led to increases in rates of children’s weight gain and obesity (discussed above). Another significant impact of the pandemic was on usual medical care: children and families faced decreased access to preventive care, care for chronic and acute conditions, and routine immunizations. Families of children with special health care needs faced particular challenges, including decreased access to health care, loss of home- and school-based services, and lack of support for caregivers.

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Food Insecurity

In the early phase of the pandemic, food insecurity was a major concern, given the precipitous drop in employment and the closure of schools and community centers. Prior to the pandemic, school meal programs provided 15 million breakfasts and 30 million lunches to children at no or low cost (Kinsey et al., 2020); when schools were closed, this food safety net disappeared. At the same time, families were experiencing job loss, which exacerbated food insecurity. In late March 2020 Congress enacted a law that made school meals free for all families and provided flexibilities in how meals were distributed. When federal efforts later wound down, states stepped in to expand access to school meals (Economou, 2022).

Unemployment benefits and income supports during the pandemic have also been critical to addressing food insecurity: studies have demonstrated that pandemic-related expanded child tax credits were associated with a decrease in food insecurity (Shaffer et al., 2022). Another analysis found that tax credits reached 61 million children in more than 36 million households and that the credits were primarily used for child care, food, housing, and other basic needs (Curran, 2021). With the expiration of the expanded child tax credits in 2022, it will be critically important to monitor and address food insecurity as the economic impact of the pandemic on families continues to evolve. (Chapter 6 provides a more in-depth analysis of the impact of child tax credits and other federal economic response programs for children and families.)

Decrease in Access to Health Care

One of the most immediate effects of the pandemic was a decrease in access to health care. Early in the pandemic, with shelter-at-home advisories in most states, visits for preventive health care services in general and visits for children dropped precipitously (Lebrun-Harris et al., 2022; Teasdale et al., 2022). Outpatient clinics moved many nonurgent or preventive health care visits to telephone or telehealth and encouraged parents to delay routine preventive health care visits (Bhaskar et al., 2020; Demeke, 2020; Shakula et al., 2022). The result was a sharp decline in pediatric vaccination rates; adherence to nationally recommended preventive health care visit schedules; and the preventive health care screening typically done during these visits, including developmental screening and anemia and lead screening for young children and screening for sexually transmitted diseases and depression for adolescents (Santoli, 2020; Courtney et al., 2021; Diaz & Kane, 2021; Lebrun-Harris et al., 2021; Noisette et al., 2021; DeSilva et al., 2022).

In an analysis of data from the Census Bureau’s Household Pulse Survey in April–May 2021, 26.4 percent of households reported that at

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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least one child or adolescent in their household had a missed or a delayed preventive health care visit because of the COVID-19 pandemic (U.S. Census Bureau, 2021). Missed and delayed visits were more prevalent among families who also reported financial hardships: rates of missed or delayed visits were 37.6 percent among families with food insecurity, compared with 25 percent for families not reporting food insecurity (Lebrun-Harris et al., 2021). The pandemic has also affected continued health care for chronic conditions and time-sensitive medical treatments (e.g., cancer therapies, new-onset type 1 diabetes). Data suggest a potential delay in health care for these patients, reduced receipt of routine well-child visits, reduced screening, and postponed procedures to reallocate medical resources during the pandemic (Gottesman et al., 2022; Radhakrishnan et al., 2022).

One consequence of these delays in health care has been a major decline in childhood immunizations. Globally, it has been reported that 23 million children missed basic childhood vaccines through routine health services in 2020, the highest number since 2009 and 3.7 million more than in 2019 (UNICEF, 2021). Early in the pandemic, orders for the national Vaccines for Children Program (which provides federally purchased vaccines to approximately 50% of U.S. children) declined, as did the number of vaccine doses administered (Santoli et al., 2020). For the influenza vaccine, fewer doses were administered to children in the 2020–2021 influenza season than in the 2019–2020 season (Roman et al., 2021). Data from eight U.S. health systems in the Vaccine Safety Datalink showed that as of September 2020, child vaccination rates and the proportion who were up to date remained lower than 2019 levels, with the lowest rates among non-Latino Black children across most age groups (DeSilva et al., 2022; Jenssen & Fiks, 2022). For example, one study found that 61 percent of 18-month-old children were up to date on immunizations in September 2019, compared with 57 percent in September 2020; for Black children, these proportions were 54 percent and 41 percent; and for Latino children, 58 percent and 54 percent (DeSilva et al., 2022).

Vaccination rates will generally be much higher for children entering school because of state and local school entry requirements. CDC has reported that for the 2020–2021 school year, the rate of kindergarteners who had received all required vaccines was 94 percent, approximately one percentage point lower than the previous year (Seither et al., 2022). These reductions in immunizations likely reflect parental concerns about potential exposure to COVID-19 during well-child visits, decreased access to vaccination (particularly early in the pandemic), and greater distrust in science and vaccines as a result of widespread misinformation. Further research is needed to assess trends and the long-terms effects on health for lapses in care for time-sensitive vaccination. It will also be important to promote vaccination for COVID-19 and all childhood immunizations, particularly in historically underserved communities.

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Children with Special Health Care Needs

Families with children with developmental disabilities and special health care needs rely on a number of services and supports, including frequent health care visits, school- or community-based services, and in-home health care. During the pandemic, particularly in the early days, these services were unavailable or moved online. Because of their reliance on these services, families of children with special needs may have faced more hardships from the pandemic than other families; however, there are few U.S.-based empirical studies to provide data on the impact of the pandemic specifically for families with children with medical complexity and developmental or intellectual disabilities. Services were shut down without clear communication about if, how, or when they would be resumed (Aishworiya & Kang, 2021), and health care encounters were limited because of closures and shelter-at-home orders. In an April–May 2020 online survey of caregivers of children and adults with a genetic diagnosis and a neurodevelopmental disorder (669 respondents in the United States, 149 in 28 non-U.S. countries), 74 percent of parents reported losing access to at least one therapy or education service, and 36 percent reported losing access to a health care provider during the initial pandemic-related restrictions (Jeste et al., 2020). However, the rapid expansion of telemedicine health services offered a solution for some families: a 2020 study found that 70 percent of survey respondents required a visit with a health care provider during the initial period of restrictions during the pandemic, and 67 percent of those families were able to conduct these visits by telemedicine (Jeste et al., 2020). The use of telemedicine among this population may represent an improvement in access to health care that can influence services for children with special health care needs beyond the pandemic.

As described above, the pandemic has had a deleterious impact on the mental health of parents and children. For the population of families with children with special health care needs, however, the mental health burden may have been even greater, in part because of the loss of important health and education services and supports for children. For households that care for these children, this stress and familial burden may have been driven by the loss of critical services. For other families, the stress may have been heightened by the online learning difficulties families needed to navigate, the economic uncertainty and financial strain, the limited social environment and opportunities for engagement, child sleep and behavior problems, and time spent on electronic devices (Kim et al., 2021). Caregivers’ reports of emotional distress, depressive symptoms, anxiety, and stress increased after the pandemic began and were higher for those in households with children who have special health care needs (Liu et al., 2021). Similarly, reports of children’s behavioral problems increased after the onset of the pandemic

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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and were higher for children with special health care needs. Parents reported more externalizing and internalizing behaviors during the pandemic than previously and at higher rates in households with children with special health care needs (Liu et al., 2021).

THE HEALTH CARE SYSTEM

While children have not suffered the same physical health effects of COVID-19 as adults, the pandemic’s effects on pediatric services have been significant. Early in the pandemic, pediatric clinicians assisted colleagues in providing health care to adults, worked tirelessly to protect children from COVID-19 infection, quickly implemented telemedicine, and led in the development of learning health systems to address the crisis (Beck et al., 2021). Pediatric health care systems faced utilization swings, sicker patients, an increase in patients with behavioral and mental health crises, decreases in revenues, clinician fatigue and burnout, and severe workforce shortages. Overlapping respiratory illnesses (respiratory syncytial virus [RSV], influenza, and COVID-19) during fall 2022 into winter 2023 further exacerbated the strain on pediatric health care systems (Agathis et al., 2023).

Children’s hospitals and pediatricians have not had the same access to federal relief as other health care systems (Children’s Hospital Association, 2021). Moving forward it will be critical to assess how the pediatric health care system has been affected by the pandemic, how patients and families have been affected, and how the system can be strengthened in the future.

Access to Coverage

As a joint federal and state program, Medicaid provides health care coverage to low-income children and families, low-income seniors, and people with disabilities. The Children’s Health Insurance Program (CHIP) is a joint federal and state program that was established to provide coverage to children in households with incomes too high to qualify for Medicaid that may not have access to employer-sponsored insurance. In 2021, Medicaid and CHIP covered 39 percent of U.S. children, an increase of 1.5 percentage points from 2019 (KFF, 2023a). Racially and ethnically minoritized children were disproportionately covered by Medicaid, with 61 percent of Black children, 55 percent of Latino children, and 59 percent of Native American and Alaska Native children covered by Medicaid/CHIP in 2021 (Artiga et al., 2021). Unlike Medicare, Medicaid is administered at the state level, making it more vulnerable to state cuts in times of financial uncertainty, such as the pandemic. Moreover, Medicaid fee-for-service payments are on average nearly 30 percent lower than Medicare payment levels, which themselves are a fraction of commercial insurance rates (Currie & Chorniy, 2021).

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Between February 2020 and August 2022, enrollment in Medicaid and CHIP increased 27.3 percent, or roughly 19.3 million people (Centers for Medicare & Medicaid Services, 2022; Corallo & Moreno, 2022). Adult enrollment in Medicaid increased by 38 percent from February 2020 to August 2022, and child enrollment in Medicaid/CHIP increased by 16.3 percent, or 5.8 million children (Corallo & Moreno, 2022). This overall growth was mainly due to Medicaid (29.5% increase), rather than CHIP (4.6% increase), largely because in many states decreases in family household income resulted in children shifting from CHIP to Medicaid coverage. Over this period, all states experienced increases in total Medicaid/CHIP enrollment. This increase during the pandemic to date follows a previous steady rate of decline in enrollment from 2017 to 2019 (Corallo & Moreno, 2022).

Much of the Medicaid/CHIP increase in enrollment during the pandemic is thought to have been driven by the maintenance of eligibility provisions under the Families First Coronavirus Response Act (FFCRA). These provisions increased the federal share of Medicaid funding to states to maintain continuous enrollment requirements during the public health emergency. All states participated, received the increased Medicaid funding, and thus were prohibited from disenrolling Medicaid enrollees during the emergency period. When the continuous enrollment requirement begins its specified “winding down period” and states can resume disenrollment effective April 1, 2023, many individuals, both adults and children, could lose coverage as states return to their usual renewal process, which is known to present multiple administrative barriers to families (Dague et al., 2022). Those barriers are largely due to paperwork challenges in the Medicaid redetermination processes, as well as fluctuations in family income and circumstances. These factors result in “churn”—as Medicaid beneficiaries lose coverage and then reenroll within a short period of time, creating consequential gaps in coverage.

Studies have shown that churn in Medicaid is associated with higher health care costs, delayed care, less preventive health care, more emergency department visits, unfilled prescriptions, and less access to health care (Brantley & Ku, 2022). Churn can affect both children and adults. It is particularly salient for women during the postpartum period, in which 55 percent of Medicaid-insured women will experience a coverage gap, compared with 35 percent of postpartum women with private insurance (Daw et al., 2017; also see below). The variation among states in terms of policies that effectively encourage churn is wide and often relates to redetermination procedures in which families may be required to quickly respond to requests by mailing or telephone. In Texas, for example, parents received multiple mailings during a 12-month period to verify their income during state checks of income eligibility for Medicaid-enrolled children; the parent or caregiver had 10 days to respond to the income verification. It

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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is estimated that delays in response account for as much as 90 percent of Medicaid coverage loss for children (FamiliesUSA, 2019).

Despite the known benefits of continuous eligibility for children and adults (Wagner & Solomon, 2021), as of May 2022 only 24 states offered 12-month continuous eligibility to children, and no state allowed continuous eligibility for a period of more than 12 months (Lee, 2022). This situation will change next year: on December 29, 2022, President Biden signed the Consolidated Appropriations Act 2023, which requires states to provide 12-month continuous eligibility for children in Medicaid and CHIP, effective January 1, 2024 (Park et al., 2023).

The Consolidated Appropriation Act also amended the American Rescue Plan Act of 2021 by giving states the option to permanently extend postpartum coverage for women for 12 months for comprehensive benefits and continuous eligibility (KFF, 2023b; Park et al., 2023). Currently, all state Medicaid programs are required to provide continuous pregnancy-related coverage through only 60 days postpartum. At the end of this two-month postpartum period, new mothers could suddenly become uninsured; this is a particular risk for women who live in states that have not expanded Medicaid, as income eligibility ceilings for parents are much lower than income eligibility for pregnant women (Ranji et al., 2021).7

Some states have adopted what are known as express lane eligibility and presumptive eligibility (Park et al., 2023, 2021). Express lane eligibility allows states to use eligibility information from other programs (such as Temporary Assistance for Needy Families; Supplemental Nutrition Assistance Program; and the Special Supplemental Nutrition Program for Women, Infants, and Children) to determine Medicaid and CHIP eligibility, reducing administrative burden on both programs and families. With presumptive eligibility, states can allow qualified entities (such as hospitals and health care providers) to screen individuals for Medicaid eligibility and temporarily enroll them, allowing them to receive coverage and services quickly.

The maintenance of eligibility provisions under the Families First Coronavirus Response Act (FFCRA) has contributed to reduced churn for Medicaid-insured children and adults, thus increasing Medicaid/CHIP enrollment during the pandemic. It is clear that such provisions can ensure more continuous insurance coverage for children and their parents. The Consolidated Appropriations Act of 2023 separates the Medicaid continuous coverage requirement from the public health emergency, which is set to end on May 11, 2023. The Act provides a phase-out of the increased federal Medicaid matching rates that states receive under FFCRA: after the continuous coverage ends on March 31, 2023, states will continue to receive some level of increased matching rates through December 31, 2023, but will have to follow regulations related to protections for Medicaid

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7 As of October 6, 2022, 26 states and the District of Columbia had implemented this 12-month postpartum extension, and another eight states indicated plans to do so.

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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enrollees during this “unwinding period” (e.g., states cannot restrict eligibility standards, increase premiums, or disenroll individuals on the basis of returned mail). Even with this regulated winding down period, states will need to enact additional mechanisms to ensure continuous coverage, and thus access to health care for children and their families.

Historically underserved populations, including low-income, Black, Latino, and Native American children disproportionately rely on Medicaid/CHIP. Medicaid provides comprehensive coverage and cost-sharing protections, but restricted eligibility and low provider payment threaten access to health care and health equity (Perrin et al., 2020); Medicaid pays about two-thirds of what Medicare pays, resulting in lower provider participation and reduced access (Rosenbaum, 2014). The pandemic has revealed longstanding racial, ethnic, and socioeconomic disparities in access to health care. One way to reduce the stigma of Medicaid and address these disparities would be for Medicaid parity with Medicare, with full federal financing and the same payment rates for the same services, as was recently discussed in Implementing High-Quality Primary Care: Rebuilding the Foundation of Health (the National Academies of Sciences, Engineering, and Medicine [the National Academies], 2021).8

Under the Affordable Care Act (ACA), 39 states and Washington, DC, had adopted Medicaid expansion as of November 2022, which expanded coverage to adults aged 18–64 with incomes up to 138 percent of the federal poverty level and provided states with enhanced federal matching rates for this new population (KFF, 2022a). This population includes low-income parents in the “coverage gap,” with incomes too high to qualify for Medicaid in their state but too low to be eligible for premium subsidies on the ACA marketplace (which ranges from 17% to under 100% of the federal poverty level; Garfield et al., 2021).

Nearly two-thirds of adults caught in this coverage gap are from racial and ethnic minoritized groups (Garfield et al., 2021). The benefits of Medicaid expansion prior to the pandemic are well documented: they include increased coverage, health service use, and quality of care among low-income adults (Mazurenko et al., 2018); the benefits also include increased coverage for parents and postpartum women (Bellerose et al., 2022) and, among parents, reduced problems paying medical bills and reduced severe psychological distress (McMorrow et al., 2017). There are also spillover effects on children, including increased visits for preventive services (Venkataramani et al., 2017) and increased Medicaid coverage (Hudson & Moriya, 2017; Hamersma et al., 2019).

States saw another benefit of Medicaid expansion, namely, protection against larger increases in uninsured adults associated with pandemic-related

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8 This sentence was changed since the prepublication release of the report, replacing “recommended” with “discussed,” to clarify that the National Academies, 2021 report discussed Medicaid parity with Medicare, but the report did not specifically recommend such parity.

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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unemployment. A study using data from the Census Bureau’s Experimental Pulse Survey found that in states that implemented expanded coverage, compared with those without, adults with pandemic-related job losses were nine percentage points more likely to report Medicaid insurance and seven percentage points less likely to be uninsured (Benitez & Dubay, 2022). In another study using nationally representative data from the 2020 to 2021 Current Population Survey’s Annual Social and Economic Supplement, nonexpansion states had a greater level of uninsurance associated with pandemic-era unemployment, in contrast to expansion states, where the newly unemployed were more likely to enroll in Medicaid, presumably due to Medicaid expansion (Benitez, 2022; Benitez & Dubay, 2022). It is important to note that across all nonexpansion states, an estimated four million adults would become eligible for Medicaid coverage if these states adopted Medicaid expansion; more than 2 million of these are women, and more than 1.1 million are parents (Straw et al., 2021). The American Rescue Plan included additional financial incentives for states to adopt Medicaid expansion for adults: a 2-year 5 percentage point increase in federal match, in addition to the already 90 percent federal matching funds for expansion.

Under the ACA, individuals and families in expansion states with incomes of 100–400 percent of the federal poverty level can purchase coverage in the ACA marketplace; in nonexpansion states, they can do so with incomes of 138–400 percent of the federal poverty level. The American Rescue Plan temporarily increased the value of premium tax credits for those already eligible for subsidies on the ACA marketplace and expanded eligibility for subsidies to adults and families who were previously not eligible because their incomes were higher than 400 percent of federal poverty level (Sommers & Haffajee, 2021). These provisions made marketplace coverage more affordable; the proportion of uninsured people eligible for zero premium plans increased by 19 percentage points, and the proportion of people eligible for plans with monthly premiums $50 or less increased by 16 percentage points (Branham et al., 2021).

These federal pandemic relief measures (Medicaid continuous coverage and enhanced premium tax credits and expanded subsidy eligibility for the ACA marketplace) were intended to increase health insurance coverage and ensure that individuals and families had health care coverage despite widespread job losses and financial hardships during the pandemic. (Other federal provisions related to education and economic aid to families are discussed elsewhere in this report.) Many of these health coverage provisions are set to expire in 2023,9 and without intervention, the loss of these provisions is likely to result in loss of critical health care coverage for millions of children and families.

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9 Some have already expired: premium tax credits expansions were only through 2022, and the continuous coverage provision expired in January 2023.

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Strengthening the System for the Future

The COVID-19 pandemic will not be the last time that the pediatric health system is tested. In order to ensure readiness for future events, it is important that prepandemic disaster planning efforts continue and that they incorporate lessons learned from the pandemic. The primary underlying principle in disaster planning for hospitals and health systems is that everyday readiness is necessary to ensure event preparedness. Hospital and health system readiness for pediatric patients will benefit from an all-hazard capability and being family centered (Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health System, 2006).

There has been a recent focus on pediatric readiness of emergency departments in the United States and, by extension, assessment of the continuum of care needs for pediatric patients in hospital inpatient and critical health care settings, including the need for transportation to specialized levels of care (Ray et al., 2018). However, inattention to pediatric settings persists in the domain of disaster planning: for example, fewer than half of respondents to a national survey reported inclusion of the specific needs of children in their hospital disaster plans (Gausche-Hill et al., 2015). Efforts to close these preparedness gaps have generated a series of evidence-based checklists and toolkits designed to guide hospitals and health systems in the provision of the necessary equipment, personnel, and policies in order to optimally address the needs of children (Remick et al., 2018).

The translation of these preparedness efforts for emergency departments and hospitals in the context of health system pandemic readiness is at a very nascent stage. Extrapolating the lessons of the 2009 H1N1 influenza pandemic, particularly given the significant effects on children, has been instructive in terms of all-hazard surge management and regionalization of critical care. However, with 12,468 deaths in the United States and 575,400 globally, H1N1 pales in comparison with the length and scale of the morbidity and mortality experienced in the COVID-19 pandemic (Hamele et al., 2018). Published documentation of pediatric preparedness and readiness activities early in the pandemic have focused on provider education and training, including the value of simulation exercises (Auerbach et al., 2021; Wagner et al., 2021). While analysis and assessment of individual health system pediatric pandemic preparedness activities are ongoing, the Health Resources and Services Administration (HRSA) announced funding support in late 2021 to establish the Regional Pediatric Pandemic Network (RPPN; Macias & Newton, 2021). Comprised of a select group of children’s hospitals, the RPPN serves as a hub-and-spoke model focusing on four domains:10

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10 See https://mchb.hrsa.gov/programs-impact/pediatric-pandemic

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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  1. access to health care: health information portability, telehealth, community/medical home, regionalization and equity, and legal issues
  2. everyday readiness: prehospital, pediatric readiness, trauma and burns, mental and behavioral health
  3. disaster preparedness: capacity and capability; deployable assets; infectious diseases; chemical, biological, radiological, and nuclear threats; reunification
  4. quality improvement: analytics; research; knowledge, education, and communications; drills and exercises; quality improvement collaboratives

As of fall 2022, additional funds were appropriated to HRSA to expand the network model, add additional centers, and incorporate domains focused on early detection, technology transformation, and equity. This framework is expected to provide the necessary clinical learning laboratory from which systematic and replicable approaches can be developed and evaluated.

A Tiered Public Health Approach

The Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988, known as the Stafford Act, describes the process and assistance derived from a presidentially declared disaster to be administered by the states for which governors apply. The Sandy Recovery Improvement Act of 2013 amended the Stafford Act, establishing that Indian tribal governments also have the option of pursuing a disaster declaration directly from the President. Similarly, the U.S. Department of Education provides Project School Emergency Response to Violence (SERV) funding for “short-term and long-term education-related services for local educational agencies and institutions of higher education to help them recover from a violent or traumatic event in which the learning environment has been disrupted” (FEMA, 2023). Both the Stafford Act and Project SERV have funded immediate and sustained systemwide mental health programs for traumatized and bereaved children that are designed to increase the capacity of child-serving systems and their coordination in a layered public health approach. They rely on comprehensive, repeated needs assessments and evidence-based interventions at each phase of initial renewed funding.

In this coordinated, layered public health approach to address children’s mental health after disasters, there are three tiers of intervention, which can overlap. Tier 1 largely focuses on universal screening, mental health promotion, and prevention of mental health concerns. Tier 2, based on screening and exposure, provides brief, short-term, and intermediate

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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interventions for those found to remain in distress and facing ongoing adversities that increase the risk of mental health disorders. Tier 3 covers more intensive intervention for children with mental health disorders, including traumatic stress or grief-related disorders. Two federally funded initiatives can provide a coordinated vehicle to support pediatric and child mental health capacity building and enhanced delivery of tiered interventions for locally implemented disaster response. The Pandemic Centers for Excellence11 are engaged in planning regional approaches and helping communities address surges in behavioral health crises. This includes regional risk screening, an integrated and coordinated systems of care model, and a stepped-care approach to levels of intervention. The approach is integrated with other funded national partners—for example, the Emergency Medical Services for Children Innovation and Improvement Center and the Pediatric Disaster Care Centers of Excellence. In addition, there is coordination with the National Child Traumatic Stress Network (NCTSN), funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), that currently has more than 160 federally funded centers, distributed widely across the United States, U.S. territories, and tribes, and with the NCTSN Disaster and Terrorism Program.

A 2007 worldwide panel of experts offered an evidence-based consensus on key intervention principles to guide and inform intervention and prevention efforts for trauma, loss, and disaster care, including for children and families. The principles included promoting a sense of safety, calming, self- and community efficacy, connectedness, and hope. Each of these five principles are critical to a tiered public mental health disaster intervention program (Hobfoll et al., 2007). This approach designates three tiers of care, which closely align with the tier concept noted above.

Tier 1: Universal Surveillance, Screening, Promotion, and Prevention

The first tier aims to (1) increase community awareness using community assets to foster healthy connections, improve adaptive coping, enhance understanding, identify areas of concerns (e.g., not showing up for school), and provide guidance about where to seek appropriate assistance; (2) provide broad-based education for youth-serving providers, parents, and caregivers, and peer to-peer support programs to increase understanding and the ability to adapt approaches to a range of COVID-19-related behavioral health consequences; (3) tailor messaging to different risk cohorts, such as children suffering COVID-19-related bereavement and those engaging in

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11 They are funded by the Administration for Strategic Preparedness and Response, an operating agency of the U.S. Public Health Service in the U.S. Department of Health and Human Services.

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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trauma-related risky behaviors (e.g., reckless driving); (4) provide broad-based education and skill building regarding the role of and family management of trauma and loss reminders that can significantly affect youth and family functioning; and (5) implement initiatives to enhance safety among youth (e.g., firearm safety campaigns to reduce lethal suicide behavior). These intervention foci are incorporated into the NCTSN and National Center for PTSD’s Psychological First Aid Field Operations Guide (Brymer et al., 2006).

Another critical element of Tier 1 involves systematic screening and surveillance to identify and monitor children and adolescents with at-risk exposures related to COVID-19 (Brymer et al., 2006). Brief screening tools can be used to assess pandemic-related trauma and bereavement experiences, secondary adversities, current reactions, and functional impairment involving family, school, or peers (Grasso et al., 2021). Child-serving systems, including schools, pediatric and family medical practices, child welfare and behavioral health agencies, and juvenile justice and residential programs can incorporate COVID-19-specific questions both now and in the years ahead so that the potential long-term effects of the pandemic continue to be monitored and addressed.

In terms of the social determinants of health, it is important to especially focus on screening high-risk populations, those child populations disproportionately affected by the pandemic, inequities, and deficiencies in the availability of services. These populations include children of hospitalized family members and family members with long COVID, as well as children who have suffered COVID-19-related family deaths. They also include children with disabilities and preexisting behavioral health conditions who had delays in receiving adequate services during the pandemic. Partnering with those groups that have been disproportionality affected by COVID-19 to identify effective outreach strategies and messaging is critical. These collaborations include community, cultural, and youth leaders. Partnering with home-school programs will be especially important for those children with illnesses and immunosuppression that has contributed to their isolation, family experience of danger, and greater reliance on homeschooling rather than returning to in-person learning.

Tier 2: Targeted Prevention, Promotion, and Intervention

Tier 2 allows for selective use of intermediate care interventions (Brymer et al., 2006). Screening includes dimensions of distress and functional impairment; Tiers 1 and 2 can overlap in the use of brief symptom screens for PTSD, depression, suicidality, prolonged grief disorder, and other behavioral disturbances, from eating disorders to school refusal. The Intermountain

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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West Care Process Model for Pediatric Traumatic Stress provides one well-tested implementation in pediatric primary care and child welfare settings that is already enhanced with COVID-19 screening, assessing suicide risk, and stratified intervention and referral (Keeshin et al., 2020).

A major intermediate intervention in this tier is Skills for Psychological Recovery (SPR), a community- and strength-based intervention that is modular in approach and incorporates cultural practices. It is one of the core intervention strategies of SAMHSA’s Crisis Counseling and Assistance Program. It can be delivered by trained community providers with behavior health supervision, including community paraprofessionals, religious professionals, youth leaders, and educators.

SPR addresses traumatic stress and bereavement, as well as adjustment to secondary adversities and disturbances in interpersonal relationships, with a strong emphasis on problem-solving skills to increase a sense of efficacy and hopefulness. Short-term, family-oriented clinical interventions, such as the Child and Family Traumatic Stress Intervention,12 have proven effective in reducing the risk of PTSD and enhancing parent–child mutual support (Hahn et al., 2019). A strong recommendation throughout all tiers of intervention is to place emphasis on strengthening parenting by providing tools to manage stresses and challenges (Wood et al., 2021), such as the Child Adult Relationship Enhancement training (Gurwitch et al., 2016).13

Tier 2 interventions include the incorporation of youth trauma-informed suicide prevention programs directed at youth identified to be at risk in emergency departments, primary health care settings, and schools (Tunno et al., 2021), as part of an overall Blueprint for Youth Suicide Prevention program.14

Tier 3: Intensive Intervention

Tier 3 covers evidence-based clinical interventions (Brymer et al., 2006). From a public health perspective, communities need to consider trauma and grief interventions that have been adapted for different age ranges and cultural groups and directed at the core risk and clinical categories. There are a number of effective interventions across age ranges in the field of child traumatic stress and bereavement, including trauma-focused cognitive behavioral therapy,15 trauma and grief component therapy,16 trauma

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12 See https://www.nctsn.org/interventions/child-and-family-traumatic-stress-intervention

13 See https://www.nctsn.org/interventions/child-adult-relationship-enhancement

14 See https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention

15 See https://www.nctsn.org/interventions/trauma-focused-cognitive-behavioral-therapy

16 See https://www.nctsn.org/interventions/trauma-and-grief-component-therapy-adolescents

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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systems therapy for children and teens,17 cognitive-behavioral intervention for trauma in schools,18 and child–parent psychotherapy.19

CONCLUSIONS

The pandemic’s long-term health legacy and its overall effect on the development course for the children who are experiencing life in the time of COVID-19 are yet to be determined. However, recognizing the large effects on children’s physical and mental health and the lasting effects of previous pandemics, it will be critical to monitor and buffer the many negative effects of the COVID-19 pandemic on children and their families. The COVID-19 pandemic has had the greatest negative impact on the physical and mental health of children and families who were already facing inadequate health care access, quality, and services. These are children who are from disproportionately Black, Latino, and Native American populations; live in households with low incomes; and generally have unmet physical and mental health problems.

Conclusion 5-1: Without a focused strategy to change the altered life trajectory that the COVID-19 pandemic has created for many children, a generation of young people will enter adulthood with worse mental health and a greater burden of chronic disease and impaired physical health as they age through adulthood. This is most pronounced for children from minoritized and low-income communities.

Conclusion 5-2: An adequate and robust, coordinated, federal health response is needed to address the physical and mental health and well-being of children who have been and may continue to be most directly affected by the COVID-19 pandemic. These children have suffered traumatic stress from serious illness, hospitalization, or the loss of a family member or loved one during the pandemic, as well as fear and isolation resulting from the pandemic and the measures taken to combat it.

Conclusion 5-3: Federal efforts to halt disenrollment from Medicaid during the public health emergency were critical to increased Medicaid enrollment throughout the pandemic. Medicaid will be an important part of ensuring that children in low-income families have coverage to address the increased physical and mental health burdens they have faced and are facing.

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17 See https://www.nctsn.org/interventions/trauma-systems-therapy

18 See https://www.nctsn.org/interventions/cognitive-behavioral-intervention-trauma-schools

19 See https://www.nctsn.org/interventions/child-parent-psychotherapy

Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Conclusion 5-4: Available data on the physical and mental health effects of the COVID-19 pandemic are incomplete, and there is still much unknown about the long-term effects that the pandemic may have on the physical and mental health of children.

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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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Suggested Citation:"5 Health Effects." National Academies of Sciences, Engineering, and Medicine. 2023. Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families. Washington, DC: The National Academies Press. doi: 10.17226/26809.
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The COVID-19 pandemic has had an unprecedented impact on the lives of children and their families, who have faced innumerable challenges such as illness and death; school closures; social isolation; financial hardship; food insecurity; deleterious mental health effects; and difficulties accessing health care. In almost every outcome related to social, emotional, behavioral, educational, mental, physical, and economic health and well-being, families identifying as Black, Latino, and Native American, and those with low incomes, have disproportionately borne the brunt of the negative effects of the pandemic.

The effects of the COVID-19 pandemic on children and families will be felt for years to come. While these long-term effects are unknown, they are likely to have particularly significant implications for children and families from racially and ethnically minoritized communities and with low incomes.

Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families identifies social, emotional, behavioral, educational, mental, physical, and economic effects of the COVID-19 pandemic and looks at strategies for addressing the challenges and obstacles that the pandemic introduced for children and families in marginalized communities. This report provides recommendations for programs, supports, and interventions to counteract the negative effects of the pandemic on child and family well-being and offers a path forward to recover from the harms of the pandemic, address inequities, and prepare for the future.

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