Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and Families (2023) / Chapter Skim
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5 Health Effects
5 Health Effects
Pages 116-171
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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)
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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)
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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)
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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.
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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 & Rasmussen, 2021; MyClymont et al., 2022)
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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.
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. 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, 2022c)
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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.
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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.
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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 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)
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. Vaccine confidence was particularly low among pregnant women who are Prepublication copy, uncorrected proofs 126
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. 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)
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. 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)
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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. The remainder of this section examines specific mental health symptoms and conditions that have been highlighted or exacerbated by the COVID-19 pandemic.
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. 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)
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. Studies indicating large increases in anxiety and depression symptoms during the pandemic used more biased samples (e.g., social media recruitment, emergency department visits)
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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.
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, 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)
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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)
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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.
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. 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)
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. 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.
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It will also be important to promote vaccination for COVID-19 and all childhood immunizations, particularly in historically underserved communities. 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.
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. 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)
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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)
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, 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, 2022)
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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 and Haffajee, 2021)
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. 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)
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The Pandemic Centers for Excellence 10 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.
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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.
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. 12 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)
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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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. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: Living systematic review and meta-analysis.
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. Association of COVID-19 acute respiratory distress syndrome with symptoms of posttraumatic stress disorder in family members after ICU discharge.
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Comparison of Unemployment-Related Health Insurance Coverage Changes in Medicaid Expansion vs Nonexpansion States During the COVID-19 Pandemic. JAMA Health Forum, 3(6)
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Morbidity and Mortality Weekly Report, 71(Suppl-2)
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. COVID-19 vaccination coverage and vaccine confidence among children.
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Morbidity and Mortality Weekly Report, 7i0(5)
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. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic, United States, June 24–30, Morbidity and Mortality Weekly Report, 69(32)
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. Infant outcomes following maternal infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
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. A national assessment of pediatric readiness of emergency departments.
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"The effect of parental Medicaid expansions on children's health insurance coverage." Contemporary Economic Policy 37.2 (2019)
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. Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the US.
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Morbidity and Mortality Weekly Report, 69(32)
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. US Pediatric emergency department visits for mental health conditions during the COVID-19 pandemic.
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The effects of Medicaid expansion under the ACA: a systematic review. Health Aff (Millwood)
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. Preterm birth among pregnant persons with severe acute respiratory syndrome Prepublication copy, uncorrected proofs 162
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Morbidity and Mortality Weekly Report, 62(02)
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. Pediatric emergency department visits before and during the COVID-19 pandemic -- United States, January 2019–January 2022.
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. Risk factors for severe acute respiratory syndrome coronavirus 2 infection in pregnant women.
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. Trends in COVID-19 cases, emergency department visits, and hospital admissions among children and adolescents aged 0-17 years -- United States, August 2020–August 2021.
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emergency department visits related to suspected or confirmed child abuse and neglect among children and adolescents aged <18 years before and during the COVID-19 Pandemic -- United States, January 2019– September 2020. Morbidity and Mortality Weekly Reports, 69(49)
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. Maternal outcomes and risk factors for COVID-19 severity among pregnant women.
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Morbidity and Mortality Weekly Reports, 71(3)
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mRNA vaccination against multisystem inflammatory syndrome in children among persons aged 12-18 years -- United States, July–December 2021. Morbidity and Mortality Weekly Reports, 71(2)
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. The Pediatric infectious disease journal, 40(12)
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