The debate over school openings has highlighted the implications of the coronavirus pandemic for children and their families. While experts continue to gather data on children’s risk for contracting and transmitting coronavirus, current research suggests that though children are more likely to be asymptomatic and less likely to experience severe disease than adults, they can transmit to both other children and adults.
In addition to the risk of disease and illness, COVID-19 has led to changes in schooling, health services delivery, and other disruptions of normal routines that will likely affect children’s health and well-being, regardless of whether they are infected.
This brief examines how a range of economic and societal disruptions stemming from COVID-19 may affect the health and well-being of children and families. It draws on published literature as well as pre-pandemic data from the National Survey of Children’s Health and the National School-Based Health Care Census, recent survey data on experiences during the pandemic, data tracking the number of cases resulting from school openings, and preliminary reports based on claims data evaluating service utilization among Medicaid and CHIP child beneficiaries.
It finds that school openings/closures, social distancing, loss of health coverage, and disruptions in medical care could negatively impact the health and well-being of children in the US (Figure 1).1 Key findings include:
Early research has documented high rates of clinginess, distraction, irritability, and fear among children, particularly younger children, and increases in some substance use among adolescents, and one survey found that nearly a third of parents said their child had experienced harm to their emotional or mental health. Exposure to adverse childhood experiences have documented effects of lifelong physical and mental health problems.
Children’s lower risk of serious illness due to COVID-19 has led most discussion and policy debate over the pandemic to focus on adults at high risk, though the recent debate over school openings has shifted focus to children’s health and wellbeing.
Many children are currently facing substantial access barriers, emotional strain, and financial hardship that could have long-term repercussions for their lives.
The debate over school openings has highlighted the implications of the coronavirus pandemic for the nation’s 76 million children and their families. Experts continue to gather data on the children’s risk for contracting and transmitting coronavirus, but current research suggests that though children are more likely to be asymptomatic and less likely to experience severe disease than adults, they can transmit to both children and adults.
As of September 17th, 2020, state data showed that there were over half a million COVID-19 cases among children nationwide, accounting for just over 10% of all cases (children make up about a quarter of the population in the US); however, new cases among children in the period September 3rd through September 17th represented a 15% increase over the prior two week period. In addition, social distancing policies and the economic downturn have important implications for the health and well-being of children, particularly low-income children and children of color.
These groups faced increased health, social, and economic challenges prior to the pandemic, and research shows that, like adults, minority and socioeconomically disadvantaged children have a higher risk of contracting coronavirus. This brief analyzes the potential implications of the COVID-19 pandemic for children’s mental and physical health, well-being, and access to and use of health care.
States and school districts have made varying decisions about how to conduct school in the 2020-21 academic year.
Students who attend in-person school face direct risks of contracting coronavirus, with early tracking documenting nearly 12,400 cases across 3,900 schools. A KFF review found that evidence is mixed about whether children are less likely than adults to become infected when exposed, and while disease severity is significantly less in children, a small subset becomes quite sick.
KFF polling data from July 2020 showed high rates of parent concern over health risks due to school re-opening, with 70% of parents of a child age 5-17 saying they were somewhat or very worried about their child getting sick from coronavirus due to school attendance; parents of color were more likely to express this concern (91% versus 55% of White parents) and also more likely to say their child’s school lacks the resources to safely reopen (82% versus 54% of White parents).
As of September 22nd, The National Education Association has confirmed nearly 12,400 cases in Pre-K to high school students across the country. Given the lack of universal testing among students in school and higher likelihood of children being asymptomatic, the number of cases is likely higher than what is reported. Children who contract coronavirus may also pose a risk beyond their school community, as 3.3 million adults age 65 or older live in a household with a school-age child.
The risks of contracting coronavirus due to school may be greater for low-income or minority students due to differences in school structure and commuting patterns. In addition to higher risk due to in-person attendance, minority or low-income children may be at higher risk from transportation to and from school, as students from low-income households may lack alternatives to school transportation or live in neighborhoods without safe walking routes to school.
Longer commute times on school busses and other forms of public transportation may put students at higher risk for contracting the virus due to the increased time spent in an enclosed and crowded space.
Students who do not attend school in person may face difficulty accessing health care services typically provided through school. School based health clinics (SBHCs) provide primary care and behavioral health services to nearly 6.3 million students across over 10,600 public schools in the US, accounting for nearly 13% of students nationwide.
Social distancing policies may cause reduced social connections and physical activity for children. Parents report high rates of concern about limited social interaction, with data from a July KFF Tracking Poll finding that 67% of parents are worried their children will fall behind socially and emotionally if schools do not reopen.
Both students attending and not attending in-person school may face emotional or behavioral challenges due to disruptions to routines. Early researchreported high rates of clinginess, distraction, irritability, and fear among children, with younger children being more likely to exhibit these behaviors.
In a June 2020 survey, 29% of parents reported that their child had already experienced harm to their emotional or mental health. Children with pre-existing mental or behavioral health problems may be at particularly high risk; prior to the pandemic, more than one in ten adolescents ages 12 to 17 had depression or anxiety. Pre-pandemic rates of mental illness were higher among children of color, and these children were also less likely to receive treatment for their mental or emotional problems.
Increases in parent stress may also negatively affect children’s health. With long-term closures of schools and childcare centers, many parents are experiencing new challenges in childcare, homeschooling, and disruption to normal routines.
With many sources of care unavailable, parents who are still working (either in person or via telework) are having to balance childcare or schooling with work. KFF Tracking Polls conducted following widespread shelter-in-place orders found that over half of women and just under half of men with children under the age of 18 have reported negative impacts to their mental health due to worry and stress from the coronavirus.6
COVID-19 has led to a surge in unemployment and income declines for many families with children. Social distancing policies required to address the crisis have led many businesses to cut hours, cease operations, or close altogether. KFF estimates of job loss between March 1st and May 2nd, 2020 find that over 20 million children are in a family in which someone lost a job. Job losses have continued since that date, and a greater number of children may be in a family in which someone retained their job but has experienced some loss of income.
Job loss may lead to disruptions in children’s health coverage, though most children in families losing employer-sponsored health insurance are likely eligible for coverage under the ACA. KFF analysis of job loss and potential loss of employer coverage as of early May found that millions of people who lost their job as of May 2 were at risk of losing their employer health benefits, and over 6 million people at risk of losing ESI and becoming uninsured are children.
Loss of family income also affects parents’ ability to provide for children’s basic needs. Data from the August 19-31 Household Pulse Survey shows that 38% of adults in households with children said it was somewhat or very difficult to pay for usual household expenses during the pandemic, a higher share than among adults without children (26%) (Figure 2).
The share of households with children who sometimes or often did not have sufficient food to eat increased during the pandemic, with 10% of these households reporting insufficient food prior to March 13th, as compared to 12% as of August 31st. Food insufficiency is particularly pronounced for Black (20%) and Latino (16%) households with children when compared to White (9%) households.
School closures may further limit low-income children’s ability to access food through free- and reduced-price school meal programs. Just over 1 in 3 students between the ages of 5 and 17 qualifies for a free or reduced-cost meal.11 Given that these students often depend on school for two meals a day, school closures may limit their ability to eat regularly and access nutritious food.
Preliminary reports based on claims data show significant declines in service utilization among Medicaid/CHIP beneficiaries under the age of 18 between January and May 2020, which may be due to social distancing policies as well as concerns about exposure (Figure 3).
Prior to the pandemic, utilization of preventive and primary care was generally high among children: In 2018, the large majority (96%) of children had a regular source of health care, nearly 90% had received a well-child visit in the past year, and only a small share (2.5%) delayed care due to cost. However, early analysis of claims data by the Center for Medicare and Medicaid Services (CMS) shows substantial declines in use of regular and preventive care.
Though some data shows increases in use of telehealth services among children during the pandemic, it has not offset declines in in-person visits. Preliminary reports by CMS based on Medicaid claims data shows that delivery of any services via telehealth to children increased by over 2,500% from February to April 2020, but these increases did not offset declines in in-person visits and utilization still declined substantially across many services.
Challenges accessing health services are particularly problematic for the 13 million children with special health care needs (CSHCN). Children with special health care needs require ongoing care and specialized services due to intellectual/developmental disabilities, physical disabilities, and/or mental health disabilities.
These disabilities may include asthma, cerebral palsy, cystic fibrosis, diabetes, muscular dystrophy, brain injury, or epilepsy. Many of these children rely on continual care, especially those who have ongoing complications or who have recently had procedures.
The pandemic has led to many services in child welfare systems being cut back or postponed, leading to concerns of both increased child abuse and decreased reporting. Many child welfare agencies have cut back on in-person inspections of homes, which puts vulnerable children at even greater risk for abuse and neglect.
Children’s lower risk of serious illness from COVID-19 has led most discussion and policy debate over the pandemic to focus on adults at high risk, though the recent debate over school openings has shifted focus to children’s health and well-being.
With many schools re-opening, tracking cases, and serious illness among children and understanding who is at the highest risk can help policymakers design education and support systems to minimize exposure, risk, and illness. In addition, many children are already facing substantial access barriers, emotional strain, and financial hardship that could have long-term repercussions for their lives.
This analysis underscores the importance of pursuing safe approaches to opening schools to balance physical and emotional health. Policies to facilitate enrollment in health coverage, ensure access to health services, particularly behavioral health services, and facilitate access to social services to support families with children, can help address some consequences for children are currently facing.