Sandy L. Chung, MD, FAAP, FACHE

Conversations within families about school in the fall are occurring across the United States. It will be very important for pediatricians to focus on the concerns and challenges that children and adolescents will face as the nation returns to consistent in-person learning.

Certainly, schools are the places where children receive academic instruction and educational advancement, but they also play a hugely significant role in the overall development and health of children and adolescents. Essential services are delivered in schools, including socioemotional skill building; physical/occupational/speech therapy; mental and behavioral health care; nutrition; safety; and physical activity.

As we emerge from the worst of the pandemic, during which time students have been in varying degrees of virtual learning, it will be critical that pediatricians and pediatric clinicians focus on how to address the health impact and developmental gaps that occurred. Unfortunately, disparities that existed prior to the pandemic were exacerbated by the disproportionate impact on learning for children who are Black, Latinx, American Indian/Alaska Native, or living in poverty, and for those who have disabilities.

Without time, funding, and resources to prepare, virtual learning was not equitable despite concerted efforts to reach all students. The “digital divide” or technology gap was quite evident during the pandemic, with 15% of households with school-age children lacking an internet connection at home, according to the Pew Research Center.

 The cost of internet connectivity disproportionately affected those with lower household incomes. The Government Accounting Office estimated in 2019 that nearly half of households with incomes less than $25,000 lacked internet access. Some studies estimate that more than 25 million family households did not have internet access during the pandemic.

 This created challenges for equitable access to learning, especially for families who have multiple children, limited devices, and minimal to no internet access.

In a virtual learning environment, students miss opportunities to engage directly with teachers to receive additional help with classwork or homework. Teachers are less able to identify which students need special education supports or to identify children who need further assessments for behavioral or mental health conditions, such as attention-deficit/hyperactivity disorder, depression, or anxiety. Some students are less able or unable to engage with virtual learning depending on their age, learning styles, abilities, or interest in school.

Many students lost months of learning, and studies show that long breaks from learning result in loss of skills. For example, the Northwest Evaluation Association (now known as the NWEA) demonstrated that in a normal summer break from in-person schooling following third grade, prior to the pandemic, students lose nearly 20% of their gains in reading and 27% of their gains in math.

 This loss of learning was even more prominent in adolescents in middle school. Another study demonstrated that the shift to virtual learning compounded racial disparities in learning and achievement. Data from Fall 2020 showed that White students were behind by 1 to 3 months in math, whereas students of color lost 3 to 5 months.

Mental health and access to mental health care were significantly affected by the pandemic and virtual learning. Among adolescents who received mental health services between 2012 and 2015, 35% received these services exclusively from school settings, according to data from the National Survey on Drug Use and Health.

 More than 1 in 5 (22.1%) of US children have 1 or more mental, emotional, developmental, or behavioral problems.

During the pandemic, more than 25% of high school students reported worsened emotional and cognitive health. Parents with children aged 5 to 12 years were surveyed as well, and 20% reported that their children experienced worsened mental or emotional health.

 Loneliness and isolation resulting from virtual learning, social distancing, and stay-at-home orders all negatively affected mental health and exacerbated conditions for those who already had previous diagnoses of depression and anxiety.

As pediatricians see children and adolescents during the summer months this year, it will be of utmost importance to screen patients for developmental, behavioral, and mental health conditions. Early intervention to avoid further worsening of conditions will be of paramount importance to avoid poor health outcomes over the long term.

The impact of virtual learning was not only felt by children, but by the parents and caregivers as well. An 

 comparing parents of children receiving in-person schooling with parents of remote learners found that parents of children receiving virtual instruction more frequently reported their own emotional distress, difficulty sleeping, loss of work, concern about job stability, childcare challenges, and conflict between working and providing childcare.

Pediatric clinicians should address the family and provide culturally appropriate social and mental health supports and community resources as much as possible.

As schools in most areas of the country return to in-person learning the Fall, it is reasonable to expect that some students will have concerns or anxiety about doing so. Similarly, parents/caregivers who are hesitant to send their children back to school for various reasons will need reassurance. Reacclimatization techniques may be helpful, especially for younger students. Parents and caregivers may want to see if opportunities are available for their child to visit the classroom setting prior to school starting. Although pediatricians are used to giving this type of advice for those just starting school (such as entering preschool or kindergarten), this year it may make sense for older children to experience this as well.

To help start the conversation, some opening questions to ask children and adolescents include:

“What are you looking forward to when school starts?”

“What are you nervous about when school starts?”

Counsel parents and caregivers to try to keep their own anxieties from impacting their child. Children sense the emotions of their parents/caregivers and can react with somatic and behavioral changes. Parental self-care is important; this helps parents be good role models for their child.

Teach parents to normalize their child’s concerns and worries. Telling children and adolescents that it is normal to be nervous about change can help them to understand that they are not alone.

If they have significant anxiety that will impede learning and successful reentry to in-person schooling, consider teaching stress management techniques such as meditation, mindfulness, and cognitive restructuring. If needed, refer them to a licensed mental health provider for therapy, such as cognitive behavioral therapy.

Before school begins, consider restarting daily routines that mimic going to school. Earlier bedtimes and waking routines, preparing and getting dressed in the mornings, eating breakfast, and being ready for a full day may be routines that need to be practiced. Resetting circadian rhythms, by going to bed 15 to 30 minutes earlier each day until the child or adolescent is going to sleep at a normal school-day bedtime, will help make the transition easier.

For families with children with special health care needs, including behavioral and mental health, therapies and treatments may have been missed or delayed to avoid potential exposure to COVID-19. Pediatric clinicians must reinforce how critical it will be to not delay care any longer. Help parents or caregivers understand early childhood brain development and the changing adolescent brain to encourage earlier treatment. Early childhood brain development research makes it clear that early trauma and early exposures change physiology and genetic expression, ultimately changing long-term health outcomes. For the adolescent brain going through the “pruning” process of normal brain development, the experiences of this past year affected this biologic process.

One can only surmise that the events of the pandemic have permanently changed genetic expression and brain development for many, and that we will be dealing with the impact of this year for decades to come. As pediatricians, it will be our job to work intently and rapidly to help children and adolescents receive the care and treatment they need to mitigate the impact, so that we can help our youngest and most vulnerable achieve optimal health care outcomes.

1. American Academy of Pediatrics. COVID-19 guidance for safe schools. Updated March 25, 2021. Accessed June 22, 2021.

https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/

2. Anderson M, Perrin A. Nearly one-in-five teens can’t always finish their homework because of the digital divide. Pew Research Center. October 26, 2018. Accessed June 22, 2021. https://www.pewresearch.org/fact-tank/2018/10/26/nearly-one-in-five-teens-cant-always-finish-their-homework-because-of-the-digital-divide/

3. Off-campus internet connectivity needs of K-12 school students and public library patrons in the United States during COVID-19 pandemic, Funds For Learning, April 23, 2020, 1-16.

4. Kuhfeld M. Summer learning loss: what we know and what we’re learning. NWEA. June 1, 2021. Accessed June 15, 2021. https://www.nwea.org/blog/2018/summer-learning-loss-what-we-know-what-were-learning/

5. Dorn E. COVID-19 and learning loss—disparities grow and students need help. McKinsey & Company. December 8, 2020. Accessed June 25, 2021.

 https://www.mckinsey.com/industries/public-and-social-sector/our-insights/covid-19-and-learning-loss-disparities-grow-and-students-need-help#

6. Ali MM, West K, Teich JL, Lynch S, Mutter R, Dubenitz J. Utilization of mental health services in educational setting by adolescents in the United States. 

. 2019;89(5):393-401. doi:10.1111/josh.12753

7. The National Survey of Children’s Health. Data Resource Center for Child & Adolescent Health. Accessed June 25, 2021. 

https://www.childhealthdata.org/learn-about-the-nsch/NSCH

8. Panchal N, Kamal R, Cox C, Garfield R, Chidambaram P. Mental health and substance use considerations among children during the COVID-19 pandemic. Kaiser Family Foundation. May 26, 2021. Accessed June 25, 2021. 

https://www.kff.org/coronavirus-covid-19/issue-brief/mental-health-and-substance-use-considerations-among-children-during-the-covid-19-pandemic/

9. The state of mental health in America. 2020 Statistics. Mental Health America. Acessed June 25, 2021. 

https://mhanational.org/issues/2020/mental-health-america-all-data

10. Verlenden JV, Pampati S, Rasberry CN, et al. Association of children’s mode of school instruction with child and parent experiences and well-being during the COVID-19 pandemic — COVID Experiences Survey, United States, October 8-November 13, 2020. 

2021;70(11):369-376. doi:10.15585/mmwr.mm7011a1

Articles

With the impending return to in-person learning, it is time to address the challenges and limitations children and families faced with virtual learning over the past several months.

Sandy L. Chung, MD, FAAP, FACHE

Articles

The challenge of virtual learning