Kids Languish Amid School Closures, but No Clear Solution to Reopening

When Mercedes Muñoz, a special education teacher at Franklin High School in Portland, Oregon, scrambled to switch to distance learning in the spring semester, the primary response from her students was "absolute despair."

Her students, many of whom have learning disabilities and health impairments, didn't like being on camera and struggled to focus using the virtual learning model -- and that was among the few who ever signed on. Four-fifths of her class never participated at all.

With the relatively low rate at which children have been infected with COVID-19, pediatricians and educators are balancing the mental health burden of social isolation and the developmental delays resulting from school closures with the public health risks of reopening them in the fall.

"In all honesty, there is nothing more that I would like than to be back in our classrooms," Muñoz told MedPage Today. "Our teaching practices are intimate and students look for that and rely on that sense of consistency and routine."

Fewer than 1% of COVID-19 cases involve children and pediatric cases tend to be relatively mild, with a mortality rate of less than 1%. Although troubling and serious cases of a Kawasaki disease-like illness have been increasingly documented in kids, some physicians say the risks cited by infectious disease specialists to close schools were overblown, with the closures' impact on child development and well being given short shrift.

Cognitively, younger children cannot meaningfully engage with distance learning and are completely missing the social and emotional development they would be experiencing in the classroom, said Dimitri A. Christakis MD, MPH, of Seattle Children's Hospital, and editor-in-chief of JAMA Pediatrics.

"Teachers can tell when a child is not engaged or is struggling with something," Christakis told MedPage Today. "You can't really do that over Zoom."

A Widening Gap?

For older children and adolescents, stay-at-home measures deprive them of social connectedness and interrupt a development period in which they learn to identify themselves outside of the family structure, said Susan Kressly, MD, a pediatrician in Warrington, Pennsylvania, about 20 miles north of Philadelphia.

"Adolescence is supposed to be the time where children are going through a process of finding their identity and autonomy," Kressly told MedPage Today. "We are delaying what should be a healthy, natural process if we don't figure out how to let them continue that process in a safe way."

A student from an economically advantaged family, whose parents were able to home-school them, will be more likely to return to school in the fall ready for the next grade compared to others: students with learning disabilities or from lower income households, or whose parents are essential frontline workers. All of these are linked to poorer learning outcomes, said Robert Sege, MD, of Tufts Medical Center in Boston.

Children with special needs, who require constant attention from parents to learn, may also disproportionately suffer from distance learning, Sege added.

"We're worried that the existing education gap will be made even worse," Sege told MedPage Today.

Muñoz has many students who are economically disadvantaged, without internet access, who she was unable to reach for the entire semester. The Oregon Department of Education recommended focusing curriculum on well-being and review initially.

"It became, 'don't introduce any new content,' and 'everything should be review,' but the kids who most needed the review are not the ones showing up," Muñoz said.

She and colleagues switched to doing mental health check ins and wellness exercises.

Families from varying income levels struggled with access. Some children whose parents had been involved early on also stopped attending class because of issues with distance learning, Muñoz added.

"What I heard from parents was: 'This is overwhelming,'" Muñoz said. "It's too much to manage along with their own depression, worrying about their own job insecurity, or feeling inadequately trained for the subject matter."

Adverse childhood experiences, including family violence, trauma, and mental illness, are expected to increase during stay-at-home measures and worsen along with economic turmoil, according to a study published Wednesday in CMAJ.

In a viewpoint published in JAMA Pediatrics, Christakis said up to a full year of learning could be lost in the fall, exacerbated further if in-person schooling doesn't resume.

Pediatricians have shared anecdotal evidence of the mental health problems youth are facing amid the pandemic. A recent review of pre-pandemic research confirmed that isolation can lead to depression and loneliness among young people; and a study conducted in Wuhan, China, a couple of weeks into the outbreak there, found 40% of adolescents surveyed were experiencing psychological problems, including elevated rates of post-traumatic stress disorder.

At Kressly's clinic, she administers the nine-item Patient Health Questionnaire (PHQ-9) to teens through telemedicine and well visits, and the proportion of her patients with anxiety and depression symptoms is significantly higher than it was pre-pandemic, she said.

"We can't just go back to school and expect this adverse life experience won't have lingering effects that will affect kids differently," Kressly said. "We haven't spent the money to embed enough guidance counselors and social workers in our education system to just send them back there without the appropriate support."

The New Normal

Not everyone agrees, however, that school closures will necessarily cause lasting damage to childrens' education or psyches.

"We need to be creative and not just throw up our hands and say, 'this whole generation is just going to be a mess,'" Cora Collette Breuner, MD, MPH, of Seattle Children's Hospital, told MedPage Today. For example, she noted that some children, who were bullied in regular school or suffer social anxiety, appear to thrive with distance learning.

That aside, though, Breuner said teachers and families alike -- especially those with autoimmune conditions or those living with grandparents -- may be hesitant to attend in-person schooling even if districts are able to open their doors again in the fall.

Muñoz said she expects her school to continue with distance learning, because her students' safety, as well as that of staff (she herself is immunocompromised), is paramount.

In many locations, however, parental pressure to reopen is overwhelming.

Upper Perkiomen school district near Philadelphia, which includes about 3,300 K-12 students, surveyed parents at the end of the spring term. Andrea J. Farina, EdD, assistant superintendent, said 75% indicated they preferred in-person schooling.

"Those are our stakeholders who we want to serve, but we have this competing medical guidance," Farina told MedPage Today. "Outside of learning, safety is the other priority we have, but schools just don't have the financial resources to meet the expectation of the CDC guidelines."

On May 16, the CDC released a report to help guide school districts in reopening for the fall, with a three-tiered approach for varying degrees of community spread. For schools in areas of mild to moderate risk, they recommend keeping desks 6 feet apart, staggering arrival and dismissal times, and canceling assemblies and other large gatherings. If there is substantial community spread, they recommend dismissing schools for 2-week periods while continuing to implement distance learning.

Regardless of community risk, the CDC recommends face coverings, increased routine cleaning, and offering distance learning to children and staff who are at an increased risk of infection.

Farina said her district has the capacity to adhere to social distancing requirements in classrooms, but transportation and sanitation are two "huge financial hurdles" to overcome. For example, the maximum capacity of a standard school bus is 72 passengers, but with social distancing requirements, just 12 children would fit. Simple arithmetic suggests her district needs six times as many buses to stay within the guidelines.

"It's money our district doesn't have in any way, shape, or form," Farina said. "We say this tongue in cheek that we could pull it off in schools with shields, masks, and sanitation between classes, but we may not be able to get the kids here."

In another JAMA Pediatrics viewpoint, Italian pediatricians Susanna Esposito, MD, and Nicola Principi, MD, proposed only allowing children who tested positive for SARS-CoV-2 antibodies to physically attend schools, but without widespread, reliable testing, this approach seems unlikely.

On the other hand, the rate at which children are transmitting the virus in crowded spaces remains unclear, since school closures were implemented so early in the pandemic, and most other venues where kids would congregate were closed as well.

There were exceptions, however.

NPR reported Wednesday that child care centers operated by the YMCA and New York City government during the pandemic had no outbreaks to speak of. No more than one case was seen in any single YMCA location, among the 40,000 children in its system, the organization told NPR. Both the Y and New York City implemented CDC guidelines.

In South Korea, meanwhile, where schools reopened in late May, children were separated by plastic dividers in cafeterias and classrooms, wore masks, and lined up 6 feet apart to receive temperature checks. But clusters of the virus quickly broke out after school reopenings, leading the government to close them again.

Sege said he wouldn't be surprised if some school districts opened and closed many times throughout the next academic year, fluctuating with waves of the virus.

"Even if schools open, it's not going to be how it was," Sege said. "Pediatricians and parents need to help kids process what is going on and how they can accomplish the same things."

Christakis formed a task force with pediatricians, educators, and infectious disease experts to review evidence on the pros and cons of school closures and make recommendations for states to reopen schools in the fall. They plan to publish guidelines in July, he said.

Kressly emphasized the importance of pediatricians and teachers working together to build resilience in children over the summer, before schools resume in the fall.

"We need to start inviting ourselves to the table and bringing our folding chairs if we have to," Kressly said. "We understand the normal process of adolescent child development, and explaining it to those who may not have that framework ... is part of what we do when we advocate for kids, whether it's one patient at a time or collectively in our community."

Comment