Reflections on COVID: AAP’s Commitment to Children and Families

From the beginning of the pandemic, children and their families were faced with a series of unprecedented challenges. The shift to virtual schools exacerbated learning gaps, while quarantines and stay-at-home orders amplified mental health challenges and stress at home. Children with medical conditions struggled to access in-person care; families who relied on free and reduced-cost meals struggled to access food; and many youths with special health care needs lost access to academic support, mental health services, and physical, occupational and speech therapy. 

Throughout the pandemic, AAP members were resolute in speaking up for children, be it within their clinic walls, at socially distanced community town halls or in front of a computer screen talking with congressional staff.

“While our members faced unprecedented challenges of their own, both professional and personal, they continued showing up and finding new ways to make a difference for their patients,” said Moira A. Szilagyi, MD, Ph.D, FAAP, and 2022 president of the AAP. “In the face of the ongoing pandemic, the Academy was able to make tangible progress for child health that cannot be overlooked.”

Tracking Cases

From the beginning of the pandemic, several organizations gathered and reported data on COVID-19 cases, hospitalizations and deaths. But information was not provided by age group, and data on pediatric cases was scant. 

“As the American Academy of Pediatrics, we are singularly focused on the health and well-being of children and families. And to do that, we needed good information,” said Lee Savio Beers, MD, FAAP, and 2021 president of AAP. “Leaders across the country began to look at this and they said there's no place we can go to see what the impact is specifically on children.

In April 2020, the AAP Research team collaborated with the Children’s Hospital Association to begin collecting, analyzing and sharing all publicly available data from states on child COVID-19 cases, hospitalizations and deaths. Reports were posted to the AAP website each week throughout the pandemic.

“Initially we sort of thought, this is going to be good for us internally and it'll help us with our decision making because we want to make sure we're making the best decisions we can with the most up-to-date information that we have,” Dr. Beers said. “Very quickly, it became clear that we were really the only ones doing this… That data became a very trusted source of information.”

Nearly 15.6 million children were reported to have tested positive for COVID-19 over the course of the pandemic, according to available state reports. In that time, the highest number of child cases reported in a week was more than 1.1 million for the week ending January 20, 2022. Over the three years where AAP tracked cases, between April 2020 and June 2022, children represented 17.9% of total cases.

Schools Move Online, With Alarming Results

As the pandemic intensified in spring 2020, the majority of American schools transitioned to distance education models. According to the National Center for Education Statistics, 77 percent of public schools moved to online distance learning during this period. The abrupt shift to online classes had devastating ramifications. 

“What we know about children is they need routines. Routines are reassuring. Routines make them feel safe. They also need stable relationships and lots of normalizing activities for healthy development. And so much of that went away,” Dr. Szilagyi said. 

Online classes erased learning gains, particularly for younger students. Meanwhile, uneven access to technology and broadband internet  widened learning gaps for poor children and children of color. 

One parent said: "The only real challenge was that remote learning was hard to keep up with, and the lack of motivation and exercise made it difficult for my daughter. She and I both developed a vitamin D deficiency from staying inside, and she kept falling asleep over her laptop."

Families and caregivers of youth with special health care needs experienced persistent challenges, reporting high rates of disruption in child care, health care and employment, as well as loss of technological and therapeutic supports. 

“Teenage angst was already prevalent in my house. COVID-19 made that worse. School became remote, and my child's desire to learn became almost non-existent.”

— Parent surveyed in March 2021

In June 2020, AAP urged school districts to mitigate, not eliminate, the risk of COVID-19 in schools and prioritize the return of in-person instruction. 

“One of the most critical lessons of the COVID-19 pandemic is the importance of in-person school. Remote learning exacerbated existing educational inequities, was detrimental to educational attainment, and drastically worsened the growing mental health crisis among children and adolescents,” AAP’s guidance said.

Over the course of the pandemic, AAP was committed to advocating for:

• Using science to make local and state decisions to protect communities from COVID-19
• Combating disinformation and misinformation 
• Prioritizing in-person learning by continuing support for schools to implement recommended health and safety measures
• Creating policies that put the well-being of children and adolescents first, including children and youth who are immunocompromised or have a disability.

Masks: Protective Yet Controversial

Masks are a powerful tool to help prevent the spread of infectious disease, and with COVID-19 it’s no different. The AAP recommends that people 2 years of age and older in areas of the country with high transmission of COVID-19 wear masks. 

Mask wearing and testing programs were key parts of the AAP’s strategy to get children back to in-person school.

But public resistance to masks grew over the course of 2021, with some accusing physicians who promoted their use of taking bribes from mask manufacturers or pharmaceutical companies.

“I don’t believe public health should ever be political,” said Tracie Newman, MD, FAAP, and a pediatrician in Fargo, N.D., who served on her local school board. “But it seemed like masks got singled out as this ‘overreach’ of our authority.”

Mental Health Emergency Is Declared

Over the course of the pandemic, as people’s sense of safety and stability was upended, pediatricians witnessed soaring rates of mental health challenges among children, adolescents and their families.

The disruptions caused by the pandemic combined with adverse conditions for many families exacerbated difficulties that had existed before the pandemic. Rates of childhood mental health concerns and suicide rose steadily between 2010 and 2020, and by 2018 suicide was the second leading cause of death for youth ages 10-24. The pandemic worsened this crisis: Across the country, emergency room visits for mental health emergencies and suspected suicide attempts increased dramatically for children and teenagers.

“It became very clear to us that this was a concern that was escalating and that pediatricians and their families and communities did not have the resources to deal with it,” Dr. Beers said, noting that she heard from some doctors who were treating more mental health cases than ear infections. 

A Centers for Disease Control and Prevention survey in the first half of 2021 found that during the pandemic, more than half of teenagers experienced emotional abuse, 44% felt persistent sadness/hopelessness and 20% seriously considered attempting suicide. Females, students of color and lesbian, gay or bisexual students tended to fare the worst. In addition, in the first two years of the pandemic, more than 200,000 American children lost a parent or caregiver to COVID-19. 

In October 2021, the AAP, American Academy of Child and Adolescent Psychiatry and Children’s Hospital Association declared a national emergency in children’s mental health, citing the serious toll of the COVID-19 pandemic on top of existing challenges.

“Many children lost family members or people close to them. It was just the sort of fear of not knowing what was going to happen next.”

— Dr. Lee Beers. 2021 president of the American Academy of Pediatrics and a professor of pediatrics at Children's National Hospital in Washington, D.C.

On the heels of the declaration, the U.S. surgeon general issued an advisory highlighting the need for immediate action. And as a result of AAP advocacy, the American Rescue Plan included funding for the Pediatric Mental Health Care Access Program, which increases access to mental health services for children and adolescents. This funding helped expand the program from 21 to 45 jurisdictions. AAP also advocated for the reauthorization of the program in 2022.

Impact on Families: The Positive and Negative

The pandemic brought families together in new ways. For some, increased time together at home brought families closer. For others, it exacerbated stress caused by financial worries, interpersonal violence and food and housing insecurity.

“When kids don't have hope, when adults don't have hope, it changes their emotional well-being."

- Dr. Moira A. Szilagyi, 2022 AAP president and a general pediatrician at UCLA.

The vast majority of families surveyed by the AAP (80%) reported major disruptions in their children’s lives.Nearly half of respondents (47%) said that helping their children with learning had been stressful or caused household tension. But despite the stress, 60% of families reported they grew closer.

“Having more time with my son. My days off and lost hours have given me more time with him and allows me to help him with homework through the day so we can play after he's done,” said one parent.

“That time taken from the work commute allows for more time with the kids, cooking meals and helping around the house," said another.

"The only challenge we had was being in the house all the time together and not getting a break from each other," another parent said.

About half of parents and caregivers surveyed by AAP reported a change in their employment status to provide care. Among parents who reduced their work hours, the highest proportion had a child who was 5-to-9 years of age, followed by parents whose children were 10-to-14 years old, which may indicate that parents and caregivers felt they had to leave work to help their children with remote schooling.

"Being able to focus on my child and not have to split my time between a job has been really nice. With financial and emotional support from my spouse, I was able to quit my job and focus on just child and housework, rather than being pulled in three different directions," one parent said.

The Story So Far: Pandemic Reflections & Lessons