The COVID-19 pandemic has led to the nationwide closure of schools and universities in more than 190 countries, impacting 1.57 billion students.
These closures greatly affect students, teachers, and families—especially as education systems face an uncertain future. With this uncertainty comes additional concerns, such as school closures’ influence on the economy and society, especially as talks to reopen businesses around the world begin.
Is it possible to safely send kids—and the adults who work there—back to school in the midst of a pandemic?
A comprehensive school reopening strategy will need to include social distancing, increased personal protective equipment (PPE), and expanded testing and contact tracing. But alone, these measures are not enough. There’s no doubt that the current pandemic and measures taken to reduce the spread of disease will have a profound economic, societal, and psychological impact on many—and children will not be excluded from those effects. When schools reopen, we must ensure that the physical, mental, and emotional health of children is our top priority.
In pediatric clinical research, we focus on the needs of the child first and foremost. By incorporating strategies employed in pediatric trials such as counselling, assent, and age-appropriate resources into school reopening plans, we can better support our students as they transition back to school.
COVID-19 in Children
There’s still a lot we don’t know about the effects of COVID-19 on pediatric populations. Early data suggest that the virus does not affect pediatric populations as severely as it does adults. However, children are not immune to the virus and serious COVID-19 illness resulting in hospitalization still occurs in this age group. Just as in adults, children with underlying conditions such as chronic lung disease, cardiovascular disease, and immunosuppression have an increased risk for more significant illness, as do infants.
Pediatric populations are often neglected when studying diseases and treatments. Many drugs given to children have never actually been studied in pediatric populations. It’s not surprising that, out of 275 COVID-19 interventional clinical trials, only 30 were open for patients under the age of 18.
Kids are not small adults. We’re already seeing differences in the way COVID-19 impacts children versus adults, and more research is needed to understand why these discrepancies exist.
“COVID toes” is one such symptom that, although observed in both children and adults, seems to occur more frequently in pediatric populations. A red, blue, or purple discoloration of the toes or fingers—similar in appearance to frostbite—could be an indication of a COVID-19 infection. These lesions may hurt or feel warm to the touch and might be accompanied by other COVID-19 symptoms, including runny nose, cough, fever, vomiting, or diarrhea. While “COVID toes” seem to resolve on their own, children presenting with this symptom should be tested and self-isolate to ensure they don’t spread the disease to others.
A rare but potentially severe syndrome in children related to COVID-19 was recently reported by the UK and the New York City Health department, now known as “Pediatric Multi-System Inflammatory Syndrome Potentially Associated with COVID-19.” This emerging syndrome is very similar to Kawasaki disease, a rare inflammatory illness often affecting children younger than 5 years old. It’s marked by persistent fever, inflammation, and poor function in one or more organs. More information is still needed to understand how and why this COVID-associated illness is impacting children.
Impact of School Closures
In an attempt to slow the spread of COVID-19, many countries enacted preventative measures including social distancing, self-isolation, and widespread school closures. China, where the first-known cases of the novel coronavirus were discovered, was the first to close schools at the end of January but other countries subsequently followed. By the end of March, nearly 90% of students around the world were out of school.
This is not the first time widespread school closures were prompted due to infectious disease outbreaks. Past outbreaks have proven that when implemented early, closures tend to be more effective. However, there is always the risk of increased infection rates when schools close too late in an outbreak or reopen too soon.
While many school-aged children may not be at dire risk, closing schools helps protect the adults who work there, as well as students’ vulnerable family members at home. Like with many infectious diseases, children could play a major role in community-based transmission, especially those that are asymptomatic. Some evidence does suggest that kids are less likely to catch or spread COVID-19, but more research is needed to truly determine the validity of this claim.
While school closures can be effective in slowing the spread of disease, wide-spread consequences also exist. For many parents, schools provide both education and childcare. School closures have forced some parents to work from home—or stop working entirely—to stay home and care for their children. This alone can lead to economic hardships for families.
“Even though my children are older, working from home with them remains a challenge in this unsettling and prolonged time,” Jacqui Whiteway of the Center for Pediatric Clinical Development shares. “I have to ensure my family stays on track with online schooling, Zoom music lessons, and their mental health all while making sure I don’t fall behind on my work.” Whiteway acknowledges there have been some positives to quarantining—for instance, more homecooked meals eaten together as a family have actually helped her son’s nutrition improve—but she does worry about the mental health impact extended isolation will have on children and adolescents, especially as time goes on.
Essential workers may not have the option to stay home at all. These families may rely on more vulnerable family members like grandparents to care for their children while they’re at work. Many healthcare workers are making adjustments at home to better protect their families, often self-isolating themselves from their children and loved ones so as not to potentially spread the disease. All of these measures can take a significant toll on the health and wellbeing of children and their families.
School closures have also shed light on issues such as food insecurity, homelessness, domestic violence, and even the internet. As is not uncommon, the impacts of these closures are often felt most severely by particularly vulnerable children. While social distancing strategies can be effective in slowing the spread of disease, they can also be especially dangerous for women and children with violent partners or guardians. Throughout this crisis, reports of domestic violence have already increased around the world. Additionally, students who rely on free school meals could go hungry. Those without internet access or the technology needed to complete assignments will likely fall behind on their learning. For all students, the loss of structure and socialization can be psychologically harmful.
What Will it Take to Reopen Schools?
School closures undoubtedly take a huge toll on society. The longer schools stay closed, the more significant consequences we may face. However, we can’t simply return to normal. Until a vaccine is approved—and distributed widely—school systems will need to take drastic measures to ensure the safety of students and faculty before they can open their doors and welcome anyone back in.
As we await a vaccine, schools must enforce social distancing, good hygienic practices, and use of PPE. For younger students especially, these new restrictions will be challenging. Masks alone present a variety of issues. They’re uncomfortable and distracting. Teachers will likely have trouble enforcing students to wear them properly. Additionally, masks will make communication and certain classes more difficult—for instance, students will no longer be able to watch how their language teacher forms an unfamiliar word with their mouth.
Masks could also present security threats. Katherine Waller, an English teacher at Panther Creek High School in Cary, North Carolina explains, “Teachers and school personnel are taught to look for people who don’t belong. Mandatory masks would make it more challenging for school staff to identify individuals, complicating school security.”
The enforcement of social distancing poses a significant challenge. Schools are inherently social places. Students gather in groups to collaborate on class projects, joke with one another at lunchtime, and play games at recess. Schools will need to figure out how to help children understand the importance of new social distancing rules and ensure compliance with these restrictions. Schools can spread out desks to maximize social distancing, stagger start times, and potentially decrease class sizes, but these measures could create even bigger challenges related to space, resources, and staff needed to teach newly-created classes, especially for schools already operating with large class sizes up to 35 students. For schools with limited indoor and outdoor space, managing social aspects like recess and lunchtime will be even harder.
When students return to school, we cannot rule out the potentially severe psychological impact of time spent in quarantine. Many students will be returning from what may have been an isolating or traumatic period for them to a school structure that looks very different. Many traditions that students and staff alike look forward to—sporting events, assemblies, school dances—will likely remain canceled. These activities provide students the opportunity to be active, bond with classmates, and gain new skills and confidence. Without them, many students’ mental and emotional health could be impacted. Not only will schools need to pick up academics where they left off, they’ll also need to address the mental state of returning students. When planning pediatric trials, we provide patients and their family members access to therapy and mental health tools that can support them throughout the trial process, which is often a new and uncertain experience for participants. As we look to reopen schools, a similar strategy that incorporates counselling or teletherapy may help students and their families as they prepare to go back to school.
It’s also important to note that many children are already missing routine vaccinations due to COVID-19. Some parents and healthcare providers are delaying what is considered “non-priority” care during the pandemic so as not to put otherwise healthy patients at risk. Unfortunately, missing these routine vaccinations now could lead to greater public health problems later—especially as children return to school. Not only will school systems need to be alert to potential cases of COVID-19, they’ll also need to monitor for outbreaks of other otherwise preventable diseases like measles.
As we continue to discuss how to reopen schools, we must take into account the perspectives of children in our planning. How do kids feel about being quarantined at home, away from their friends? Are they worried about going back to school? How has the pandemic affected them directly? A lot of attention has been placed on the economic impacts of school closures, but it’s equally important to remember that the decisions we make will greatly affect children.
In pediatric studies, assent is a critical component of the enrollment process. While children are unable to give informed consent until they reach the age of consent (which varies by country but is often around 18 years old), the assent process allows them to agree or not agree to participate in a trial. During this process, we must clearly explain to the child what will happen throughout a study, as well as what they are expected to do, in terms they can understand. By asking a child for assent, we’re respecting their autonomy and we can also ensure they feel comfortable participating.
Perhaps this and many of the lessons and strategies applied in pediatric clinical trials can be adopted here. What will students and their parents need to feel safe returning to school, especially parents of immunocompromised or at-risk children—and what rights will these families have if their needs aren’t met? This pandemic will undoubtedly leave a mark on children, both mentally and physically. We suggest welcoming their thoughts and opinions into the reopening process for schools and society as a whole.
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