Understanding and attenuating pandemic-related disruptions: a plan to reduce inequalities in child development

The Secretary General of the United Nations described the impact of COVID-19-related school closures as a “generational catastrophe.” What will be the legacy of the 2020–2021 pandemic-related disruptions in 5, 10, 20 years from now, as regards education and well-being of children and youth? Addressing the disproportionate impact on those growing up in socio-economically disadvantaged areas or on those with pre-existing learning challenges is key to sustainable recovery. This commentary builds on the four literature reviews presented in this Special Section on a Pandemic Recovery Plan for Children and proposes strategies to understand and attenuate the impact of pandemic-related lockdown measures. Importantly, we need a monitoring strategy to assess indicators of child development in three areas of functioning: education and learning, health, and well-being (or mental health). Surveillance needs to begin in the critical prenatal period (with prenatal care to expectant parents), and extend to the end of formal high school/college education. Based on child development indicators, a stepped strategy for intervention, ranging from all-encompassing population-based health and education promotion initiatives to targeted prevention programs and targeted remedial/therapeutic interventions, can be offered. As proposed in the UN plan for recovery, ensuring healthy present and future generations involves a concerted and intensive intersectoral effort from the education, health, psychosocial services, and scientific communities.


Keywords Children · Education · COVID-19 · Mental health · Prevention · Evaluation
Mots-clés Enfants · éducation · COVID-19 · santé mentale · prévention · évaluation The Secretary General of the United Nations described the impact of COVID-19-related school closures as a "generational catastrophe" (United Nations, 2021a). What will be the legacy of the 2020-2021 pandemic in 5, 10, 20 years from now, as regards education and well-being? Will children, teens, and young people recuperate quickly, without specific intervention? Or will they suffer long-term consequences, requiring intensive support? Will societal expectations be reduced, such that the negative impact on education will not be strikingly evident? This Special Section on a Pandemic Recovery Plan for Children presents four review papers on the consequences of the pandemic for children in terms of education (learning loss), healthy lifestyles, mental health and well-being, and the potential of early preventive strategies. Based on these reviews, this commentary summarizes the area of concerns for children and youth, and proposes a monitoring system to understand the short-and long-term impacts, as well as a series of interventions to improve the health and education in the general population and to catch those with delays.
As outlined in the four reviews in this special section, surveillance of child development in terms of education and well-being will be key throughout the 2020s and 2030s. Newly minted international data tend to confirm what many expected-a disproportionate impact on certain populations depending on specific vulnerabilities and areas of concern. The size of the impact is likely to vary according to the intensity of the pandemic in any given geographical region. We need to fill in key data gaps before we can grasp the full magnitude of the effect. With the literature reviews presented, this special section summarizes childhood developmental dimensions on which to focus recovery efforts and outlines four levels of intervention to attenuate the impact of the pandemic, ranging from universal health and education promotion to specific therapeutic intervention.

Defining priorities: who and what should be the focus of recovery efforts
Virtually all children and adolescents have experienced major disruptions in schooling and in social and physical activities and all ecological spheres of human functioning have been affected. From the reviews emerges a nuanced picture of the impact of pandemic-related disruptions on learning losses, mental health/well-being, and healthy lifestyles.

Concern 1: Learning loss
For children and youth, the COVID-19 pandemic has not, thus far, presented major concerns in terms of physical health. But the loss of time in a structured learning environment is particularly concerning for children at risk because of disadvantaged socio-economic status or special needs. Children in families with low education level are least likely to receive support from family or private services.
As of March 29, 2021, schools in Canada had closed for 40 weeks (13 weeks full-time and 27 weeks part-time for high school students); furthermore, there were regular class closures due to outbreaks (Gallagher-Mackay et al., 2021). Online teaching was deployed unevenly and engaged less than 50% of students, as compared with 80% in class (Naitre et Grandir, 2021). Haeck and Larose (2021) expect significant learning losses in all children, with a performance gap between children with and without academic problems increasing by 30%. The few goodquality studies indeed highlight a decrease in school grades ranging from 2 to 6 percentiles for all children and from 4.5 to 17 percentiles for children from families where parents have a low level of education or among those attending schools from disadvantaged backgrounds (Lewis et al., 2021;Engzell et al., 2021).
Importantly, preliminary evidence suggests that graduation standards have been adjusted to match general levels of population performance. For example, high school graduation rates in various countries were no different or even higher in 2020 than in previous years (UNESCO et al., 2020). In addition, school curricula have been adjusted to focus on essential learning. Thus, the consequences of the pandemic may not be felt unless standardized tests compare the state of learning pre-and post-pandemic. These assessments will help monitor the medium-term effects of school disruptions as well as progress in remediation, particularly as concerns the most vulnerable students.

Concern 2: Mental health and well-being
The second area of concern is mental health and well-being. Here again, the impact of the pandemic is not uniform. A meta-analysis of 136 studies conducted during the first year of the pandemic (between March 2020 and February 2021) suggests that rates of clinically elevated depression and anxiety among youth (<18 years) have doubled compared to prepandemic levels. One in 4 youth globally are experiencing depression symptoms, while 1 in 5 youth are experiencing anxiety symptoms. These estimates, which increased over time, are higher for older children and for girls (Racine et al., 2021). Of note, the population most at risk may not necessarily be the one with the most severe mental health problems prior to the pandemic (Watkins-Martin et al., 2021). For instance, 48% of parents report de novo mental health challenges in their children (Inspiring Healthy Futures, 2021).
Similarly, patterns of substance use are not increasingly worse across the board, but rather depend on the type and pattern of use. Specifically, there are indications of decreases in binge drinking among young adults (Pocuca et al., under review). This probably relates to the lack of social opportunity for consuming alcohol, due to pandemic lockdowns. Data on suicide also vary, depending on a number of parameters such as type and source of data. Chadi et al. (2021) in this special section note an increase in suicide attempts (according to hospital data), but no increase in rates of death by suicide. Thus, research is needed to put together the pieces and understand who is impacted and, most importantly, to document the putative lasting effects of pandemicrelated disruptions in services and daily activities on mental health.

Concern 3: Healthy lifestyle
Educational settings provide norms and rhythms essential to regulating social interactions and healthy behaviours such as eating and physical activity, during both school and extracurricular activities. As pointed out by Gauvin et al. (2021) in this section, pandemic-related school disruptions have led to marked reductions in physical activity, accompanied by increased sedentary behaviour and screen time, and increased food intake and unhealthy snacking. Deleterious effects in physical activity appear to be more pronounced in socio-economically vulnerable groups, particularly in urban areas (Gauvin et al., 2021). It is therefore not surprising that a recent American study (n = 191,509) reports that children 5-15 years of age gained on average 2.3 kg more than they did during a pre-pandemic comparison period, and that rates of obesity increased by 8.7% (Woolford et al., 2021).
There has been a strong global trend for increased screen time since the pandemic began (Sultana et al., 2021), in part because some or most schoolwork was remote and required online access. However, the concern with the use of electronic devices is not as much related to schoolwork as it is with leisure activities. Digital literacy should be among our top educational priorities (OECD, 2021). Digital literacy refers to individual interest, attitude, and ability in the use of digital technology and communication tools in order to appropriately access, manage, integrate, analyze, and evaluate information, construct new knowledge, and create and communicate with others (Government of British Columbia, 2021). In children, digital literacy should be part of educational curricula (OECD, 2021), while the use of electronic devices for play should be structured and supervised by adults.

A unified monitoring strategy
As stated in the plan for post-pandemic recovery proposed by the UN, investment in data systems and infrastructures is going to be the linchpin in recovery efforts (United Nations, 2020). All authors of the review articles in this special section underscore the importance of research efforts to distinguish transient from persistent effects of the pandemic.
Deliberate and concerted efforts need to be deployed in order to overcome two important data gaps and challenges: (1) the lack of intersectoral data; and (2) the lack of longitudinal data. First, the necessary data are collected and stored in different database systems (research data; administrative databases in education, health, social services) by different parties (researchers and distinct ministries). The first challenge is encountered when a researcher testing a tutoring program for improvements in academic achievement and reduction of psychostimulant medications needs data from educational and medical sources, which are not matched. The second challenge (longitudinal data) arises whenever attempting to map the care or education trajectory of a child across developmental periods. For instance, to understand whether a change in early child care and education policy (i.e., daycare services) is related to better school readiness, higher graduation rates, and lower use of psychosocial services, one needs to access data on child care use in the first 5 years as well as health, education, and administrative data during the elementary school years. A monitoring system allowing to track indicators of learning and well-being longitudinally is needed.
In most territories/provinces, the lack of a unified longitudinal monitoring system is an important obstacle to the implementation of early preventive or therapeutic services. A notable exception is the Manitoba Population Research Data Repository (University of Manitoba, 2020). The Research Data Repository is a comprehensive collection of administrative, registry, survey, and other data primarily relating to residents of Manitoba. It was developed to describe and explain patterns of health care and profiles of health and illness, facilitating interdisciplinary research in areas such as health care, education, social services, and justice. A unique identifier-the Personal Health Identification Number (PHIN)-facilitates linkages from birth to old age across all government service and data sources.
In line with the Manitoba model, a first step forward would be to facilitate linkages between key indicators via the use of a unique identifier. Data collected during pregnancy, at age 1½-2 years (vaccination), at school entry (age 6 years), at the end of elementary school, and at the end of high school could be matched in a secure space. The repository should rely on (a) routinely collected indicators (e.g., birth records, standardized academic tests in elementary school, government high school leaving exams); and (b) brief assessments of normative development in three spheres (physical, cognitive/academic, socio-emotional).

A stepped intervention strategy
As presented in Tremblay's paper (Tremblay, 2021), much can be done in terms of preventive intervention from conception onwards. Many are the lost opportunities for gentle, non-invasive, non-stigmatizing services that could modify developmental trajectories in high-risk children. The availability of reliable data on indicators of children's learning losses, well-being, and health is the critical first step in implementing interventions tailored to the needs of distinct groups.
The data needed to monitor indicators of learning and well-being are shown in Fig. 1. With this information, community-level intervention can be envisioned. A stepped intervention approach proposes that the most effective yet least resource-intensive intervention is delivered first, only "stepping up" to more intensive and targeted intervention as required. The rectangles at the bottom, from outer to inner, represent Level 1 interventions (universal), Level 2 interventions (preventive for individuals with personal risks and health promotive for individuals with social risks), and Level 3 interventions (therapeutic/specialized care).
We revisited the concept of graded interventions with the objective of mitigating the impact of the pandemic on child development. The four levels of intervention shown in Table 1 present a gradient in the intensity of the intervention and the size of the population targeted: from universal where the entire population is exposed (e.g., childcare services), to targeted groups, to individuals in need.

Level 1: Universal health promotion interventions
The first level of intervention applies to the entire population of families in a given territory, regardless of environmental or individual risk factors. Examples include access to high-quality child care and education services prior to school entry for every child, promotion of digital literacy

Levels 2 and 3: Targeted preventive intervention: environmental and individual risk
The second level of intervention concerns environmental risks, such as living in a socio-economically deprived neighbourhood. The third applies to personal risk factors, such as learning or socio-emotional challenges. These two risk levels may at times overlap, but not always. For instance, most socio-economically disadvantaged children do well, and children with developmental issues are not necessarily from socio-economically disadvantaged families. However, the odds of mental/physical and/or academic challenges are higher in disadvantaged populations as compared with non-disadvantaged (Laurin et al., 2015;Orri et al., 2019).
Interventions should include health promotion programs to empower individuals exposed to risks and boost the quality of an otherwise deprived environment, while preventive action works to further develop personal skills. Tutoring programs have shown high efficacy in addressing learning loss and are being implemented across the world. Evidence from populations most affected by school disruptions suggests that tutoring be offered to children/ teens in socio-economically disadvantaged environments (Level 2) or to children/teens with prior learning difficulties (Level 3). However, simply implementing a tutoring program is insufficient. Meta-analyses and systematic reviews have identified various conditions for significant results (Cheung et al., 2021;Gersten et al., 2020;Pellegrini et al., 2021). As pointed out by Haeck and Larose (2021), tutoring by teachers and education professionals during school hours has greater impact than tutoring by peers or adult volunteers (Cheung et al., 2021;Gersten et al., 2020;Pellegrini et al., 2021). Given the lack of teachers in most school boards, however, individuals without formal training are being called upon. Evidence suggests that providing adequate training and supervision to non-professionals can be helpful (Nickow et al., 2020). As regards mental health and well-being, studies have shown promising results and feasibility for cognitive behavioural approaches, including virtual mindfulness interventions (Malboeuf-Hurtubise et al., 2021a, b).

Level 4: Targeted therapeutic intervention
The fourth level applies to individuals with clinically severe problems that require specialized and intensive educational or health interventions. Level 1-3 interventions can nonetheless reduce the number of individuals affected; in particular, by offering adequate care to expectant mothers with physical (e.g., diabetes) or mental health problems (e.g., clinical depression, anxiety, substance abuse). Nevertheless, there will always be a need for individual high-quality therapeutic services, both in the clinic (pediatric care, physio/occupational therapy) and in school (psychoeducation, remedial tutoring). Chadi et al. (2021) insist on a pressing need for government investment to support, improve, and adapt existing mental health treatments for an efficient response to the demand created by COVID-19 lockdowns, including a shift towards digital health therapies. Monitoring of the long-term effectiveness of in-person and online services for youth mental health will be key to understanding whether virtual therapeutic solutions should be scaled up.

Conclusion
Available data suggest that the impact of the COVID-19 pandemic on learning, health, and well-being in children and teens varies according to domain (e.g., mental health vs. learning loss) and individual risk (e.g., socio-economic status vs. personal factors). To date, data on learning loss indicates that children/teens from socio-economically disadvantaged families and/or with prior learning disabilities have suffered the most. As we move forward, we need an intersectoral monitoring system that will distinguish transient from long-term consequences of pandemic-related lockdown measures. Second, we should be ready to deploy a stepped strategy to intervention, ranging from universal promotive interventions to more intensive and targeted interventions, and to specialized remedial or therapeutic care. In particular, as recommended by the United Nations (United Nations, 2021b) and the Lancet Task Force on COVID-19 (Aknin et al., 2021), expectant parents should be offered spaces in high-quality early childcare and education services to (a) maximize parent and child personal and professional growth; and (b) ensure adequate access to preschool preventive services. Third, children living in socio-economically deprived neighbourhoods or those with individual risk factors (mental health challenges, learning delays) should be offered programs promoting mental and physical health. In particular, academic tutoring should be easily accessible in socio-economically disadvantaged settings. Finally, medical care and educational remediation services should be adapted to accommodate the potentially higher number of children with clinically severe problems. Importantly, as expectant parents and children/teens with mental/physical health risks are disproportionally found in low socio-economic contexts, the interventions and services modifying lived environments are key to reducing social inequalities in present and future generations.