Tick tock, tick tock.

In elementary school, my friend Krystal (not her real name) kept a perpetual clock running in her head. When she was at home, she would count down the minutes until she could come back to school. School was a safe haven for her, a place of comfort where she was shielded from the abuse she witnessed and experienced daily.

One day she showed me her bruises. By doing that she included me in the countdown.

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I kept a different clock running in my head. While we were in school, I counted down the minutes until she would have to return home. Eventually, I mustered the courage to tell my teacher, and both clocks stopped.

Krystal was not alone. Many children run silent timers that stop when they get to school. But what happens when the clock doesn’t stop, like when schools are shut down so we can fight the Covid-19 pandemic with isolation and social distancing?

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For far too many children, shutting down schools is not a risk-benefit proposition. It’s a risk-risk one, a trade-off between contracting a viral illness they can spread to their vulnerable family members and teachers versus being exposed to hunger, child abuse, homelessness, mental health issues, and other forms of domestic distress.

National recommendations now call for gatherings of no more than 10 people, and preferably fewer than that. Many states have called for residents to shelter in place. Most states closed schools through April, and many have closed them through May, or even for the remainder of the school year. Day care and learning centers have closed their doors, putting family members in close proximity to each other day in and day out, keeping the timer running with no end in sight for many children.

As a pediatrician, I worry about the implications of this.

Even before the emergence of Covid-19, kids across the country were experiencing significant stressors and trauma.

Many of my patients have abnormal hunger vital signs — evidence of crises before they are officially declared. It is why the mother of one of my patients brought her to the emergency department in the middle of the day instead of taking her to the clinic. When I asked why, she admitted, “Because they give you free food in the emergency department.” It was the end of the month and they were barely making ends meet.

Her answer reminded me of the harsh reality for many families. Fifty percent of public schools qualified as mid-high and high poverty schools during the 2015-2016 academic school year. In these schools, half or more of students were eligible for free or reduced-price lunch. These school lunch programs are a lifeline for minority children: 70% to 80% of Black, American Indian, and Latino children depend on these programs for at least one meal a day.

Before the coronavirus began its deadly sweep around the world, I also managed teenagers who had suicidal thoughts and made suicidal gestures, largely due to stressors at home. I cared for kids who experienced nonaccidental trauma who were sheltered with their abusers. I wasn’t surprised to be seeing these cases, since the rate of suicide in the U.S. among adolescents and young adults was 14.5 per 100,000 people in 2017. And 4 million referrals were made in 2015 for alleged maltreatment of children.

Before the coronavirus crisis, I also saw families grappling with the consequences of homelessness. It is why the mother of one of my patients wouldn’t let her daughter be discharged from the hospital for hours beyond the time she was ready to go. I tried to reassure her that her daughter had improved and was doing well. She agreed, but was still reluctant. She said she did not have the prescriptions needed for her daughter, so I had our in-hospital pharmacy bring them to the bedside. She said she needed transportation, so our social workers gave her a prepaid card for the train. She finally shared with me that her child could not be discharged home because they did not have a home.

That was my first experience with homelessness, but it was not my last. About 1.5 million school-aged children experienced homelessness during the 2017-2018 school year.

The Covid-19 pandemic did not create these stresses for children, but it certainly is amplifying them. At least for now, school can no longer offer an escape.

During a recent shift I worked in the intensive care unit in an urban children’s hospital, my colleagues and I talked about the increasing number of nonaccidental traumas and intentional overdoses we have seen over the last few weeks. Domestic violence is on an upward trend and children are watching. They are also involved. For them, the clock keeps ticking.

How do we protect vulnerable children during these difficult times? And how do we protect children who celebrate coming to school to get away from abuse like my elementary school friend Krystal? Many efforts have been made to start the countdown again. Here are three of them:

To fight hunger, the USDA’s Food and Nutrition Service (FNS) has approved waivers to let organizations that run the Summer Food Service Program to serve meals outside of the standard school meal times and meals do not have to be eaten on site. In some states, parents can pick up a meal without the child being present. FNS is also allowing states to submit plans for temporary Supplemental Nutrition Assistance Program (SNAP) benefits for children who receive free or reduced meals when schools are open. The CARES Act has allocated funding for child nutrition, SNAP, and food banks. And some restaurants are stepping up to provide free meals for children.

The CARES Act allocated funding to Family Violence Prevention and Services Act programs that provide shelter, resources, and a hotline for survivors of domestic violence.

Rental assistance funds have been allocated for states, public housing authorities, and municipalities to prevent homelessness. Funding for federal Emergency Solutions Grants or short- and medium-term housing will be released in waves to help homeless families.

Pediatricians have long understood the importance of screening patients for social needs and connecting them to community resources. Despite evidence showing its importance, such screening has not been implemented universally. Now is the time to implement the concept of widespread screening for food insecurity, housing insecurity, and safety in the home. We need to identify and connect patients and families to the resources they need.

At the same time, physicians must continue to urge Congress to expand funding for social services and resources. While some funding has been allocated for these vital services, it is not enough. SNAP benefits should be increased to support families who are now providing more meals for children at home. Funding should be increased to allow states to expand rental assistance for all tenants. States should have funding to use uninhabited dorms and hotels as temporary housing for families. And Congress should expand health insurance coverage. Employment is closely linked to health insurance, which affects access to mental health services and critical health care needs during this time.

Every day as I drive to work and pass Noyes Elementary School in Northeast Washington, D.C., I think of Krystal and my patients. Experts say we are getting close to seeing the peak effects of coronavirus. That means we are getting close to seeing the peak effects of school closures, too. I hear the clock ticking.

Paula Magee works as a hospitalist in a pediatric intensive care unit in Washington, D.C.

  • The valuable points that this writer makes have likely not been on the forefront in this pandemic. Not everywhere “home” means safety and shelter : for many children “school” = safety + shelter + food. This pandemic underscores that American society as a whole needs to become more caring of those who are not being taken care of and/or can not take care of themselves. The hard, selfish, money-oriented disposition of far too many needs to change to become much more compassionate, as without it the country never will be truly great.

  • Very informative, frightening & predicable information . As a retired nurse, my fears have been focused on our elderly and on our children . School is closed until at least Sept. & I agree with Dr. Magee about the huge, resulting problems for our already, at risk families & children. Any suggestions on how to help?

  • Neil’s comment is exactly on point. What’s also true is that there’s not a completely linear relationship between being in school and reduced child abuse rates. Often grade pressure is a pretext for parents to physically abuse their kids, and right now that pressure is mostly off as schools are often engaging in drastically curtailed school days with lessened workloads and pass-fail grading. Additionally some parents are able to parent better when they’re not working. Not saying this is true across the board, but neither is the assumption made by the author that abuse will jump predictably.

  • “I wasn’t surprised to be seeing these cases, since the rate of suicide in the U.S. among children and teenagers was 14.5% in 2017.”

    This is an error.

    From the CDC report:

    Suicide rates for children, young people jumped between 2007 to 2017: CDC
    The suicide rate among those between ages 10 to 24 jumped between 2007 and 2017, according to a report released by the Centers for Disease Control and Prevention (CDC) on Thursday.

    The 56-percent jump in that decade contrasted with a more stable suicide rate among the age group previously. In 2007, there were 6.8 suicides per 100,000 people among ages 10 to 24, while in 2017 there were 10.6 suicides, according to the CDC.

    Nonetheless, we have a problem. But a rate of 14.5% would be catastrophic.

    • I have no doubt that the risk for abuse of children at hone during extended lockdown is increased. I also have no doubt that the 2020 CDC report on youth suicide will see a dramatic plunge in cases. The school environment itself is toxic for many children, and produces desdly outcomes when combined with social media bullying. It’s time for us to consider common sense school control.

    • I have no doubt that the risk for abuse of children at home during extended lockdown is increased. I also have no doubt that the 2020 CDC report on youth suicide will see a dramatic plunge in cases. The school environment itself is toxic for many children, and produces desdly outcomes when combined with social media bullying. It’s time for us to consider common sense school control.

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