Structural Inequities in Self-compassion and Parental Burnout.

Objectives: When parenting-related stressors and coping resources are chronically imbalanced, there is risk of parental burnout, and consequent negative impact on parent and child wellbeing. The objective of this study was to determine the relations between structural and social determinants of health inequities, self-compassion (a theoretically indicated coping practice), and parental burnout during the COVID-19 pandemic. Method: Participants were parents (n = 2324) with at least one child aged 4-17 in the household recruited from NORC's AmeriSpeak Panel (a probability-based panel providing coverage of 97% of the US household population). Parents completed an online or telephone questionnaire in English or Spanish in December 2020. Structural equation modeling was used to test a system of relations between income, race and ethnicity, parental burnout, and parent and child mental health. Indirect effects and moderation by self-compassion were also tested. Results: On average, parents experienced symptoms of burnout several days per week. Symptoms were the most frequent among parents with the least income, as well as female-identified and Asian parents. More self-compassion was associated with less parental burnout, and fewer parent and child mental health difficulties. Black and Hispanic parents were more self-compassionate compared to white parents, helping to explain similar levels of parental burnout and relatively better mental health outcomes, despite comparatively more stressors. Conclusions: Self-compassion is a potentially promising target for interventions aiming to address parental burnout; however, such efforts must not detract from critical structural changes to reduce parenting stressors, particularly those impacting parents experiencing systemic racism and other forms of socioeconomic disadvantage. Preregistration: This study is not preregistered. Supplementary Information: The online version contains supplementary material available at 10.1007/s12671-023-02104-9.

Leveraging Serologic Testing to Identify Children at Risk For Post-Acute Sequelae of SARS-CoV-2 Infection: An Electronic Health Record-Based Cohort Study from the RECOVER Program.

Using an electronic health record-based algorithm, we identified children with Coronavirus disease 2019 (COVID-19) based exclusively on serologic testing between March 2020 and April 2022. Compared with the 131 537 polymerase chain reaction-positive children, the 2714 serology-positive children were more likely to be inpatients (24% vs 2%), to have a chronic condition (37% vs 24%), and to have a diagnosis of multisystem inflammatory syndrome in children (23% vs <1%). Identification of children who could have been asymptomatic or paucisymptomatic and not tested is critical to define the burden of post-acute sequelae of severe acute respiratory syndrome coronavirus 2 infection in children.

Problematic Child Media Use During the COVID-19 Pandemic.

OBJECTIVES: Assess how family stressors (including structural stressors, social determinants of health inequities, and parent psychological distress) relate to media rule implementation and problematic child media use during the coronavirus disease 2019 pandemic. METHODS: Nationally representative survey of 1000 United States parents with at least one 6 to 17 year old child was conducted in October through November 2020. RESULTS: Problematic use was greater in families where parents were employed full time, present in the home (eg, working from home), had low levels or formal educational attainment, and were experiencing more psychological distress. Although there was a small decline in the number of media-related rules implemented during the pandemic (fewer parents enforced screen limits on weekdays or weekends or limited screen use at mealtimes), there was no association between rule implementation and problematic media use. CONCLUSIONS: Family stressors were associated with problematic child media use during the coronavirus disease 2019 pandemic. As we emerge from the pandemic, it will be important to help parents adjust their family's media practices cognizant of the fact that additional children may have developed problematic screen use behaviors. Such efforts should center the role of structural and social determinants of health inequities on the stressors that families experience and that impact media use.

Understanding Transgender and Gender-Diverse Youth's Experiences Receiving Care via Telemedicine: Qualitative Interview Study.

BACKGROUND: Access to virtual care has increased since the beginning of the COVID-19 pandemic, yet little is known about transgender and gender-diverse (TGD) youth's experiences and perspectives on receiving care via telemedicine. OBJECTIVE: The purpose of this study was to explore these experiences to (1) inform necessary changes to the provision of pediatric gender-affirming care and (2) help providers and health systems determine if and how telemedicine should be made available post pandemic. METHODS: Youth (aged 14-17 years) who completed a telemedicine visit in the Seattle Children's Gender Clinic were invited to participate in a semistructured interview exploring perceived advantages or disadvantages of telemedicine and preferred visit modalities. Interview transcriptions were analyzed by 2 research team members using an inductive thematic analysis framework. RESULTS: A total of 15 TGD youth completed an interview. Commonly cited advantages of telemedicine were convenience and comfort with having visits in their own environments. Reported disadvantages included technical issues, discomfort with the impersonal nature, lack of familiarity with the platform, and privacy concerns. Overall, slightly more youth preferred in-person visits over telemedicine, referencing both specific characteristics of the clinical visit (ie, initial vs return and complexity) and proximity to the clinic as reasons for this preference. Although a plurality of TGD youth preferred in-person visits, they also recognized the value of telemedicine and the impact it may have in facilitating access to care. CONCLUSIONS: Given the variations in needs and visit complexity, our study supports the provision of both in-person and telemedicine modalities as options for pediatric gender-affirming care.

Clinical Features and Burden of Postacute Sequelae of SARS-CoV-2 Infection in Children and Adolescents.

Importance: The postacute sequelae of SARS-CoV-2 infection (PASC) has emerged as a long-term complication in adults, but current understanding of the clinical presentation of PASC in children is limited. Objective: To identify diagnosed symptoms, diagnosed health conditions, and medications associated with PASC in children. Design, Setting and Participants: This retrospective cohort study used electronic health records from 9 US children's hospitals for individuals younger than 21 years who underwent antigen or reverse transcriptase-polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 between March 1, 2020, and October 31, 2021, and had at least 1 encounter in the 3 years before testing. Exposures: SARS-CoV-2 positivity by viral test (antigen or RT-PCR). Main Outcomes and Measures: Syndromic (symptoms), systemic (conditions), and medication PASC features were identified in the 28 to 179 days following the initial test date. Adjusted hazard ratios (aHRs) were obtained for 151 clinically predicted PASC features by contrasting viral test-positive groups with viral test-negative groups using proportional hazards models, adjusting for site, age, sex, testing location, race and ethnicity, and time period of cohort entrance. The incidence proportion for any syndromic, systemic, or medication PASC feature was estimated in the 2 groups to obtain a burden of PASC estimate. Results: Among 659 286 children in the study sample, 348 091 (52.8%) were male, and the mean (SD) age was 8.1 (5.7) years. A total of 59 893 (9.1%) tested positive by viral test for SARS-CoV-2, and 599 393 (90.9%) tested negative. Most were tested in outpatient testing facility settings (322 813 [50.3%]) or office settings (162 138 [24.6%]). The most common syndromic, systemic, and medication features were loss of taste or smell (aHR, 1.96; 95% CI, 1.16-3.32), myocarditis (aHR, 3.10; 95% CI, 1.94-4.96), and cough and cold preparations (aHR, 1.52; 95% CI, 1.18-1.96), respectively. The incidence of at least 1 systemic, syndromic, or medication feature of PASC was 41.9% (95% CI, 41.4-42.4) among viral test-positive children vs 38.2% (95% CI, 38.1-38.4) among viral test-negative children, with an incidence proportion difference of 3.7% (95% CI, 3.2-4.2). A higher strength of association for PASC was identified in those cared for in the intensive care unit during the acute illness phase, children younger than 5 years, and individuals with complex chronic conditions. Conclusions and Relevance: In this large-scale, exploratory study, the burden of pediatric PASC that presented to health systems was low. Myocarditis was the most commonly diagnosed PASC-associated condition. Acute illness severity, young age, and comorbid complex chronic disease increased the risk of PASC.

Cardiac Complications After SARS-CoV-2 Infection and mRNA COVID-19 Vaccination - PCORnet, United States, January 2021-January 2022.

Cardiac complications, particularly myocarditis and pericarditis, have been associated with SARS-CoV-2 (the virus that causes COVID-19) infection (1-3) and mRNA COVID-19 vaccination (2-5). Multisystem inflammatory syndrome (MIS) is a rare but serious complication of SARS-CoV-2 infection with frequent cardiac involvement (6). Using electronic health record (EHR) data from 40 U.S. health care systems during January 1, 2021-January 31, 2022, investigators calculated incidences of cardiac outcomes (myocarditis; myocarditis or pericarditis; and myocarditis, pericarditis, or MIS) among persons aged ≥5 years who had SARS-CoV-2 infection, stratified by sex (male or female) and age group (5-11, 12-17, 18-29, and ≥30 years). Incidences of myocarditis and myocarditis or pericarditis were calculated after first, second, unspecified, or any (first, second, or unspecified) dose of mRNA COVID-19 (BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna]) vaccines, stratified by sex and age group. Risk ratios (RR) were calculated to compare risk for cardiac outcomes after SARS-CoV-2 infection to that after mRNA COVID-19 vaccination. The incidence of cardiac outcomes after mRNA COVID-19 vaccination was highest for males aged 12-17 years after the second vaccine dose; however, within this demographic group, the risk for cardiac outcomes was 1.8-5.6 times as high after SARS-CoV-2 infection than after the second vaccine dose. The risk for cardiac outcomes was likewise significantly higher after SARS-CoV-2 infection than after first, second, or unspecified dose of mRNA COVID-19 vaccination for all other groups by sex and age (RR 2.2-115.2). These findings support continued use of mRNA COVID-19 vaccines among all eligible persons aged ≥5 years.

Severity of Acute COVID-19 in Children <18 Years Old March 2020 to December 2021.

This national study evaluated trends in illness severity among 82 798 children with coronavirus disease 2019 from March 1, 2020, to December 30, 2021.

Association of Screen Time With Internalizing and Externalizing Behavior Problems in Children 12 Years or Younger: A Systematic Review and Meta-analysis.

Importance: Currently, there is a lack of consensus in the literature on the association between screen time (eg, television, video games) and children's behavior problems. Objective: To assess the association between the duration of screen time and externalizing and internalizing behavior problems among children 12 years or younger. Data Sources: For this systematic review and meta-analysis, MEDLINE, Embase, and PsycINFO databases were searched for articles published from January 1960 to May 2021. Reference lists were manually searched for additional studies. Study Selection: Included studies measured screen time (ie, duration) and externalizing or internalizing behavior problems in children 12 years or younger, were observational or experimental (with baseline data), were available in English, and had data that could be transformed into an effect size. Studies conducted during the COVID-19 pandemic were excluded. Of 25 196 nonduplicate articles identified and screened for inclusion, 595 met the selection criteria. Data Extraction and Synthesis: The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Extracted variables were child age, sex, and socioeconomic status; informants and measurement type for screen time and behavior problems; study publication year; and study design and quality. Data were extracted by 2 independent coders and were pooled using a random-effects model. Main Outcomes and Measures: The primary outcome was the association of screen time duration with externalizing (eg, aggression, attention deficit/hyperactivity disorder symptoms) and internalizing (eg, depression, anxiety) behaviors or diagnoses. Results: Of the 595 full-text articles assessed for eligibility, 87 studies met all inclusion criteria, comprising 98 independent samples and 159 425 participants (mean [SD] age, 6.07 [2.89] years; 83 246 [51.30%] male). Increased duration of screen time had a small but significant correlation with more externalizing problems (90 samples; r, 0.11; 95% CI, 0.10-0.12) and internalizing problems (43 samples; r, 0.07; 95% CI, 0.05-0.08) in children. Several methodological moderators explained between-study heterogeneity. There was evidence of significant between study heterogeneity (I2 = 87.80). Conclusions and Relevance: This systematic review and meta-analysis found small but significant correlations between screen time and children's behavior problems. Methodological differences across studies likely contributed to the mixed findings in the literature.

The Association Between School Closures and Child Mental Health During COVID-19.

Importance: In-person schooling has been disrupted for most school-aged youth during the COVID-19 pandemic, with low-income, Black, and Hispanic populations most likely to receive fully remote instruction. Disruptions to in-person schooling may have negatively and inequitably affected children's mental health. Objective: To estimate the association between school closures and child mental health outcomes and how it varies across sociodemographic factors. Design, Setting, and Participants: This cross-sectional population-based survey study included a nationally representative sample of US adults aged 18 to 64 years with at least 1 child in the household. The survey was administered between December 2 and December 21, 2020, via web and telephone in English and Spanish. Participants were recruited from the NORC AmeriSpeak panel, an address-based panel with known probability sampling and coverage of 97% of US households. Exposures: Schooling modality (in person, fully remote, or hybrid), household income, age. Main Outcomes and Measures: Child mental health difficulties were measured with the parent-report version of the Strengths and Difficulties Questionnaire, with small, medium, and large effect sizes defined as 1.3-, 3.3-, and 5.2-point differences, respectively. Results: A total of 2324 adults completed the survey. Overall, 1671 respondents (71.9%) were women, 244 (10.5%) were Black, 372 (16.0%) were Hispanic, and 421 (18.1%) had a high school education or less. Children attending school in-person had higher household incomes (mean difference, $9719; 95% CI, $4327 to $15 111; P < .001) and were more likely to be White compared with those attending remotely (366 of 556 [65.8%] vs 597 of 1340 [44.5%]; P < .001). Older children in remote schooling had more mental health difficulties than those attending in-person schooling (standardized effect size, 0.23 [95% CI, 0.07 to 0.39] per year older; P = .006), corresponding to small effect sizes in favor of in-person schooling for older children and very small effect sizes favoring remote schooling for younger children. Children from families with higher income benefitted more from attending schools in-person compared with their peers from families with lower income (B = -0.20 [95% CI, -0.10 to -0.30] per $10 000-increase in annual income; P < .001), although this advantage was not apparent for children attending hybrid school (B = -0.05 [95% CI, -0.16 to 0.06] per $10 000-increase in annual income; P = .34), and directionally lower but not significantly different for children attending remote school (B = -0.12 [95% CI, -0.04 to -0.20] per $10 000-increase in annual income; P < .001). Learning pods fully buffered the associations of hybrid schooling (d = -0.25; 95% CI, -0.47 to -0.04) but not remote schooling (d = 0.04; 95% CI, -0.10 to 0.18) with negative mental health outcomes. Conclusions and Relevance: The findings of this study suggest that older and Black and Hispanic children as well as those from families with lower income who attend school remotely may experience greater impairment to mental health than their younger, White, and higher-income counterparts. Ensuring that all students have access to additional educational and mental health resources must be an important public health priority, met with appropriate funding and workforce augmentation, during and beyond the COVID-19 pandemic.

Assessment of 135 794 Pediatric Patients Tested for Severe Acute Respiratory Syndrome Coronavirus 2 Across the United States.

Importance: There is limited information on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and infection among pediatric patients across the United States. Objective: To describe testing for SARS-CoV-2 and the epidemiology of infected patients. Design, Setting, and Participants: A retrospective cohort study was conducted using electronic health record data from 135 794 patients younger than 25 years who were tested for SARS-CoV-2 from January 1 through September 8, 2020. Data were from PEDSnet, a network of 7 US pediatric health systems, comprising 6.5 million patients primarily from 11 states. Data analysis was performed from September 8 to 24, 2020. Exposure: Testing for SARS-CoV-2. Main Outcomes and Measures: SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19) illness. Results: A total of 135 794 pediatric patients (53% male; mean [SD] age, 8.8 [6.7] years; 3% Asian patients, 15% Black patients, 11% Hispanic patients, and 59% White patients; 290 per 10 000 population [range, 155-395 per 10 000 population across health systems]) were tested for SARS-CoV-2, and 5374 (4%) were infected with the virus (12 per 10 000 population [range, 7-16 per 10 000 population]). Compared with White patients, those of Black, Hispanic, and Asian race/ethnicity had lower rates of testing (Black: odds ratio [OR], 0.70 [95% CI, 0.68-0.72]; Hispanic: OR, 0.65 [95% CI, 0.63-0.67]; Asian: OR, 0.60 [95% CI, 0.57-0.63]); however, they were significantly more likely to have positive test results (Black: OR, 2.66 [95% CI, 2.43-2.90]; Hispanic: OR, 3.75 [95% CI, 3.39-4.15]; Asian: OR, 2.04 [95% CI, 1.69-2.48]). Older age (5-11 years: OR, 1.25 [95% CI, 1.13-1.38]; 12-17 years: OR, 1.92 [95% CI, 1.73-2.12]; 18-24 years: OR, 3.51 [95% CI, 3.11-3.97]), public payer (OR, 1.43 [95% CI, 1.31-1.57]), outpatient testing (OR, 2.13 [1.86-2.44]), and emergency department testing (OR, 3.16 [95% CI, 2.72-3.67]) were also associated with increased risk of infection. In univariate analyses, nonmalignant chronic disease was associated with lower likelihood of testing, and preexisting respiratory conditions were associated with lower risk of positive test results (standardized ratio [SR], 0.78 [95% CI, 0.73-0.84]). However, several other diagnosis groups were associated with a higher risk of positive test results: malignant disorders (SR, 1.54 [95% CI, 1.19-1.93]), cardiac disorders (SR, 1.18 [95% CI, 1.05-1.32]), endocrinologic disorders (SR, 1.52 [95% CI, 1.31-1.75]), gastrointestinal disorders (SR, 2.00 [95% CI, 1.04-1.38]), genetic disorders (SR, 1.19 [95% CI, 1.00-1.40]), hematologic disorders (SR, 1.26 [95% CI, 1.06-1.47]), musculoskeletal disorders (SR, 1.18 [95% CI, 1.07-1.30]), mental health disorders (SR, 1.20 [95% CI, 1.10-1.30]), and metabolic disorders (SR, 1.42 [95% CI, 1.24-1.61]). Among the 5374 patients with positive test results, 359 (7%) were hospitalized for respiratory, hypotensive, or COVID-19-specific illness. Of these, 99 (28%) required intensive care unit services, and 33 (9%) required mechanical ventilation. The case fatality rate was 0.2% (8 of 5374). The number of patients with a diagnosis of Kawasaki disease in early 2020 was 40% lower (259 vs 433 and 430) than in 2018 or 2019. Conclusions and Relevance: In this large cohort study of US pediatric patients, SARS-CoV-2 infection rates were low, and clinical manifestations were typically mild. Black, Hispanic, and Asian race/ethnicity; adolescence and young adulthood; and nonrespiratory chronic medical conditions were associated with identified infection. Kawasaki disease diagnosis is not an effective proxy for multisystem inflammatory syndrome of childhood.

Estimation of US Children's Educational Attainment and Years of Life Lost Associated With Primary School Closures During the Coronavirus Disease 2019 Pandemic.

Importance: United States primary school closures during the 2020 coronavirus disease 2019 (COVID-19) pandemic affected millions of children, with little understanding of the potential health outcomes associated with educational disruption. Objective: To estimate the potential years of life lost (YLL) associated with the COVID-19 pandemic conditioned on primary schools being closed or remaining open. Design, Setting, and Participants: This decision analytical model estimated the association between school closures and reduced educational attainment and the association between reduced educational attainment and life expectancy using publicly available data sources, including data for 2020 from the US Centers for Disease Control and Prevention, the US Social Security Administration, and the US Census Bureau. Direct COVID-19 mortality and potential increases in mortality that might have resulted if school opening led to increased transmission of COVID-19 were also estimated. Main Outcomes and Measures: Years of life lost. Results: A total of 24.2 million children aged 5 to 11 years attended public schools that were closed during the 2020 pandemic, losing a median of 54 (interquartile range, 48-62.5) days of instruction. Missed instruction was associated with a mean loss of 0.31 (95% credible interval [CI], 0.10-0.65) years of final educational attainment for boys and 0.21 (95% CI, 0.06-0.46) years for girls. Summed across the population, an estimated 5.53 million (95% CI, 1.88-10.80) YLL may be associated with school closures. The Centers for Disease Control and Prevention reported a total of 88 241 US deaths from COVID-19 through the end of May 2020, with an estimated 1.50 million (95% CI, 1.23-1.85 million) YLL as a result. Had schools remained open, 1.47 million (95% credible interval, 0.45-2.59) additional YLL could have been expected as a result, based on results of studies associating school closure with decreased pandemic spread. Comparing the full distributions of estimated YLL under both "schools open" and "schools closed" conditions, the analysis observed a 98.1% probability that school opening would have been associated with a lower total YLL than school closure. Conclusions and Relevance: In this decision analytical model of years of life potentially lost under differing conditions of school closure, the analysis favored schools remaining open. Future decisions regarding school closures during the pandemic should consider the association between educational disruption and decreased expected lifespan and give greater weight to the potential outcomes of school closure on children's health.