By: Paul H. Dworkin, MD

As the COVID-19 pandemic accelerated across the nation and the world, child health providers took some comfort in recognizing the relatively limited impact of the disease on children as compared to adults and, particularly, seniors. Notwithstanding the emergence of a rare, serious COVID-19 related disorder, Multisystem Inflammatory Syndrome in Children, as well as the recognition that a small number of children required critical care and experienced fatalities, the direct disease impact on children remains relatively modest. However, the indirect impact of the pandemic on families and their children is profound and likely to linger long after the virus runs its course.

This is especially true for minority populations that are affected to a greater degree by the virus due to socioeconomic factors such as less capacity to shelter in place, increased exposure due to crowding and front-line working conditions, and increased complications from underlying medical factors that have resulted in higher death rates.

At Connecticut Children’s Office for Community Child Health (the Office), we are committed to strengthening families to enable them to promote their children’s optimal heath, development, and well-being. We place a particular focus on those families impacted by disparities that arise from social, economic, environmental, and behavioral factors. Such disparities are particularly critical in guiding our responses to families’ pandemic-related needs.

Strengthening Families: Addressing COVID-19 Needs

The pandemic sharply increased the acute needs of families, which debunked the myth of a modest COVID-19 impact on children. Our Help Me Grow National Center conducted a survey of its state affiliates and found that family needs fall into three categories: basic needs, including such items as food, formula, diapers, and wipes; childcare, especially for essential, front-line workers; and behavioral health services, especially during the prenatal and post-partum periods.  Such needs are greater among disadvantaged families, as the pandemic has exposed the disparities within society that particularly impact people of color in urban and underserved rural areas.

For example, COVID-19 and its impact on the economy have led to widespread food insecurity. A recent COVID-19 Impact Survey conducted by the non-partisan and objective research organization NORC at the University of Chicago found the following:

• 37% of unemployed adults reported running out of food in the past month and 46% reported being worried about running out of food;
• 20% of working adults reported running out of food in the past month and 25% reported being worried about running out of food; and
• 40% of households earning less than $50,000 per year reported sometimes being worried about running out of food. Among such households with children, 31% reported being especially likely to run out of food and 36% reported being worried about running out of food.

Four Key Principles to Strengthening Families

The Office strives to build stronger systems of support so children and families everywhere can thrive in challenging times. Our work addresses the social determinants of health, which encompass the circumstances in which people live and work, and are proven to influence life outcomes to a far greater degree than quality health care alone. Our guiding principles form the foundation for all of our work, and are especially critical to reinforce during times of uncertainty, such as during COVID-19.

In order to bring about a more equitable society, our path forward must include strengthening families to ensure all children have equal opportunities to achieve optimal health, development and well-being. We do this by ensuring our work aligns with the following key principles:

• Embrace the implications related to the science of the “Biology of Adversity”: Such implications include the impact of toxic stress, adverse childhood experiences, and social determinants of health on long-term health and development outcomes.
• Recognize the drivers of children’s health, development and well-being: Research shows that social, environmental, genetic/epigenetic, and behavioral influences all combine to represent 80 to 90% of overall outcomes, with quality health care accounting for the remaining 10 to 20%.
• Strengthen protective factors: Research shows that boosting families’ protective factors ensures that they are better able to withstand life’s challenges. At the Office, we embrace the Strengthening Families Protective Factors Framework developed by the Center for the Study of Social Policy. The framework encourages those working with children and families to help them build the following areas: family resilience; social connections; knowledge of parenting and child development; access to concrete supports in times of need; and social and emotional competence of children. These protective factors inform our interventions and serve as measures of our impact.
• Engage all critical sectors to address needs: All child- and family-serving sectors must work together in order to maximize collective impact and effectively address disparities. Working in isolation of each other will continue to yield little progress in achieving the long-term health and development outcomes for children that we ultimately seek. While we have long recognized the importance of child health services, early care and education (e.g., child care), and family support (e.g., home visiting), we also recognize the need to ensure a strong interface with such sectors as housing, food and nutrition, public safety, transportation, among many others.

Hope, Optimism and Advocacy for the Future

Even in the midst of a pandemic, we have reasons for optimism about transforming child health services to strengthen families to promote children’s optimal health, development and well-being.

In Connecticut, a key resource to support such change is the Office of Healthcare Strategy’s State Innovation Model, which includes the Person Centered Medical Home Plus (PCMH+) program as well as Health Enhancement Communities (HECs) across the state. PCMH+ includes enhanced integration between physical and behavioral health services, encourages culturally-competent services, strengthens care coordination, ensures supports for children and youth with special health care needs, and shares report cards with health care providers. HECs currently involve select communities chosen by the state, which develop and execute community-driven action plans that address poor health outcomes, health inequity, and rising health care costs. Each community establishes a collaborative consisting of residents, community-based organizations, health care providers, health departments, government agencies, social services agencies, housing agencies and schools. The priorities for all HECs include improving child well-being in Connecticut pre-birth to age 8 and improving healthy weight and physical fitness for all residents. These priorities afford child health providers a remarkable platform to transform service delivery.

As we strive to address the challenging needs of families and their communities during COVID-19, we must be mindful of the impact on all providers, front-line and otherwise. Providers’ self-care is bolstered by a feeling of agency and impact. One helpful self-care strategy is to engage in some form of advocacy. Defined most broadly, such advocacy may encompass such diverse actions as writing a letter to the editor, corresponding with an elected official, having a conversation with a colleague, engaging with a professional organization, supporting a community-based organization, and other acts.

Opportunities for such advocacy are plentiful. Mona Hanna-Attisha, the physician who exposed the lead contamination in Flint, Michigan, recently reminded us in a New York Times Op-Ed that, “Babies don’t choose where they’re born.” She offered a checklist of potential issues worthy of our attention and action including universal basic income and living wages, health and safety precautions, paid parental and sick leave, desegregated and well-funded public education, child care as a fundamental right, universal health care untethered from employment, and strengthened, enforced environmental regulations.

To state that these are challenging times is, of course, an understatement. Reference to a “silver lining” seems premature, and even callous, in the midst of such ongoing suffering and uncertainty.  Nonetheless, the pandemic has certainly exposed long-standing inequities that demand our attention and our action. Perhaps most importantly, we understand the inappropriateness of longing for a nostalgic return to a “past normal” and acknowledge the daunting challenges of a better future.

The dedication of the Office to strengthening families to ensure that one day, a person’s zip code will no longer determine the quality of their health and life outcomes, speaks to our commitment to critical change. Our sentiment is captured in the lyrics of a Billy Joel song, “Keeping the Faith,” from the album, “An Innocent Man,” released on August 8, 1983:  “The good ole days weren’t always good, and tomorrow ain’t as bad as it seems.”

Paul H. Dworkin, MD is executive vice president for community child health at Connecticut Children’s, director of Connecticut Children’s Office for Community Child Health and founding director of Help Me Grow National Center. Dr. Dworkin is also a professor of pediatrics at UConn School of Medicine.  Learn more »

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