Well-being of Parents and Children During the COVID-19 ......Jul 22, 2020 · ©2020 American Academy of Pediatrics . American Academy of Pediatrics, the American Academy of Child

Prepublication Release

©2020 American Academy of Pediatrics

Well-being of Parents and Children During the COVID-19 Pandemic: A National Survey

Stephen W. Patrick, MD, MPH, MS, Laura E. Henkhaus, PhD, Joseph S. Zickafoose, MD, MS, Kim Lovell, MPH, MBA, Alese Halvorson, MS, Sarah Loch, MPH,

Mia Letterie, BA, Matthew M. Davis, MD, MAPP

DOI: 10.1542/peds.2020-016824

Journal: Pediatrics

Article Type: Regular Article

Citation: Patrick SW, Henkhaus LE, Zickafoose JS, et al. Well-being of parents and children during the COVID-19 pandemic: a national survey. Pediatrics. 2020; doi: 10.1542/peds.2020-016824

This is a prepublication version of an article that has undergone peer review and been accepted for publication but is not the final version of record. This paper may be cited using the DOI and date of access. This paper may contain information that has errors in facts, figures, and statements, and will be corrected in the final published version. The journal is providing an early version of this article to expedite access to this information. The American Academy of Pediatrics, the editors, and authors are not responsible for inaccurate information and data described in this version.

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Well-being of Parents and Children During the COVID-19 Pandemic: A National Survey

Stephen W. Patrick, MD, MPH, MS1,2,3,4, Laura E. Henkhaus, PhD1,3, 5, Joseph S. Zickafoose, MD, MS1,2,6, Kim Lovell, MPH, MBA1,3, Alese Halvorson, MS7, Sarah Loch, MPH1, Mia

Letterie, BA1, Matthew M. Davis, MD, MAPP8.9

1Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN 2Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 3Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN 4Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, TN 5Data Science Institute, Vanderbilt University, Nashville, TN

6Mathematica, Nashville, TN 7Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 8Mary Ann & J. Milburn Smith Child Health Research, Outreach and Advocacy Center, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 9Departments of Pediatrics, Medicine, Medical Social Sciences, and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL

Address correspondence to:

Stephen W. Patrick, MD, MPH, MS Vanderbilt Center for Child Health Policy 2525 West End Ave, Suite 1200 Nashville, TN 37203 Telephone: 615-875-5893 Facsimile: 615-343-1763 E-mail: [email protected]

Abbreviations: CARES = Coronavirus Aid, Relief, and Economic Securities; COVID-19 = coronavirus 2019; FFCRA = The Families First Coronavirus Response Act; NSLP = National School Lunch Program; P-EBT = Pandemic Electronic Benefit Transfer; SNAP = Supplemental




Nutrition Assistance Program; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children

Financial Disclosure Statement: None of the authors have any financial relationships relevant to this article to disclose.

Funding Source: None

Conflict of Interest: None of the authors have any conflicts of interest to disclose.

Table of Contents Summary: In this national survey, we assessed how COVID-19 and physical distancing measures affected parent and child wellbeing.

What’s Known on This Subject:

The COVID-19 pandemic and protective measures associated with it created widespread

disruptions in daily life of US parents and children. Families with children disproportionately

live in poverty, potentially increasing their risk to COVID-19-related economic distress and

difficulties sustaining basic needs.

What This Study Adds:

COVID-19 has had a substantial impact on the wellbeing of parents and children. As

policymakers consider additional measures to mitigate the health and economic effects of the

pandemic, they should consider the unique needs of families with children.

Author Contributions:

Stephen W. Patrick conceptualized the study, was involved in conducting the analysis, was

involved in interpretation of the results drafted the initial manuscript and approved the final

manuscript as submitted.

Matthew M. Davis conceptualized the study, was involved in conducting the analysis, was

involved in interpretation of the results and approved the final manuscript as submitted.




Alese Halvorson conducted the analysis, was involved in interpretation of the results, revised and

approved the manuscript as written.

Laura E. Henkhaus, Joseph S. Zickafoose, Kim Lovell, Mia Letterie, and Sarah Loch, were

involved in the analytic plan and interpretation of the results, revised and approved the

manuscript as written.

All authors approved the final manuscript as submitted and agree to be accountable for all

aspects of the work.




Abstract

Background: As the COVID-19 pandemic spread across the US and protective measures to

mitigate its impact were enacted, parents and children experienced widespread disruptions in

daily life. The objective of this national survey was to determine how the pandemic and

mitigation efforts affected the physical and emotional wellbeing of parents and children in the

US through early June 2020.

Methods: In June 2020, we conducted a national survey of parents with children under age 18 to

measure changes in health status, insurance status, food security, utilization of public food

assistance resources, childcare and use of health care services since the pandemic began.

Results: Since March 2020, 27% of parents reported worsening mental health for themselves,

and 14% reported worsening behavioral health for their children. The proportion of families with

moderate or severe food insecurity increased from 6% before March 2020 to 8% after, employer-

sponsored insurance coverage of children decreased from 63% to 60%, and 24% of parents

reported a loss of regular childcare. Worsening mental health for parents occurred alongside

worsening behavioral health for children in nearly 1 in 10 families, among whom 48% reported

loss of regular childcare, 16% reported change in insurance status, and 11% reported worsening

food security.




Conclusions: The COVID-19 pandemic has had a substantial tandem impact on parents and

children in the US. As policymakers consider additional measures to mitigate the health and

economic effects of the pandemic, they should consider the unique needs of families with

children.

Introduction

The emergence of COVID-19 has had a sudden and profound effect on communities nationwide.

As cases and deaths due to the novel virus increased, protective measures such as physical

distancing were enacted to mitigate the virus’ spread,1 resulting in abrupt closures of schools,

childcare, community programs, and workplaces. These changes have resulted in social isolation,

psychological distress among adults,2 and substantial economic distress3 with the highest level of

unemployment since the Great Depression.4

Families with children have faced myriad stresses from losses of economic and psychological

support for parents and their children. In addition, families with children disproportionately live

in poverty,5 potentially increasing the risk of economic distress through acute job loss and related

difficulties sustaining basic needs, such as food security and reliable childcare. Each of these

stressors, in turn, may increase psychological strain on families. Government agencies6 and

professional organizations7 have expressed concern that children, in particular, may be at

increased risk for psychological disturbances. Despite concern that parents and children may

both be at risk for many of the sequalae associated with the COVID-19 pandemic, data

examining the impact of COVID-19 on these populations are sparse.




The objective of this national survey of parents with children under 18 years old was to

determine how the COVID-19 pandemic and mitigation efforts affected the physical and

emotional wellbeing of parents and children in the US. We further aimed to examine how the

economic downturn due to COVID-19 affected health insurance status, caregiver responsibilities,

and supports to mitigate hunger.

Methods

Data Collection

We fielded the Vanderbilt Child Health COVID-19 Poll from June 5 to June 10, 2020, using the

Ipsos KnowledgePanel, a large online research panel created using probability-based address

sampling of US households.8-13 Households without internet at the time of recruitment are

provided with an internet-enabled tablet. Participants in KnowledgePanel receive nominal

periodic incentives to participate. This study of unidentified persons was considered exempt

from human subjects review by the Vanderbilt University Medical Center Institutional Review

Board.

Survey Methods

For this survey, we included parents in KnowledgePanel with at least 1 child in the household

younger than 18 years old. Eligible participants were randomly selected from the standing panel,

sent an e-mail notification, and sent a subsequent reminder 3 days later. This survey had a 50%




completion rate,14 with a total of 1,011 responses. Survey weights were designed to provide

national estimates of parents with children less than 18 years of age, accounting for differential

nonresponse. Benchmarks for survey weighting were obtained from the 2019 March Supplement

of the Current Population Survey15 for all variables, except for language proficiency which was

obtained from the 2018 American Community Survey.16 Survey weights were constructed by

first ranking geodemographic distributions of the 18-years-and-over parent population with

children ages 0-17 years. Once all survey data were collected, design weights are adjusted to

account for differential nonresponse. The following demographic data were collected and used in

survey weights: respondent self-identified gender (male and female), respondent age (18-34, 35-

44, 45+), race-ethnicity (white/Non-Hispanic, Black/Non-Hispanic, Other/Non-Hispanic,

Hispanic, 2+ Races/Non-Hispanic), census region (Northeast, Midwest, South, and West),

metropolitan status (metro and non-metro), education (less than high school, high school, some

college, bachelor or higher), annual household income (under $25K, $25K-$49,999, $50K-

$74,999, $75K-$99,999, $100K-$149,999, $150K and over) and language (Appendix).

Survey Instrument

We developed the survey instrument to capture changes in physical, mental (parent) and

behavioral (child) health, health insurance status, food security, use of public food assistance

resources, childcare, and use of health care services. We adapted questions from the National

Survey of Children’s Health on food security, enrollment in food assistance programs (e.g., the

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the

Supplemental Nutrition Assistance Program (SNAP)), and health insurance.17 We constructed

additional questions to capture changes in the physical health of parents and children, parents’




mental health, children’s behavioral health, children’s insurance status, and childcare. For all

questions about changes, we asked respondents to use March 2020 as the reference point for the

period before or at the very beginning of the pandemic. We also asked questions about delays in

medical care among children (Appendix). We categorized food insecurity as mild (“we could

always afford enough to eat but not always the kinds of food we should eat”), moderate

(“sometimes we could not afford enough to eat”) and severe (“often we could not afford enough

to eat”). The survey was available in English and Spanish.

Data Analysis

We conducted all analyses using survey weights to provide national estimates. Descriptive

statistics were calculated to summarize response frequency. Respondents who refused to answer

a question were considered missing and not used in calculating proportions. All questions had

fewer than 0.5% refusals. We report all summary statistics as the weighted proportion estimate

with its 95% confidence interval. We conducted significance testing for unpaired questions using

Rao-Scott corrected chi-square tests. For paired testing of questions that asked for pre- and post-

COVID-19 comparisons, we used global p-values from McNemar and Exact Multinomial tests

for symmetry. The significance level was set at α=.05, and all tests were 2-sided. All analyses

were conducted using R version 3.6.2 (R Core Team, Vienna, Austria).




Results

Changes in Health Status, Health Insurance, and Health Care Delays

Compared to March 2020, 26.9% (95% confidence interval (CI): 23.9-29.9%) of parents reported

worsening of mental health, and 14.3% (95% CI: 12.0-16.7%) reported worsening in their

children’s behavioral health (Figure 1). For physical health, 17.7% (15.0-20.3%) of parents

reported a worsening of their own, and 3.8% (2.5-5.1%) reported a worsening of their children’s.

The reported declines in mental health for parents, behavioral health for children, and physical

health were similar across respondents from most racial/ethnic, income, education groups and

US Census Regions, but female and unmarried parents reported higher rates of worsening of

their own mental health. Further, a higher proportion of families with younger children reported

worsening mental and behavioral health when compared to families with older children (Table

1). About one in ten (9.6%, 7.6-11.7%) parents reported worsening of both their mental health

and their children’s behavioral health (Supplemental Table 1).

Parents reported statistically significant differences in the source of their children’s health

insurance compared to March 2020 with a decrease in employer-sponsored insurance, small

increases in other sources of private insurance and public insurance, and no substantial change in

the proportion who were uninsured (Table 2; p<0.001). Slightly more than one-third (39.9%,

36.6-43.2%) of families reported cancelations or delays in their children’s health care since

March 2020. The most commonly delayed visit types were well child visits (49.4%, 44.0-




54.7%), visits with subspecialists (13.0%, 9.5-16.5%), and behavioral health visits (9.4%, 6.3-

12.5%; Supplemental Table 2).

Food Security

Parents reported more food insecurity at the time of the survey compared to March 2020 with the

proportion reporting any food insecurity increasing from 32.6% (29.4-35.8%) to 36.0% (32.7-

39.3%; Table 2). Parents did not report significant changes in enrollment in SNAP or WIC.

There was a statistically significant difference in parents reporting the use of food banks or

pantries before and after March 2020, but the absolute increase was very small (0.3 percentage

points). An estimated 17.5% (14.8-20.1%) of parents reported that their children received free or

reduced-price lunch at schools prior to the pandemic, making them eligible for free school-

related food programs and the Pandemic Electronic Benefit Transfer (P-EBT) program during

COVID-19. At the time of the survey, 15.4% (12.9-17.8%) of all parents reported receiving free

food from schools for their children, and 5.0% (3.5-6.5%) reported enrollment in the P-EBT

program.

Childcare

Disruptions in childcare were common, with nearly one-quarter (24.1%, 21.1-27.1%) of parents

reporting loss of regular childcare. Among parents who lost childcare, the majority (74.1%, 67.6-

80.7%) reported that their child was watched by a parent (Supplemental Table 3). Disruption of

regular childcare varied substantially by the age of the children in the home. For homes with




children 0-5 years old, 38.6% (33.4-43.7) experienced disruptions compared with 7.5% (4.9-

10.1) of families with adolescents 13-17 years old (Supplemental Table 4).

Factors Co-occurring with Parent Mental Health and Child Behavioral Health

Among the 10% of families in which parents reported both worsening of their own mental health

and their children’s behavioral health, 47.6% (36.3-58.9%) lost regular childcare during the

pandemic and 11.1% (3.7-18.5%) also reported less food security (Table 3).

Discussion

Parents and children have been substantially affected by the COVID-19 pandemic. More than 1

in 4 parents reported worsening mental health and 1 in 7 parents reported worsening behavioral

health for their children since the pandemic began. Worsening of parental mental health and

children’s behavioral health were at times intertwined, with nearly 1 in 10 families reporting

worsening of both. Loss of childcare, delays in health care visits, and worsened food security

were common among families experiencing worse mental and behavioral health.

Disruption in routines can be detrimental for children, especially those already with behavioral

health diagnoses.18 For some children, this is complicated by challenges accessing traditional

office-based services and the loss of mental health services that students may receive at school.19

A recent poll found that parents were worried about how school closure was affecting their

children’s mental and emotional health,20 and similar disruptions are evident in our study. The




American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry21

and the American Psychiatric Association21 recently released guidance on school reopening that

addresses physical and mental wellbeing of children. These recommendations suggest that

schools prepare for a range of mental health conditions among children, provide enhanced

training for teachers, engage mental health professionals in COVID-19-related messaging to

children, address the mental health needs of staff, and focus additional resources for children

with special needs. The issues around school openings across the US are complex, and plans will

vary by community. In some communities, school will be remote, and schools should consider

working with pediatricians and mental health professionals on how they may address mental

health of children, parents and staff even when school is remote. To implement these strategies

effectively, Congress could consider enhanced funding to schools to address schools’ budgetary

challenges related to implementing these recommendations. To address the mental health needs

of children, providing funding to support the availability of tele-behavioral health services

through schools or other sources in the community and parity of coverage and reimbursement

between video and audio-only modalities for children who lack reliable internet access may be

important.

We also observed improvements in behavioral, mental and physical health for a subset of the

population and no changes in these domains for the majority of the population, highlighting the

heterogeneity in the effects of the pandemic and its consequences on families. Notably, we find

that rates of worsening parental mental health and child behavioral health are similar among

many socio-demographic groups (e.g., race, income). However, our results suggest that some

populations have been disproportionately affected, including single-parent families and those




with younger children. Supports for families who lost regular caregiver support for young

children may need to be tailored.

Our findings revealed small but potentially important changes to children’s insurance status with

an approximately three percentage point reduction in employer-sponsored insurance,

representing about two and a half million children. This decrease within just one calendar quarter

could be due to the large increase in unemployment4 that occurred during the economic recession

that followed social distancing measures. We did not find changes in uninsurance status,

suggesting that small increases in Medicaid and private plans on health insurance exchanges may

offset some short-term losses of employer-sponsored insurance. However, changes in insurance

status and other social influences on health for children should continue to be monitored as the

pandemic and the resulting economic effects continue. Congress could consider additional

supports to state Medicaid programs through enhancing the federal match,22,23 employer-

sponsored insurance by providing subsidies to families to maintain converge (i.e., COBRA

subsidies), and health insurance exchanges through expanded open enrollment periods.

Nearly 1 in 10 families reported moderate or severe food insecurity since March 2020. Despite

the increase in food insecurity, there was not an increase in parents reporting receipt of SNAP or

WIC. We found only a small increase in food bank use, however, it is possible the utilization of

food banks may be underestimated since families may have received food support from

organizations they did not identify as food banks (e.g., schools). The Families First Coronavirus

Response Act24 (FFCRA) and the Coronavirus Aid, Relief, and Economic Securities (CARES)

Act25 were signed into law in March 2020 to provide relief from the economic impact of




COVID-19.26 These laws included provisions authorizing emergency funding for food assistance

programs, including additional support for existing SNAP recipients and the establishment of the

P-EBT program for families with children who receive free or reduced- price meals at school

through the National School Lunch Program (NSLP). The NSLP serves 30 million children,27

making schools an essential source of nutrition for many children, many of whom had been out

of school for months at the time of our study. In this study, the uptake of P-EBT was limited,

though many families appeared eligible based on participation in other food assistance programs.

Early reports on P-EBT suggest uneven adoption among states even as need for the program

surged.28 Our findings suggest additional efforts may be needed to mitigate observed reductions

in family food security, including connecting families eligible for existing programs with support

through outreach and reduction of administrative burdens.

Limitations

The results of our study should be interpreted in the context of certain limitations. First, our data

were collected at one time point rather than longitudinally. However, the recall period was

relatively short (three months), and our results demonstrating worsening behavioral and mental

health for children and parents are qualitatively similar to a panel study early in the pandemic

from a large city.15 Second, our survey respondents had higher levels of socioeconomic status

compared to non-respondents. The potential for non-response bias should be mitigated by the

relatively rich data on non-respondents and our approach to survey weights. Finally, our data rely

on self-reports rather than clinical health assessments or administrative data on enrollment in

programs. Our findings about adult mental health – as an example, however, are consistent with




a recent poll using the validated Kessler 6 Psychological Distress Scale with an adult sample in

April 2020.2

Conclusion

The COVID-19 pandemic is having a substantial tandem impact on parents and children in the

US. As policymakers consider additional measures to mitigate the health and economic effects of

the pandemic, they should consider the unique needs of families with children, including support

for mental and behavioral health and efforts to improve food security.

Acknowledgments: The authors would like to thank William Dupont, PhD and Elizabeth

McNeer, MS for their statistical input on this manuscript.

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Figure 1. Parental Physical and Mental Health and Child Physical and Behavioral Health Changes Since March 2020.

*Differences in health status between parents and children p<0.001 by Rao-Scott corrected-Chi-square test




Table 1. Proportion of Parents and Children with Reported Worsening Physical, Mental and Behavioral Health Since March 2020 by Demographic Groups.

Parent Child

Physical

Health

Mental

Health

Physical

Health

Behavioral

Health

Reference Before March 2020 Weighted %

(95% CI)

Weighted %

(95% CI)

Weighted % (95% CI)

Weighted %

(95% CI)

Parent education

High School or Less (n=343) 12.5% (8.4, 16.6) 23.3% (18.1, 28.6) 2.9% (0.8, 5.0) 11.8% (7.9, 15.6)

Some College (n=261) 20.5% (14.9, 26.1) 28.1% (21.9, 34.4) 4.5% (1.5, 7.5) 16.8% (11.6, 22.1)

4-year College Degree or more (n=407)

20.2% (16.0, 24.3) 29.0% (24.5, 33.5) 4.1% (2.1, 6.1) 14.9% (11.4, 18.3)

Race/Ethnicity

White non-Hispanic (n=579) 16.8% (13.8, 19.8) 29.0% (25.3, 32.6) 2.7% (1.5, 3.9) 15.8% (12.8, 18.8)

Black non-Hispanic (n=109) 16.4% (7.6, 25.2) 26.1% (15.3, 37.0) 2.1% (-0.8, 4.9) 15.0% (7.1, 22.9)

Hispanic (n=221) 17.6% (11.4, 23.8) 20.4% (13.9, 26.8) 5.2% (1.6, 8.7) 11.1% (6.1, 16.0)

Other (n=103) 24.0% (13.4, 34.5) 29.6% (18.6, 40.6) 9.0% (1.7, 16.4) 12.2% (3.8, 20.5)

Income

<25,000 (n=91) 19.1% (10.2, 28.1) 22.7% (13.1, 32.3) 5.5% (-0.6, 11.6) 17.6% (8.6, 26.6)

25,000 to <50,000 (n=164) 19.2% (11.9, 26.6) 30.1% (21.7, 38.6) 7.1% (2.4, 11.9) 15.0% (8.7, 21.3)

50,000 to <100,000 (n=313) 14.7% (10.2, 19.2) 26.2% (20.8, 31.6) 1.6% (0.3, 2.9) 15.8% (11.2, 20.4)

>100,000 (n=444) 18.8% (15.0, 22.7) 27.0% (22.6, 31.3) 3.8% (1.9, 5.7) 12.3% (9.2, 15.4)

Marital Status

Married (n=817) 16.7% (13.9, 19.5) 25.0% (21.8, 28.2) 3.5% (2.1, 4.9) 13.2% (10.7, 15.7)

Unmarried (n=194) 21.6% (14.7, 28.6) 34.7% (26.7, 42.7) 4.9% (1.3, 8.6) 19.0% (12.5, 25.5)

Parent Gender

Female (n=560) 18.5% (14.9, 22.1) 31.5% (27.3, 35.8) 3.2% (1.7, 4.8) 15.8% (12.6, 19.1)




Male (n=451) 16.7% (12.8, 20.5) 21.1% (17.0, 25.1) 4.5% (2.3, 6.7) 12.5% (9.1, 15.8)

Census Region

Northeast (n=163) 19.5% (12.5, 26.6) 28.7% (20.5, 36.8) 3.3% (0.2, 6.4) 18.3% (11.5, 25.1)

Midwest (n=217) 18.8% (13.4, 24.3) 30.6% (24.0, 37.1) 3.0% (0.6, 5.4) 14.9% (9.8, 19.9)

South (n=381) 15.8% (11.5, 20.1) 23.7% (18.8, 28.6) 4.1% (1.7, 6.4) 10.5% (7.1, 13.9)

West (n=249) 18.2% (13.1, 23.3) 27.3% (21.6, 32.9) 4.4% (1.7, 7.2) 17.1% (12.2, 21.9)

Child(ren) Age*

0-5 (n=462) 20.8% (16.5, 25.1) 31.4% (26.5, 36.2) 2.5% (0.8, 4.2) 17.8% (13.8, 21.8)

6-12 (n=512) 19.9% (16.1, 23.7) 29.9% (25.6, 34.2) 5.2% (3.1, 7.4) 14.9% (11.6, 18.2)

13-17 (n=448) 14.4% (10.9, 17.9) 22.1% (18.0, 26.2) 4.1% (2.0, 6.2) 11.3% (8.4, 14.3)

* Due to the potential of parents to have children in more than one age group, the n for this section may sum to larger than the total sample size




Table 2. Changes in Insurance Status, Food Insecurity and Food Assistance Programs, Before and After March 2020.

Before March 2020 Since March 2020

% (95%CI) % (95% CI) p-value

Insurance Status* <0.001

Employer-Sponsored Insurance 62.7% (59.4, 66.1) 59.6% (56.3, 63.0)

Medicaid or CHIP 22.7% (19.7, 25.7) 23.3% (20.3, 26.3)

Private insurance 3.3% (2.1, 4.5) 4.5% (3.2, 5.8)

Exchange Plan 1.8% (1.0, 2.6) 2.7% (1.6, 3.7)

TriCare 3% (1.9, 4.0) 3.2% (2.0, 4.4)

Uninsured 4.1% (2.6, 5.5) 3.5% (2.2, 4.8)

Other 2.4% (1.4, 3.4) 3.3% (2.1, 4.5)

Food insecurity* <0.001

None 67.4% (64.2, 70.6) 64.0% (60.7, 67.3)

Mild 26.7% (23.7, 29.7) 28% (25.0, 31.1)

Moderate 4.6% (3.1, 6.1) 6.2% (4.4, 8.1)

Severe 1.3% (0.4, 2.2) 1.8% (0.7, 2.8)

Food Assistance Programs**

Food Stamps or SNAP 10.1% (8.0, 12.1) 9.5% (7.5, 11.6) 0.256

WIC 5.8% (4.0, 7.6) 5.8% (4.0, 7.6) 1.000

Food Banks 4.6% (3.1, 6.2) 4.9% (3.3, 6.5) 0.002

Free or Reduced-Price School Lunch 17.5% (14.8, 20.1) -

Pandemic-EBT*** - 5.0% (3.5, 6.5)

Free Food from School - 15.4% (12.9, 17.8)

None 74.4% (71.3, 77.5) 70.2% (67.0, 73.4) 0.001

*Global p-value reported from an Exact Multinomial Test for symmetry between paired Before and Since March 2020 responses **p-values reported from McNemar tests for symmetry between each paired Before and Since March 2020 response ***Only families who qualified for free or reduced-price school meals Pre COVID-19 were eligible for Pandemic-EBT enrollment




Table 3. Co-occurrence of Worsening of Parent Mental Health and Child Behavioral Health with Changes in Food Security, Health Care Delays, Childcare, and Insurance During the COVID-19 Pandemic

Behavioral and Mental Health Worsening

Parent only Child only Both Child & Parent

Weighted % (95%CI) Weighted % (95%CI) Weighted % (95%CI)

Worsened Food Security 7.4% (3.1, 11.7) 19.0% (6.3, 31.6) 11.1% (3.7, 18.5)

Health Care Visit Delay 45.1% (37.0, 53.2) 56.9% (42.5, 71.4) 55.9% (44.8, 67.0)

Lost Regular Childcare 35.1% (27.2, 43.0) 45.4% (30.8, 60.1) 47.6% (36.3, 58.9)

Change in Insurance 7.5% (3.8, 11.3) 8.7% (1.1, 16.3) 16.0% (8.0, 24.0)




Supplemental Table 1. Changes in Physical, Mental and Behavioral Health Among Parents and Children.

Child

Physical

Health

Parent Physical Health

Better Worse No Change

Better 3.1% (1.8, 4.4) 0.3% (0.0, 0.7) 2.5% (1.5, 3.6)

Worse 0.2% (-0.1, 0.5) 2.3% (1.2, 3.4) 1.3% (0.6, 2.1)

No Change 6.8% (5.2, 8.4) 15.1% (12.7, 17.6) 68.3% (65.1, 71.4)

Child

Behavioral

Health

Parent Mental Health

Better Worse No Change

Better 1.6% (0.6, 2.5) 1.1% (0.3, 1.9) 2.8% (1.7, 3.9)

Worse 0.9% (0.2, 1.6) 9.6% (7.6, 11.7) 3.9% (2.7, 5.0)

No Change 2.6% (1.5, 3.7) 16.1% (13.6, 18.6) 61.4% (58.1, 64.7)




Supplemental Table 2. Child Healthcare Visit Disruptions Among Families With Children <18 Years Old.

Child Healthcare Visit Disruptions

% (95% CI)

Child Healthcare Visit Delayed or Canceled 39.9% (36.6, 43.2)

Of those, which service was disrupted?*

Well child check up 49.4% (44.0, 54.7)

Vaccination 9.3% (6.0, 12.6)

Follow-up visit for a chronic or long-term condition 8.1% (5.2, 10.9)

Sick visit to my child’s regular doctor 6.1% (3.3, 8.9)

Visit with a subspecialist doctor 13.0% (9.5, 16.5)

Surgery or procedure 4.2% (2.0, 6.4)

Radiology/Diagnostic Procedure 1.6% (0.3, 3.0)

Physical, occupational, or speech therapy appointment 6.9% (4.2, 9.6)

Behavioral health visit 9.4% (6.3, 12.5)

Medicine or drug given at a doctor’s office or hospital 2.7% (0.6, 4.9)

Other 26.6% (22.0, 31.2)

* Due to the select-all-that-apply nature of this question, the total proportion may be greater than 100%




Supplemental Table 3. Caregiver Disruptions Among Families With Children <18 Years Old.

Caregiver Disruptions

% (95% CI)

Disruption of regular childcare 24.1% (21.1, 27.1)

Of those, replacement caregiver?*

Myself or other parent 74.1% (67.6, 80.7)

Grandparent 20.4% (14.3, 26.5)

Adult Family Member 8.7% (4.7, 12.8)

Took care of themselves 5.7% (2.2, 9.3)

Older Child family member 5.3% (1.7, 8.9)

Stayed with a friend 5.2% (1.5, 9.0)

Adult neighbor/friend 3.0% (0.5, 5.4)

Older Child neighbor/friend 1.1% (-0.1, 2.3)

* Due to the select-all-that-apply nature of this question, the total proportion may be greater than 100%




Supplemental Table 4: Caregiver Disruptions Among Families With Children <18 Years Old, by Age of Children in the Home.

Stratified by parents with children in specified age groups

≥1 child 0-5 (45.7%)

≥1 child 6-12 (50.7%)

≥1 child 13-17 (44.3%)

Childcare Disruptions 38.6% (33.4,43.7)

23.2% (19.2,27.2)

7.5% (4.9,10.1)

Of those, replacement caregiver?*

Myself or other parent 74.6% (66.6,82.7)

75.3% (66.8,83.8)

67.9% (50.3,85.4)

Grandparent 23% (15.5,30.6)

16.1% (8.5,23.7)

21.4% (5.1,37.6)

Adult Family Member 7.8% (2.9,12.6)

9.7% (4.1,15.3)

9.1% (0.7,17.5)

Stayed with a friend 6.6% (1.6,11.6)

2.8% (-1.2,6.8) 0% (0,0)

Older Child family member 5.6% (1.3,10) 6.2% (0.8,11.6)

8.6% (-0.9,18)

Took care of themselves 3.2% (-0.4,6.8) 8% (2.8,13.1) 11.2%

(1.5,20.9)

Adult neighbor/friend 1.3% (-0.3,2.9)

3.4% (-0.4,7.2)

9.1% (-1.3,19.6)

Older Child neighbor/friend 0.5% (-0.5,1.4)

1.5% (-0.6,3.7) 2.4% (-2.3,7)

* Due to the select-all-that-apply nature of this question, these may total more than 100%; On average, parents selected 1.2 , 1.2 , 1.4 responses for each age group, respectively.




Supplemental Table 5. Changes in Food Insecurity During COVID-19 Pandemic.

Before

March 2020

Since March 2020

None Mild Moderate Severe

None 62% (58.7, 65.3) 4.5% (3.1, 5.9) 0.9% (0.2, 1.7) .

Mild 1.9% (1.0, 2.8) 22.6% (19.7, 25.4) 1.8% (0.8, 2.9) 0.3% (0.0, 0.6)

Moderate 0.1% (-0.1, 0.3) 1.0% (0.3, 1.7) 3.2% (1.9, 4.4) 0.3% (-0.1, 0.6)

Severe . . 0.1% (-0.1, 0.4) 1.2% (0.3, 2.1)




Methodological Supplement:

Ipsos KnowledgePanel and the Government & Academic Omnibus Methodology

Introduction Ipsos has recruited the first online research panel that is representative of the entire U.S. population. Panel members are randomly recruited through probability-based sampling, and non-internet households are provided with an internet-enabled tablet so that they can join the panel and complete surveys.

Ipsos recruits panel members by using address-based sampling (ABS) methods (previously we relied on random-digit dialing [RDD] methods). Once household members are recruited for the panel and assigned to a study sample, they are notified by email for survey taking, or panelists can visit their online member page for survey taking (instead of being contacted by telephone or postal mail). This allows surveys to be fielded quickly and economically. In addition, this approach reduces the burden placed on respondents, since email notification is less intrusive than telephone calls and most respondents find answering online questionnaires more interesting and engaging than being questioned by a telephone interviewer. Furthermore, respondents have the convenience to choose what day and time to complete their assigned survey.

KnowledgePanel Methodology Information KnowledgePanel is the largest online panel that relies on probability-based sampling techniques for recruitment; hence, it is the largest national sampling frame from which fully representative samples can be generated to produce statistically valid inferences for study populations. Our panel provides samples with the highest level of representativeness available in online research for measurement of public opinions, attitudes, and behaviors. The panel was first developed in 1999. Panel members are randomly selected so that survey results can properly represent the U.S. population with a measurable level of accuracy, features that are not obtainable from nonprobability panels (for comparisons of results from probability versus nonprobability methods, see Yeager et al., 20111).

KnowledgePanel’s recruitment process was originally based exclusively on a national RDD sampling methodology. In 2009, in light of the growing proportion of cellphone-only households, we migrated to an ABS recruitment methodology via the U.S. Postal Service’s Delivery Sequence File (DSF). ABS not only

1 Yeager, D., Krosnick, J., Chang, L., Javitz, H., Levendusky, M., Simper, A. and R. Wang (2011). "Comparing the Accuracy of RDD Telephone Surveys and Internet Surveys Conducted With Probability and Non-Probability Samples." Public Opinion Quarterly, Winter 2011.




improves population coverage but also provides a more effective means for recruiting hard-to-reach individuals, such as young adults and minorities. Households without Internet connection are provided with a web-enabled device and free Internet service.

After initially accepting the invitation to join the panel, participants are asked to complete a short demographic survey (the initial Core Profile Survey); answers to this survey allow efficient panel sampling and weighting for future surveys. Upon completing the Core Profile Survey, participants become Active Panel members. All panel members are provided privacy and confidentiality protections.

ABS Recruitment To enhance the DSF-based sampling frame used for address selection, we require that our sample vendor append various ancillary data to each household address, thus facilitating sample stratification to proactively address differential recruitment rates observed by some demographics.2 Taking advantage of such refinements, quarterly samples are selected using a disproportionate stratified sampling methodology; typically oversampled households include those likely to have an 18 to 29 year old, likely to have a Hispanic household member, and those in rural areas.

Adults from sampled households are invited to join KnowledgePanel through a series of mailings, including an initial invitation letter, a reminder postcard, and a subsequent follow-up letter. Moreover, telephone refusal-conversion calls are made to nonresponding households for which a telephone number could be matched to a physical address. Invited households can join the panel by:

• Completing and mailing back a paper form in a postage-paid envelope • Calling a toll-free hotline phone number maintained by Ipsos • Going to a designated Ipsos website and completing the recruitment form online

Household Member Recruitment During the initial recruitment survey, all household members are enumerated. Following enumeration, attempts are made to recruit every household member who is at least 13 years old to participate in KnowledgePanel surveys. For household members aged 13 to 17, consent is collected from the parents or the legal guardian during the initial recruitment interview. No direct communication with teenagers is attempted before obtaining parental consent. While surveys can be conducted with these teens directly, in most instances teen surveys are conducted by first selecting a sample of active members who are parents. This parent route alternative makes it possible to reach a larger sample of teens.

2 Fahimi, M. and D. Kulp (2009). “Address-Based Sampling – Alternatives for Surveys That Require Contacts with

Representative Samples of Households.” Quirk’s Marketing Research Review, May 2009.




Survey Sampling from KnowledgePanel Once panel members are recruited and profiled by completing our Core Profile Survey, they become eligible for selection for client surveys. Typically, specific survey samples are based on the equal probability selection method (EPSEM) for general population surveys. Customized stratified random sampling based on “profile” data can also be implemented as required by the study design. Profile data can also be used when a survey calls for pre-screening—that is, members are drawn from a subsample of the panel, such as females, Republicans, grocery shoppers, etc. (This can reduce screening costs, particularly for rare subgroups.) In such cases, we take care to ensure that all subsequent survey samples drawn that week are selected in such a way as to result in a sample that remains representative of the panel distributions.

Survey Administration Once assigned to a survey, members receive a notification email letting them know there is a new survey available for them to complete. This email notification contains a link that sends them to the survey. No login name or password is required. The field period depends on the client’s needs and can range anywhere from a few hours to several weeks.

After three days, automatic email reminders are sent to all non-responding panel members in the sample. Additional email reminders are sent as needed. To assist panel members with their survey taking, each individual has a personalized member portal listing all assigned surveys that have yet to be completed.

Ipsos also operates an ongoing modest incentive program to encourage participation and create member loyalty. The incentive program includes special raffles and sweepstakes with both cash rewards and other prizes to be won. Typically, we assign panel members no more than one survey per week. On average, panel members complete two to three surveys per month with durations of 10 to 15 minutes per survey. An additional incentive is usually provided for longer surveys.

Response Rates As a member of the American Association of Public Opinion Research (AAPOR), Ipsos follows the AAPOR standards for response rate reporting. While the AAPOR standards were established for single survey administrations and not for multi-stage panel surveys, we use the Callegaro-DiSogra (2008)3 algorithms for calculating KnowledgePanel survey response rates. Generally the KnowledgePanel survey completion rate is about 60%, with minor variations due to survey length, topic, sample specifications, and other fielding characteristics. In contrast, virtually all surveys that employ nonprobability online panels typically achieve survey completion rates in the low single digits.

3 Callegaro, M. and C. DiSogra (2008). “Computing Response Metrics for Online Panels.” Public Opinion Quarterly, Vol. 72, No. 5.




Survey Instrument

Base: All respondents Q1 [S] Which of the following statements best describes your household’s ability to afford the food you needed before March 2020 when coronavirus (COVID-19) began to spread in the United States?

1. We could always afford good nutritious meals 2. We could always afford enough to eat but not always the kinds of food we should eat 3. Sometimes we could not afford enough to eat 4. Often we could not afford enough to eat

Base: All respondents Q2 [S] Before March 2020 when coronavirus (COVID-19) began to spread in the US, did you or any member of your household receive benefits from (select all that apply):

Scripter, Randomize responses

1. The Food Stamp Program or SNAP (the Supplemental Nutrition Assistance Program) 2. WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children) 3. Food banks or food pantries 4. [Show if xparent=1] Free or reduced-price lunch at school (the School Lunch Program) 5. None of these (Exclusive)

Base: if xparent=1 Q3 [S] Before March 2020 when coronavirus (COVID-19) began to spread in the US, what best describes the health insurance status of your child(ren):


1. No insurance 2. Medicaid or the Children’s Health Insurance Program 3. Private insurance from my employer 4. Private insurance purchased directly from an insurer 5. Private insurance purchased on a health insurance exchange 6. TriCare 7. Other




Base: All respondents Q4 [S] Which of the following statements best describes your household’s ability to afford the food you need since March 2020 when coronavirus (COVID-19) began to spread in the US?

1. We could always afford good nutritious meals 2. We could always afford enough to eat but not always the kinds of food we should eat 3. Sometimes we could not afford enough to eat 4. Often we could not afford enough to eat

In addition to programs that existed before March 2020, Congress passed the Families First Act which allowed families of children who qualified for free or reduced-price lunch at school to receive cash to purchase food for their children in grocery stores. The program is also called Pandemic-EBT.

Base: All respondents Q5 [S] Since March 2020 when coronavirus (COVID-19) began to spread throughout the US, have you received assistance from any of the following (check all that apply):


1. The Food Stamp Program or SNAP (the Supplemental Nutrition Assistance Program) 2. WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children) 3. Food banks or food pantries 4. [Show if xparent=1] Free Pandemic EBT (benefits to purchase food for families of children who qualify for

free or reduced-price school meals) 5. [Show if xparent=1] Free Food picked up from your child’s school or delivered from the school 6. None of these (Exclusive)

Base: if xparent=1 Q6 [S] Since March 2020 when coronavirus (COVID-19) began to spread in the US, what best describes the health insurance status of your child(ren):


1. No insurance 2. Medicaid or the Children’s Health Insurance Program 3. Private insurance from my employer 4. Private insurance purchased directly from an insurer 5. Private insurance purchased on a health insurance exchange 6. TriCare 7. Other




Scripter: Rotate the order of Q7a/7b

Base: if xparent=1 Q7a [S] Since March 2020, has the physical health of any of your children gotten better or worse?

1. Yes, gotten better 2. Yes, gotten worse 3. No, there has been no change

Base: if xparent=1 Q7b [S] Since March 2020, has the behavioral health of any of your children gotten better or worse?


Base: if xparent=1 Q8 [S] Since March 2020, has your child(ren) had a healthcare visit canceled or delayed for any reason?

1. Yes 2. No

Base: if Q8=1 Q8a [M] What reasons were given for it being cancelled or delayed? Please check all that apply

Scripter: Randomize items

1. Well child check up 2. Vaccination 3. Follow-up visit for a chronic or long-term condition 4. Sick visit to my child's regular doctor 5. Visit with a subspecialist doctor (such as a pediatric allergist, cardiologist or neurologist) 6. Surgery or procedure 7. X-ray, ultrasound, CT scan, MRI scan or other diagnostic procedure 8. Physical, occupational, or speech therapy appointment 9. Behavioral health visit with a psychiatrist, psychologist, or other therapist 10. Medicine or drug given at a doctor’s office or hospital 11. other service: ________________________________________________




Base: if xparent=1 Q9 [S] Since March 2020, did you lose regular childcare arrangements for at least one day? (for example, due to cancellations from babysitters, day care center, or other care providers)

1. Yes 2. No

Base: if Q9=1 Q9a [M] When this happened, was there a replacement caregiver? Please select all that applied during this period.

1. Yes: myself or the child’s/children’s other parent 2. Yes: a grandparent 3. Yes: an adult family member 4. Yes: an older child family member 5. Yes: an adult neighbor or friend 6. Yes: an older child neighbor or friend 7. No: My child(ren) stayed with a friend during the day 8. No: my child(ren) took care of herself/himself/themselves

Scripter: Rotate the order of Q10a/10b

Base: if xparent=1 Q10a [S] Since March 2020, has your own physical health gotten better or worse?


Base: if xparent=1 Q10b [S] Since March 2020, has your own mental health gotten better or worse?



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originally published online July 24, 2020; Pediatrics Halvorson, Sarah Loch, Mia Letterie and Matthew M. Davis

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