I. Why Early Childhood Matters
The global failure to support young children’s development predates COVID-19. Prior to pandemic disruptions, early childhood care and education (ECCE) had poor outreach. In many places, it was absent altogether. In low- and middle-income countries (LMICs), access to ECCE services ranged from 20% to 55%, compared with nearly 80% in high-income countries.[1] An estimated 250 million children in LMICs, representing 43% of the world’s children, were at risk of not meeting their developmental potential due to biological and psychosocial risks in the first 5 years of life (e.g., malnutrition, inadequate early learning opportunities, maternal depression, and exposure to violence).[2] Young children in Southern Africa and South Asia bore higher burdens,[1] illustrating the fragility and inequitable access to support systems for the youngest citizens.
The pandemic further compounded existing inequities between children living in disadvantaged versus advantaged contexts, between urban and rural populations, and in remote regions around the world. In the first 11 months of the pandemic, the number of children off track in their early development increased further by an estimated 10.75 million children. Throughout the pandemic, around half of in-person teaching days were lost. In LMICs, the proportion of in-person instruction days lost due to preschool closures was 50-57%, and the number of children off track in their early development increased by slightly more than 10 million. In contrast, for young children living in high-income countries, the proportion of in-person instruction days lost was less (about 46%), with far fewer children off track in their early development (fewer than 0.5 million).[1] Early childhood development refers to the period from conception to 8 years of age. It is a sensitive window of opportunity, particularly in the first 3 years of life, when children transition from their family and home environments to neighborhoods, communities, and ECCE environments. [3] Early childhood is a time of rapid brain development that lays the foundations for sensory-motor and cognitive-language skills that will grow in the life course. Development is a robust process, with genetics forming the blueprint for foundational skills, but the child’s experiences – their exposure to the environment and their social interactions – shapes the quality of healthy brain development. Due to greater neuroplasticity, protective factors and risks both exert their influence on the developing brain.
The development established in these early years is also the foundation upon which later development, interventions, and other important points in the life course, such as adolescence, are built. The skills acquired in these early years predict later learning outcomes in adulthood. Studies on the personal, social, and emotional impacts of investments in early childhood development point to social competence of children in this age group as an indicator of positive and negative outcomes in education, employment, criminal justice, substance abuse, and mental health in adulthood.[4] Therefore, promoting protective environments and reducing the risks that emerge from harmful environments or experiences around the world’s youngest children is critical.
Much expert attention on the impact of COVID-19 on children concerns those of primary- and secondary-school age. Less attention has been devoted to the wellbeing of those in utero and the more than 800 million children aged 5 years and younger who collectively represent roughly 10% of the total world population.[1] The pandemic has impacted every aspect of nurturing care in the short and longer term: young children’s physical and mental health, safety, security, access to food and healthy nutrition, and opportunities to learn,[5] and it has disrupted childhood immunization schedules, triggering the largest backslide in childhood vaccinations in 30 years. In 2021, 25 million children missed out on one or more doses of vaccines against diphtheria, tetanus, and pertussis – 2 million more than in 2020 and 6 million more than in 2019.[6]
Furthermore, COVID-19 has affected the health, routines, and capacity of caregivers to provide optimal positive nurturing and responsive care.[7] Adults suffered through lengthy periods of job, income, food, housing, and familial insecurity. Grandparents have been socially isolated and physically, economically, and psychologically burdened. Given the dependence of the very young on their parents, grandparents, caretakers, and communities, a full study of the health, social, and economic impact of COVID-19 on early childhood development must give equal consideration to the impact on caregivers and on the environments children grow up in as well.
The rigorous and compelling research findings that have accumulated to date indicate that the full breadth and intensity of the pandemic’s consequences will take decades to manifest. Today’s young children and their families, communities, and societies will experience what is effectively a social form of long COVID over this time frame. The compounded COVID-19 impacts on these groups, if left unaddressed, have long-term implications for children’s developmental trajectories along the life course.
II. The Impact of COVID-19 on Young Children and Their Caregivers
Children’s relative insusceptibility to infection and severe disease has muted the pandemic’s impact on the health of young children. The rapid spread of the Omicron variant proved that COVID-19 infection in the very young is not uniformly benign. In the United States, for example, the hospitalization rate for children under 5 years was five times what it was during previous surges. As of July 2022, a handful of countries, among them the United States, Argentina, Bahrain, China, Cuba, and Venezuela, have authorized COVID-19 vaccines for children under 5 years.[8] Even so, the benefits of vaccinating the youngest age group remain unclear, and parent hesitation to vaccinate their very young children matches expert consensus. Since June 18 when these children became eligible in the United States, just 2.8% of this population sector has received shots, and 43% of parents report that they would “definitely not” vaccinate their children under 5 years.[9]
Nevertheless, the risks for early childhood development go beyond children’s health. The pandemic’s substantial negative spillovers with respect to the social and economic wellbeing of young children and their caregivers have magnified these risks. They are wide-ranging and include reduced ECCE access due to episodic childcare and preschool closures;[10] disruptions of access and adherence to routine immunization and other well-baby and well-child schedules; increased parental anxiety, stress, and depression; and increased violence against young children.[10,11]
COVID-19 has caused much excess morbidity and mortality throughout the world, with the World Health Organization estimating excess mortality between January 2020 and December 2021 at nearly 15 million deaths.[12] Among these losses, more than 5 million are of parents or grandparents responsible for the care of young children in the first period of the pandemic.[13] Three-quarters of these deaths are of paternal caregivers. Global estimates between March 2020 and April 2021 from 21 countries indicate that 1,042,000 children became orphans due to COVID-19 caregiver losses and nearly 1,134,000 children lost a significant primary or secondary caregiver. These vulnerable children face risks along the life course in terms of their health, their psychosocial wellbeing, and their economic security. We must think about multisectoral actions that target the most vulnerable within these populations now to ensure the risk to institutional care is mitigated. It is preferable in many cases to have family-centered care, kinship care, and high-quality foster care as options.[14]
With respect to ECCE, disrupted operations cut off young children from care, protection, and learning opportunities.[1] In the United States at the beginning of the pandemic, 40% of childcare centers were reported as being at risk of permanent closure.[15] Even when communities transitioned out of lockdowns and educational facilities reopened, households in the lowest income groups were less likely to have children return to their prior childcare routine, with implications for the safety and protection of young children.[16] While the reporting of child abuse decreased, this reduction is likely due to disruptions to children’s safety nets, such as child protection programs, social protection programs, and of course ECCE centers where educators can often flag risk.[7]
In the wake of facility closures, schooling transitioned to remote options. Here, the pandemic shed light on glaring digital divides, as some countries were better equipped to offer remote learning. Remote learning programs amid school closures could not reach at least 463 million children globally.[17] Three out of four of unreached students came from rural areas or poor households. Countries with longer durations of school closures also had lower rates of school-aged children with at-home Internet. In India, for example, schools widely offered remote instruction, but four out of 10 students lacked necessary Internet connectivity to attend.[18]
It is important to recognize, however, that online teaching, especially in public schools, was available mainly for older students. For the youngest children, online learning is not always the most appropriate method to compensate for loss of in-person learning. This, of course, had consequences for moving children off track in their development in those crucial early years – from 2 to 6 million in the low- and lower-middle income settings. [1] Sixty percent of countries reported offering digital and broadcast remote learning options to pre-primary students, compared with more than 95% offering these options for primary and secondary students. In the pre-primary schooling context, in turn, fewer than one in five LMICs reported having more than 75% of pre-primary students engage in remote learning.[17]
Furthermore, the direct and indirect impacts of the pandemic are unevenly distributed among those in utero through 6 years. For many young children, advantageous individual or community circumstances, and related adaptive behaviors, can sidestep the burdens of COVID-19. But for others, the pandemic is yet another cruel misfortune that will set them back even further in their capacity to achieve a healthy and secure existence.
COVID-19 has added to the already perilous mix faced by massive numbers of young children whose daily existence tends to be dominated by the experience of extreme stress, trauma, and insecurity due to various combinations of life circumstances, including physical or mental disability and abuse; domestic, civil, or international conflict; displacement; and race-, ethnic-, or gender-based prejudice and mistreatment. The Russian invasion of Ukraine in February 2022, for example, has displaced more than 6.3 million people from Ukraine, including nearly two-thirds of all children in Ukraine, at a rate of one child every second, reflecting today’s largest global human displacement crisis.[19] These children join the more than 400 million children who live in countries affected by violent conflict. In Yemen, where almost one-third of children aged 6 months to less than 5 years regularly suffer from wasting and two-thirds show signs of stunting, the COVID-19 pandemic has exacerbated a decline in access to nutrition and health services that an ongoing conflict in several zones had already strained.[20]
These groups of young children are especially vulnerable to COVID-19 – whether because of heightened risk of own or familial infection, lack of access to quality healthcare and schooling, loss of caregivers and social interaction, food and physical insecurity, diminished household standards of living, or increased levels of stress and related domestic violence. For young children whose early life circumstances have already weakened their social defenses to adversity and their emotional and physical reserves, the pandemic has been an especially deep, unkind, and unavoidable cut.
Insofar as COVID-19 has exacerbated inequities, it has also intensified gender disparities, given that its impacts have been felt at different intensities among men and women worldwide. Childcare facility closures constrained the capacity of caregivers to participate in the labor force, but mothers and fathers did not bear this constraint equally. Gender inequality persists in society and particularly with regard to the burden of care. Before the pandemic, mothers’ labor force participation globally (55% among women aged 25-54 years with partners and at least one child younger than 6 years at home) lagged behind women’s overall participation rate (62.1%), and it substantially lagged the participation rate of fathers (97.1%). COVID-19 only worsened these stark divides, with evidence showing a marked decline in labor force participation by mothers during the pandemic, particularly among women with young children.[21]
Despite mothers bearing the brunt of labor force decline, both qualitative and quantitative studies indicate that during the pandemic paternal involvement in caregiving for young children has increased.[7] That said, considerable room exists for additional research on the role of fathers and their experiences with COVID-19.The evidence on COVID-19 and early childhood development overwhelmingly focuses on pregnant women and children up to 18 years of age, with study samples predominantly including mothers rather than fathers. How we leverage the information available on the experiences of mothers and fathers during the recovery period and beyond is critical for more equitable care outcomes in society that emphasize psychological and social wellbeing.
The pandemic has entirely reshaped how households function and shaken the protective environments and nurturing relationships around young children that foster their healthy development in the short and longer term. These disruptions highlight the importance of understanding, valuing, and supporting the mental health of children and their caregivers. With regard to parental distress, global figures increased during the pandemic in terms of reports of depression, stress, and parenting-specific stress.[22] In a survey of about 60,000 caregivers in Colombia, Costa Rica, El Salvador, and Peru, 61% of the youngest children reported at least one symptom of mental distress.[23]
Prior to the pandemic, we already recognized that maternal depression was significant and widespread. For example, in LMICs, depression during pregnancy and post-partum was at 15% and 20%.[24] This is significantly higher than the prevalence figures that we have seen in high-income countries. This is not only negative and detrimental for the women themselves, but also has impacts in terms of the young children’s cognitive development, the quality of their attachment, behavioral development outcomes for boys, increased infections, and lower quality of mother-child interaction.[25] In addition, disturbed cognition in pregnancy accounts for 20% variance predicting offspring depression at 18 years.[25] These impacts are not only short term; given the chronicity and severity of a particular type of maternal depression, it is also likely to have reverberations along the life course.
In addition to the need to support children and their parents, COVID-19 highlighted the integral need to provide care for the infant and early child mental health workforce through its own pandemic concerns. Stressful, sporadic, and unpredictable school reopening plans as nations phased out of lockdowns and sought to return children and their parents to their pre-pandemic school and workplace routines challenged the wellbeing of this workforce. In the face of ambiguous and often absent public health messaging about safe school reopening, caregivers tasked with operating early childcare settings suffered too, and COVID-19 proved the imperative nature of care for the caregiver. The more COVID-19 stress a caregiver reported in one study, the fewer self-care behaviors they engaged in and the higher the risk for internalizing and burnout.[26]
Prior to the pandemic, we knew what worked to support young children adequately. We knew, for example, that early parenting programs or home-visiting programs recommended by the World Health Organization were essential for young children’s healthy development.[27] Several systematic reviews and meta-analyses looking at studies in high-, middle-, and low-income countries show that such programs consistently benefit children’s cognitive, language, motor, social, emotional, and behavioral outcomes, and the quality of attachment between children and their caregivers.[28] COVID-19 continues to threaten and reverse progress in early human development, with long-term consequences for health, learning, and behavior. The evidence outlined in this chapter suggests that risks do not occur in isolation, so interventions cannot happen in isolation. They require multisectoral coordination and actions to address the needs of young children holistically.
III. Accelerating Progress in Research, Programs, and Policies for Young Children: A Global Imperative
COVID-19 has spotlighted the gaping holes in the world’s institutions, policies, and collective commitments to safeguard the wellbeing of our disadvantaged, our vulnerable, and our young children. Our failure to fill these gaps is indefensible on moral, ethical, and humanitarian grounds. It is indefensible in terms of the world’s stated commitment to human rights. It is indefensible in terms of our collective interest in building cohesive, peaceful, equitable, secure, and politically stable societies. It is indefensible on grounds of economic rationality and investment in a sustainable, long-term future.
The cost of inaction to address young children’s growth can impact about $176 billion in lifetime earnings.[29] Failure to implement basic parenting and preschool programs is estimated to cost countries anywhere between 2.1% and 4.1% of their total gross domestic product,[30] and failure to address COVID-related preschool closures may result in about $800 billion in lifetime earning losses.[1]These failures, of course, lead not only to immediate losses in preschool outcomes but affect primary and secondary education as well.
So how have we responded to these challenges? While early childhood development, care, and education have certainly been visible in the Sustainable Development Goals, progress has been slow over the last decade. For example, the countries with national policies embracing early childhood development have increased, but scalable programs are few and far between, with significant gaps in our understanding of the quality of those at-scale programs.
Since the start of the pandemic, nongovernmental organizations, civil societies, and governments around the world have responded to modify programs. These efforts have aimed to innovate and to ensure that parents, caregivers, and educators around the world can reach young children through adaptation of existing home-visiting, parenting, and ECCE services. Examples of large-scale programs include Grade R in South Africa that prepares 5- to 6-year-old children for primary school; Chile Crece Contigo, which is an effort by the Chilean government to provide care across public sectors to children from the prenatal period to 4 years; Criança Feliz in Brazil, which leads home visits to promote family skills of households with young children; and the Integrated Child Development Services in India, which provides nutrition, education, immunization, health check-up, and referral services to support children 0-6 years of age.[31]
Nevertheless, these are just a handful of existing programs. For most early childhood development interventions, efforts tend to be short term and project based and have very little outreach. In fact, programs tend to reach few children relative to the scale of the challenge that existed pre-pandemic and that has been exacerbated during the pandemic.
With these caveats in mind, there are two key questions to consider: do interventions meet the needs of caregivers, or do they add to the burden of already highly distressed families during this time? Second, do interventions compound existing inequalities in society? For example, Internet access and technology solutions were a central focus of pandemic interventions.Yet, a survey by the Inter-American Development Bank shows that in the Latin American and Caribbean region, only about 45% of households have adequate access to the Internet and smartphone penetration is as low as 32%. [32]Therefore, in the recovery, we must consider blended approaches – approaches that do not exacerbate existing inequities in society.
The world has known since before the pandemic that early childhood is the foundation for lifelong outcomes. We have known about the underinvestment in early childhood interventions.We can also learn from how other crises, such as the HIV epidemic, affected early childhood to conceptualize solutions that enhance children’s growth moving forward. We must recognize, nonetheless, that much of how we conceptualized early childhood programs was not working given the underinvestment prior to the pandemic.
If the immediate crisis has a silver lining, it is that we can use this opportunity to strengthen the fragile systems that were not serving young children. Immediate policy options are extremely constrained, and leadership skills are being sorely tested in ways that no one could have foreseen just a few years ago. In conceptualizing a path forward, we must inform and stimulate discussion about the place of early childhood development against the backdrop of wider human capital investment options to prevent further losses, regain some of what has been lost, and fulfill nations’ missions by restarting the engines of progress. With regard to human capital, we are referring to the skills and capacities embodied in people that allow them to create things of value. In general terms, skills and capacities can be fostered through strong and inclusive education and health systems that are closely linked to each other and to the broader economy and society.
In designing interventions, public and government forces, in addition to private and familial units, must collaborate to tend to COVID-19 issues that affect early childhood development and keep equity front and center in devising a way forward.
Fortunately, we have options available. As nations consider priorities in their long-term development trajectories, their first and highest priority must be the immediate fulfillment of essential functions, including the consistent operation of education and health systems and related social safety net programs, especially ones that focus on nutrition and food security, which has recently become more perilous as a result of Russia’s war in Ukraine.
The second highest priority, over the longer term, would be to build a programmatic initiative around the compelling and rigorous research showcasing the importance of early childhood development to the entire life cycle with respect to
- the ability to get along with others;
- economic wellbeing; and
- the level and shape of one’s potential lifelong trajectory for cognitive function and for physical, mental, and emotional health.
Programmatic initiatives here include the design and implementation of programs for (a) rapidly assessing the physical, cognitive, and emotional health of young children, especially those at greatest risk, and (b) addressing deficits through proven interventions such as
- caregiver guidance, support, and access to resources to invest in their young children,
- food supplementation,
- access to quality healthcare,
- access to preschool programs aimed at social development,
- finance monitoring for early childhood development and progress tracking,
- the constructive engagement of community members in monitoring and supporting early child development,
- policies that support caregivers with young children (e.g., paid parental leave, subsidized high-quality childcare services).
The third highest priority, also over the longer term, would be to prioritize support for the primary healthcare components of the overall health system. Primary healthcare is a health system best buy. And that is in no small measure because of its central role in the implementation of immunization programs. While we certainly refer here to COVID-19 immunizations, we are also thinking of routine immunizations for diphtheria, tetanus, pertussis, measles, polio, rotavirus, pneumococcal disease, human papilloma virus, and hepatitis. We are also thinking of catch-up protocols for those who missed immunizations in the past few years. In support of immunization programs, we urge nations to remember the old adage that an ounce of prevention is worth a pound of cure, along with the related public health finding that immunizations are among the most cost-effective health interventions available to mankind.
Realizing Sustainable Development Goal target 4.2 (for all children to have access to early care, development, and education services) requires urgent multisectoral action to mitigate the detrimental impact on the quality of care and opportunities that young children receive. Solutions are available to address the needs of young children and their caregivers (e.g., parenting programs, ECCE services, and prevention of violence strategies). However, interventions’ design and delivery must not further exacerbate the stark inequities in access to early childhood care and opportunities for young children. Further, approaches must invest in strengthening systems that serve young children and their caregivers.
To close, we would remind everyone that Winston Churchill once urged that we should “never let a good crisis go to waste”. In the pandemic context, this is an especially interesting piece of advice because it directs us to think and act progressively and to use the pandemic to renew – not just in word but also in deed – our commitment to the world’s youngest victims of disadvantage and vulnerability.
Footnote
1. This paper is based on a presentation delivered at the February 2022 Pontifical Academy of Social Sciences workshop entitled “The Covid Generation: Children and Youth in and after the Pandemic Responding to the World Crisis”. The authors are grateful to the workshop participants for helpful comments.
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