Tagged Children and Childhood

Many Children With MIS-C Had No Covid-19 Symptoms

Pediatricians should be vigilant, experts said, after the release of the largest U.S. study of the syndrome, MIS-C, that can strike young people weeks after their coronavirus infection.

Many children and teenagers who developed the mysterious inflammatory syndrome that can emerge several weeks after contracting the coronavirus never had classic Covid-19 symptoms at the time of their infection, according to the largest study so far of cases in the United States.

The study, led by researchers from the Centers for Disease Control and Prevention, found that in over 1,000 cases in which information about whether they got sick from their initial Covid-19 illness was available, 75 percent of the patients did not experience such symptoms. But two to five weeks later, they became sick enough to be hospitalized for the condition, called Multisystem Inflammatory Syndrome in Children (MIS-C), which can affect multiple organs, especially the heart.

Published Tuesday in JAMA Pediatrics, the study said that “most MIS-C illnesses are believed to result from asymptomatic or mild Covid-19” followed by a hyper-inflammatory response that appears to occur when the patients’ bodies have produced their maximum level of antibodies to the virus. Experts do not yet know why some young people, and a smaller number of adults, respond this way.

“It means primary-care pediatricians need to have a high index of suspicion for this because Covid is so prevalent in the society and children often have asymptomatic disease as their initial Covid infection,” said Dr. Jennifer Blumenthal, a pediatric intensivist and pediatric infectious disease specialist at Boston Children’s Hospital, who was not involved in the study.

The researchers evaluated 1,733 of the 2,090 cases of the syndrome in people age 20 and younger that had been reported to the C.D.C. as of January.

The findings show that although the syndrome is rare, it can be serious. The C.D.C’s data only included patients who were hospitalized. Over 90 percent of those young people experienced symptoms involving at least four organ systems and 58 percent needed treatment in intensive care units.

Many experienced significant heart issues: over half developed low blood pressure, 37 percent developed cardiogenic shock and 31 percent experienced cardiac dysfunction involving their heart’s inability to pump adequately. The study said that a significantly higher percentage of patients who had not had Covid-19 symptoms experienced those heart problems, compared with those who had initial coronavirus symptoms. A greater percentage of initially asymptomatic patients also ended up in intensive care.

“Even the kids with severe MIS-C, who were in the I.C.U. — the vast majority of them did not have a preceding illness that they recognized,” said Dr. Roberta DeBiasi, chief of infectious diseases at Children’s National Hospital in Washington, D.C., who was not involved in the research.

The study provided the most detailed demographic and geographic picture of the syndrome to date. About 34 percent of the patients were Black and 37 percent were Hispanic, reflecting the way that the coronavirus has disproportionately affected members of those communities. As the pandemic went on, the authors wrote, the proportion of patients who were white increased, comprising 20 percent of all cases. People of Asian heritage comprised just over 1 percent of patients.

Overall, nearly 58 percent of the patients were male, but the proportion was not the same across all ages. The youngest group — newborn to age 4 — had roughly equal numbers of boys and girls, and the male-to-female ratio increased in the older groups until it was more than two-to-one male to female in the 18-to-20 group.

The vast majority of patients (nearly 86 percent) were younger than 15. The study found that those under 5 had the lowest risk of serious heart complications and were less likely to need intensive care. Patients 10 and older were significantly more likely to develop issues like shock, low blood pressure and myocarditis (inflammation of the heart muscle).

“I think that’s similar to what we saw with Covid, that the older kids seemed to have more severe disease,” Dr. DeBiasi said. “And that’s because what makes people really sick from the Covid is the inflammatory aspect of it, so maybe these older kids, for whatever reasons, make more inflammation, whether that’s in primary Covid or MIS-C.”

Still, significant numbers of the youngest patients developed heart problems. In the newborn-to-4 age group, 36 percent had low blood pressure, 25 percent had shock and 44 percent were treated in the I.C.U.

Patients of all ages in the study had about the same occurrence of some of the less-common heart issues linked to the syndrome, including coronary aneurysms and fluid buildup. Children 14 and under were more likely to have rash and red eyes, while those older than 14 were more likely to have chest pain, shortness of breath and cough. Abdominal pain and vomiting afflicted about two-thirds of all patients.

There were 24 deaths recorded, spread across all age groups. There was no information in the study about whether patients had underlying medical conditions, but doctors and researchers have reported that young people with MIS-C were often previously healthy and significantly more likely to be healthy than the relatively small number of young people who become seriously ill from initial Covid infections.

Of the 1,075 patients for whom information about initial Covid illness was available, only 265 had symptoms at that time. They were more likely to be older — their median age was 11, while the median age of those with asymptomatic Covid infections was 8. But that could be because “younger children can’t express their concerns as well,” said Dr. Blumenthal, who co-wrote an editorial about the study.

“We don’t necessarily know if there’s actually less symptomatology in the very young population, ” she said.

Similarly unclear are the reasons behind the study’s finding that in the first wave of MIS-C, from March 1 to July 1, 2020, young people were more prone to a few of the most serious heart complications. Dr. DeBiasi said that did not match the experience of her hospital, where “the kids were sicker in the second wave.”

The study documented two waves of MIS-C cases that followed surges in overall coronavirus cases by about a month or more. “The most recent third peak of the Covid-19 pandemic appears to be leading to another MIS-C peak perhaps involving urban and rural communities,” the authors wrote.

The study found that most of the states where the rate of MIS-C cases per population was highest were in the Northeast, which had the first surge of cases, and the South. By contrast, most states with high per-population rates of children with Covid-19 but low rates of MIS-C were in the Midwest and West. While the concentration of cases spread from large cities to smaller towns over time, it wasn’t as pronounced as the overall pandemic trends, the authors said.

Dr. Blumenthal said that geographic pattern could reflect that the “understanding of the complications of the disease” hadn’t caught up to its prevalence in different regions or that many states with lower rates of MIS-C have less ethnically diverse populations. “It could also be something about Covid itself, although we don’t know that,” she said. “Right now, we don’t know anything about how the variants necessarily affect children.”

The study represented only the strictest criteria for MIS-C, excluding about 350 reported cases that met the C.D.C. definition of the syndrome but had a negative antibody test or primarily involved respiratory symptoms. Dr. DeBiasi said there are also many probable MIS-C cases that are not reported to the C.D.C. because they don’t meet all the official criteria.

“These probable MIS-C kids, in real life that’s a big chunk of kids,” she said. In addition, while the focus so far has been on serious cases, “there’s another whole group of kids that may actually have mild MIS-C.”

If a community has experienced a recent coronavirus surge, then “just because the kid says, ‘I never had Covid or my parents never had it,’ that doesn’t mean the kid in front of you doesn’t have MIS-C,” Dr. DeBiasi said. “If your city has Covid, then get ready.”

Many Children With Serious Inflammatory Syndrome Had No Covid Symptoms

Pediatricians should be vigilant, experts said, after the release of the largest U.S. study of the syndrome, MIS-C, that can strike young people weeks after their coronavirus infection.

Many children and teenagers who developed the mysterious inflammatory syndrome that can emerge several weeks after contracting the coronavirus never had classic Covid-19 symptoms at the time of their infection, according to the largest study so far of cases in the United States.

The study, led by researchers from the Centers for Disease Control and Prevention, found that in over 1,000 cases in which information about whether they got sick from their initial Covid-19 illness was available, 75 percent of the patients did not experience such symptoms. But two to five weeks later, they became sick enough to be hospitalized for the condition, called Multisystem Inflammatory Syndrome in Children (MIS-C), which can affect multiple organs, especially the heart.

Published Tuesday in JAMA Pediatrics, the study said that “most MIS-C illnesses are believed to result from asymptomatic or mild Covid-19” followed by a hyper-inflammatory response that appears to occur when the patients’ bodies have produced their maximum level of antibodies to the virus. Experts do not yet know why some young people, and a smaller number of adults, respond this way.

“It means primary-care pediatricians need to have a high index of suspicion for this because Covid is so prevalent in the society and children often have asymptomatic disease as their initial Covid infection,” said Dr. Jennifer Blumenthal, a pediatric intensivist and pediatric infectious disease specialist at Boston Children’s Hospital, who was not involved in the study.

The researchers evaluated 1,733 of the 2,090 cases of the syndrome in people age 20 and younger that had been reported to the C.D.C. as of January.

The findings show that although the syndrome is rare, it can be serious. The C.D.C’s data only included patients who were hospitalized. Over 90 percent of those young people experienced symptoms involving at least four organ systems and 58 percent needed treatment in intensive care units.

Many experienced significant heart issues: over half developed low blood pressure, 37 percent developed cardiogenic shock and 31 percent experienced cardiac dysfunction involving their heart’s inability to pump adequately. The study said that a significantly higher percentage of patients who had not had Covid-19 symptoms experienced those heart problems, compared with those who had initial coronavirus symptoms. A greater percentage of initially asymptomatic patients also ended up in intensive care.

“Even the kids with severe MIS-C, who were in the I.C.U. — the vast majority of them did not have a preceding illness that they recognized,” said Dr. Roberta DeBiasi, chief of infectious diseases at Children’s National Hospital in Washington, D.C., who was not involved in the research.

The study provided the most detailed demographic and geographic picture of the syndrome to date. About 34 percent of the patients were Black and 37 percent were Hispanic, reflecting the way that the coronavirus has disproportionately affected members of those communities. As the pandemic went on, the authors wrote, the proportion of patients who were white increased, comprising 20 percent of all cases. People of Asian heritage comprised just over 1 percent of patients.

Overall, nearly 58 percent of the patients were male, but the proportion was not the same across all ages. The youngest group — newborn to age 4 — had roughly equal numbers of boys and girls, and the male-to-female ratio increased in the older groups until it was more than two-to-one male to female in the 18-to-20 group.

The vast majority of patients (nearly 86 percent) were younger than 15. The study found that those under 5 had the lowest risk of serious heart complications and were less likely to need intensive care. Patients 10 and older were significantly more likely to develop issues like shock, low blood pressure and myocarditis (inflammation of the heart muscle).

“I think that’s similar to what we saw with Covid, that the older kids seemed to have more severe disease,” Dr. DeBiasi said. “And that’s because what makes people really sick from the Covid is the inflammatory aspect of it, so maybe these older kids, for whatever reasons, make more inflammation, whether that’s in primary Covid or MIS-C.”

Still, significant numbers of the youngest patients developed heart problems. In the newborn-to-4 age group, 36 percent had low blood pressure, 25 percent had shock and 44 percent were treated in the I.C.U.

Patients of all ages in the study had about the same occurrence of some of the less-common heart issues linked to the syndrome, including coronary aneurysms and fluid buildup. Children 14 and under were more likely to have rash and red eyes, while those older than 14 were more likely to have chest pain, shortness of breath and cough. Abdominal pain and vomiting afflicted about two-thirds of all patients.

There were 24 deaths recorded, spread across all age groups. There was no information in the study about whether patients had underlying medical conditions, but doctors and researchers have reported that young people with MIS-C were often previously healthy and significantly more likely to be healthy than the relatively small number of young people who become seriously ill from initial Covid infections.

Of the 1,075 patients for whom information about initial Covid illness was available, only 265 had symptoms at that time. They were more likely to be older — their median age was 11, while the median age of those with asymptomatic Covid infections was 8. But that could be because “younger children can’t express their concerns as well,” said Dr. Blumenthal, who co-wrote an editorial about the study.

“We don’t necessarily know if there’s actually less symptomatology in the very young population, ” she said.

Similarly unclear are the reasons behind the study’s finding that in the first wave of MIS-C, from March 1 to July 1, 2020, young people were more prone to a few of the most serious heart complications. Dr. DeBiasi said that did not match the experience of her hospital, where “the kids were sicker in the second wave.”

The study documented two waves of MIS-C cases that followed surges in overall coronavirus cases by about a month or more. “The most recent third peak of the Covid-19 pandemic appears to be leading to another MIS-C peak perhaps involving urban and rural communities,” the authors wrote.

The study found that most of the states where the rate of MIS-C cases per population was highest were in the Northeast, which had the first surge of cases, and the South. By contrast, most states with high per-population rates of children with Covid-19 but low rates of MIS-C were in the Midwest and West. While the concentration of cases spread from large cities to smaller towns over time, it wasn’t as pronounced as the overall pandemic trends, the authors said.

Dr. Blumenthal said that geographic pattern could reflect that the “understanding of the complications of the disease” hadn’t caught up to its prevalence in different regions or that many states with lower rates of MIS-C have less ethnically diverse populations. “It could also be something about Covid itself, although we don’t know that,” she said. “Right now, we don’t know anything about how the variants necessarily affect children.”

The study represented only the strictest criteria for MIS-C, excluding about 350 reported cases that met the C.D.C. definition of the syndrome but had a negative antibody test or primarily involved respiratory symptoms. Dr. DeBiasi said there are also many probable MIS-C cases that are not reported to the C.D.C. because they don’t meet all the official criteria.

“These probable MIS-C kids, in real life that’s a big chunk of kids,” she said. In addition, while the focus so far has been on serious cases, “there’s another whole group of kids that may actually have mild MIS-C.”

If a community has experienced a recent coronavirus surge, then “just because the kid says, ‘I never had Covid or my parents never had it,’ that doesn’t mean the kid in front of you doesn’t have MIS-C,” Dr. DeBiasi said. “If your city has Covid, then get ready.”

Depression in Young Children

We tend to think of childhood as a time of innocence and joy, but as many as 2 to 3 percent of children from ages 6 to 12 can have serious depression.

When parents bring their children in for medical care these days, there is no such thing as a casual, “Hey, how’s it going?” We doctors walk into every exam room prepared to hear a story of sadness and stress, or at the very least, of coping and keeping it together in this very hard year, full of isolation, loss, tragedy and hardship, with routines disrupted and comfort hard to come by.

Parents have carried heavy burdens of stress and responsibility, worrying about themselves but also watching their children struggle, and there is worldwide concern about depression and suicidality among young people. But it isn’t only the adults and the young adults and teenagers who are suffering and sad; young children can also experience depression, but it can look very different, which makes it challenging for parents — or doctors — to recognize it and provide help.

Rachel Busman, a clinical psychologist at the Child Mind Institute in New York City, said that it can be hard to think about depression in younger children because we picture childhood as a time of innocence and joy. But as many as 2 to 3 percent of children ages 6 to 12 can have serious depression, she said. And children with anxiety disorders, which are present in more than 7 percent of children aged 3 to 17, are also at risk for depression.

Dr. Helen Egger, until recently the chair of child and adolescent psychiatry at N.Y.U. Langone Health, said that according to her epidemiologic research, between 1 and 2 percent of young children — as young as 3 — are depressed

Depression was originally conceived of as an adult problem. Maria Kovacs, professor of psychiatry at the University of Pittsburgh School of Medicine, said that in the 1950s and ’60s, there were child psychiatrists who believed that children did not have sufficient ego development to feel depression, but that research that she and other colleagues did in the ’70s showed that “school age children can suffer from diagnosable depression.”

Before adolescence, depression is equally common in girls and boys, though among adolescents, it is twice as common in girls, and that predominance then lasts across most of adult life, until old age, when it again appears to equalize.

What does depression look like in younger children?

When young children are depressed, Dr. Kovacs said, it’s not unusual for “the primary mood to be irritability, not sadness — it comes across as being very cranky.” And children are much less likely to understand that what they’re feeling is depression, or identify it that way. “It almost never happens that they say, ‘something’s wrong because I’m sad,’” Dr. Kovacs said. It’s up to adults to look for signs that something is not right, she said.

The best way for parents to recognize depression in young children is not so much by what a child says as by what the child does — or stops doing. Look for “significant changes in functioning,” Dr. Kovacs said, “if a child stops playing with favorite things, stops responding to what he used to respond to.”

This might mean a child loses interest in the toys or games or jokes or rituals that used to be reliably fun or entertaining, or doesn’t seem interested in the usual back and forth of family life.

“You’ve had a kid who was one way and then you see that they’re more irritable and sad,” said Dr. Egger, who is now the chief medical and scientific officer at Little Otter, a new online mental health care company for children. Children may seem flattened, have less energy or tire easily. And they may start complaining about physical symptoms, especially stomach aches and headaches. They may sleep more — or less — or lose their appetites.

A preschool-aged child might be depressed if she is having daily tantrums, with behaviors that risk hurting herself or other people. Depression “may look like a behavior problem but is really being driven by what the kid is feeling inside,” Dr. Egger said.

“It’s like walking through the world with dark-colored glasses,” Dr. Busman said. “It’s about myself, about the other person, and the world — I suck, this sucks, everything sucks.”

Should I ask about suicidal thoughts?

The irritability and the anger — or the flatness and the shutting down — can be signs of profound sadness. And while suicide attempts by elementary school-aged children are rare, they do happen and have increased in recent years. Suicide was the second leading cause of death in children 10 to 14 in 2018, and a 2019 JAMA study showed increasing emergency room visits by children for suicidal thoughts or actions from 2007 to 2015 — 41 percent in children under 11 years old. The presence of suicidal thoughts should be seen as a call for help.

The most problematic myth about suicide is the fear “that if you ask about suicide you’re putting the idea in their heads,” said Dr. Kovacs, who developed the Children’s Depression Inventory which is used all over the world.

“If you’re dealing with a child for whom this is not an issue, they’re just going to stare at you like you’re out of your head,” Dr. Kovacs said. “You cannot harm somebody by asking them.”

But what if children say they have thought of suicide? As with adults, this suggests the child is living with pain and perhaps thinking about a way out. Dr. Kovacs said, children may imagine death as “a release, a surcease, a relief.”

Dr. Busman said that she works with children who may say, “I don’t want to kill myself but I feel so bad I don’t know what else to do and say.”

If a child talks about wanting to die, ask what that child means, and get help from a therapist if you’re concerned. A statement like this can be a real signal that a child is in distress, so don’t dismiss it or write it off as something the child is just saying for attention, she said.

How can treatment help?

“Parents should take child symptoms very seriously,” said Jonathan Comer, professor of psychology and psychiatry at Florida International University. “In serious forms it snowballs with time, and earlier onset is associated with worse outcomes across the life span.”

In a 2016 longitudinal study, Dr. Kovacs and her colleagues traced the course of depression starting in childhood, and found recurrent episodes in later life.

So if you see changes like withdrawal from activities, irritability or sadness, fatigue, or sleep disturbances that persist for two weeks, consider having the child evaluated by someone who is familiar with mental health issues in children of that age. Start with your pediatrician, who will know about resources available in your area.

Parents should insist on a comprehensive mental health evaluation, Dr. Busman said, including gathering history from the parent, spending time with the child and talking to the school. An evaluation should include questions about symptoms of depression as well as looking for other problems, like attention deficit hyperactivity disorder or anxiety, which may be at the root of the child’s distress.

Early treatment is effective, Dr. Comer said, “There’s terrific evidence for family-focused treatment for child depression — it focuses on family interactions and their impact on mood.” With children from 3 to 7, he said, versions of parent-child interaction therapy, known as PCIT, are often used — essentially coaching parents, and helping them emphasize and praise what is positive about their children’s behavior.

As much as possible, parents should try to keep children going outside, taking walks, even playing outdoor games, even if they are less enthusiastic about their usual activities. As with adults, physical exercise has both mental and biological benefits — as do fresh air and sunshine.

Depression does not necessarily lend itself to simple cause-and-effect explanations, but Dr. Kovacs emphasized that with a first episode in a child, there is almost always a particular stressor that has set off the problem. It could be a change in the family constellation — a parental divorce, a death — or it could be something more subtle, like an anxiety that has spiraled out of control. If a child does begin therapy, part of the treatment will be to identify — and talk about — that stressor.

How can I find help for my child?

If you’re concerned that your child might be depressed, start with your pediatrician or other primary care provider. Some clinics and health centers will have in-house mental health services, and you may be able to have your child seen there. Some doctors will have links to local therapists with experience with young children. Mental health specialists can be in short supply (and there’s a lot of need right now), so be open to the possibility of care being delivered remotely, through telehealth. Dr. Kovacs also suggested that parents who are looking for treatment consider clinical psychology department clinics at a local university, where students in psychology and counseling are supervised by licensed psychologists; she said such clinics often have good availability.

[The Society of Clinical Child and Adolescent Psychology has advice on how to know if treatment is evidence-based.]

“Parents should see children’s struggles as opportunities to intervene,” Dr. Comer said. “The majority of early child mood problems will go away with time, sensitive parenting and supportive environments.”

The Pfizer-BioNTech Vaccine Is Said to Be Powerfully Protective in Adolescents

A clinical trial found no infections among vaccinated children ages 12 to 15, the companies said, and there were no serious side effects. The data have not yet been reviewed by independent experts.

The Pfizer-BioNTech coronavirus vaccine is extremely effective in adolescents 12 to 15 years old, perhaps even more so than in adults, the companies reported on Wednesday. No infections were found among children who received the vaccine in a recent clinical trial, the drug makers said; the children produced strong antibody responses and experienced no serious side effects.

The findings, if they hold up, may speed a return to normalcy for millions of American families. Depending on regulatory approval, vaccinations could begin before the start of the next academic year for middle school and high school students, and for elementary school children not long after.

The companies announced the results in a news release that did not include detailed data from the trial, which has not yet been peer-reviewed nor published in a scientific journal. Still, the news drew praise and excitement from experts.

“Oh my god, I’m so happy to see this — this is amazing,” said Akiko Iwasaki, an immunologist at Yale University. If the vaccines’s performance in adults was A-plus, the results in children were “A-plus-plus.”

The good news arrives even as the country records another rise in infections and health officials renew calls for Americans to heed precautions and get vaccinated. On Monday, Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention, said that rising cases had left her with sense of “impending doom,” while President Biden called on state and local officials to reinstate mask mandates.

Vaccination efforts are accelerating throughout the nation. As of Tuesday, 29 percent of adults had received at least one dose of a coronavirus vaccine, and 16 percent had been fully inoculated, according to the C.D.C.

But the country cannot hope to reach herd immunity — the point at which immunity becomes so widespread that the coronavirus slows its crawl through the population — without also inoculating the youngest Americans, some experts say. Children under 18 account for about 23 percent of the population in the United States.

“The sooner that we can get vaccines into as many people as possible, regardless of their age, the sooner we will be able to really feel like we’re ending this pandemic for good,” said Angela Rasmussen, a virologist affiliated with Georgetown University in Washington.

Data from Israel suggest that vaccinating adults alone can significantly decrease the number of cases, but “long term, to hit the herd immunity threshold, we will have to vaccinate children,” she said.

The trial included 2,260 adolescents ages 12 to 15. The children received two doses of the vaccine three weeks apart — the same amounts and schedule used for adults — or a placebo of saltwater.

The researchers recorded 18 cases of coronavirus infection in the placebo group, and none among the children who received the vaccine. Still, the low number of infections makes it difficult to be too specific about the vaccine’s efficacy in the population at large, Dr. Rasmussen said.

“But obviously, it looks good for the vaccine if there were zero Covid cases among the vaccinated people,” she added.

The adolescents who got the vaccine produced much higher levels of antibodies on average, compared with participants 16 to 25 years of age in an earlier trial. The children experienced the same minor side effects as older participants, although the companies declined to be more specific.

Dr. Iwasaki said she had expected antibody levels in adolescents to be comparable to those in young adults. “But they’re getting even better levels from the vaccines,” she said. “That’s really incredible.”

She and other experts cautioned that the vaccine might be less effective in children, and adults, against some of the variants that have begun circulating in the United States.

Pfizer and BioNTech have begun a clinical trial of the vaccine in children under 12 and started inoculations of children ages 5 to 11 just last week. Company scientists plan to start testing the vaccine next week in even younger children, ages 2 to 5, followed by trials in children ages 6 months to 2 years.

Results from that three-phase trial are expected in the second half of the year, and the companies hope to make the vaccine available for children under 12 early next year.

“We share the urgency to expand the use of our vaccine to additional populations and are encouraged by the clinical trial data from adolescents between the ages of 12 and 15,” Albert Bourla, Pfizer’s chairman and chief executive officer, said in a statement.

Moderna has also been testing its vaccine in children. Results from a trial in adolescents ages 12 to 17 are expected in the next few weeks and in children 6 months to 12 years old in the second half of this year.

AstraZeneca started testing its vaccine in children 6 months and older last month, and Johnson & Johnson has said it will wait for results from trials in older children before testing its vaccine in children under 12.

Some parents have said they are reluctant to immunize their children because the risk posed by the virus is low. Children make up fewer than 1 percent of deaths from Covid-19, but about 2 percent of children who get the illness require hospital care.

The new results may not sway all of those parents, but they may reassure parents who have been wary of the vaccines, said Jennifer Nuzzo, an epidemiologist at the Johns Hopkins Center for Health Security.

“While I don’t think we have to wait until children are vaccinated to fully reopen schools, being able to vaccinate children may help some families feel safer about returning to school,” she said.

Pfizer and BioNTech plan to request from the Food and Drug Administration an amendment to the emergency use authorization for their vaccine, in hopes of beginning immunizations of older children before the start of the next school year. The companies also are planning to submit their data for peer review and publication in a scientific journal.

They will monitor the participants for two years after the second dose to assess the vaccine’s long-term safety and efficacy. Side effects of vaccines are usually apparent within the first six weeks, said Dr. Kristin Oliver, a pediatrician and vaccine expert at Mount Sinai Hospital in New York. “Still, it’s good to know that safety monitoring is going to continue,” she said.

The C.D.C. recommends that people avoid getting other vaccines for two weeks before and after receiving the two doses of the coronavirus vaccine.

But children receive more vaccines in the few weeks before the school year than at any other time, Dr. Oliver noted, so pediatricians and parents should aim to get those other immunizations done earlier than usual.

The coronavirus vaccines should ideally be given by pediatricians who have deep experience in immunizing children, Dr. Oliver added. “Now is the time to start planning how that rollout is going to take place in this age group,” she said.

How to Lower Your Child’s Risk for Addiction

A strong sense of self-efficacy is one of the most powerful protective factors parents can give their children.

In the decade that I was an active alcoholic, my focus was on protecting my right to drink the way I wanted to drink, and keeping my drinking a secret from my family. From the day I got sober in 2013, however, my focus shifted to protecting my two sons from the genetic and environmental risks of addiction I’d strewn in their path.

For five years, I felt great about my efforts. I was setting a good example by being sober, my husband modeled healthy moderation and we were raising our kids with the support of a proverbial village of families we’d known and trusted for years.

Then, in 2018, my husband had a job opportunity that required us to leave that community and move to another state: Vermont. Our older son was already in college, so the change didn’t affect him too much, but our younger son, Finn, who was about to transition from middle to high school, was devastated.

“You are ruining my life,” he said, when we told him about the move. There was no yelling, no wild gesticulations, just a calm statement of fact, which was much, much worse.

According to all the research on risk for substance use disorder, the move had the potential to be a disaster for Finn. We had voluntarily exposed our 14-year-old boy to a host of risk factors for substance abuse during a vulnerable period of cognitive development on top of the genetic risk he already faced. A stressful physical and emotional transition that was out of his control? Check. Living in a state with permissive marijuana laws? Check. Sever ties with a peer group we trust? Check. Replace those peers and their supportive, loving parents with families we have never met? Check.

Before we moved, Finn had plenty of protections heaped on the prevention side of his metaphorical substance abuse scale: physical, financial and emotional stability; lack of stress; and his friends’ parents looking out for him and providing healthy models for sobriety, support and coping. My job was to figure out what I could do to balance the weight of his risk by loading the other side of the scale with as much protection as possible.

I could not help him make new friends, let alone pick their parents, but I could help restore Finn’s sense of control, agency and hope by building his sense of self-efficacy.

Self-efficacy, as defined by the psychologist Albert Bandura, is one’s belief in one’s ability to succeed; to regulate one’s thoughts, emotions and life; and to cope with challenges in a positive way. Self-efficacy is also the foundation for so many other positive traits, including resilience, grit, fortitude and perseverance. Self-efficacy is what gives kids a sense of control, agency and hope, even when the world around them feels out of control.

People with a weak sense of self-efficacy, on the other hand, tend to be pessimistic, inflexible, quick to give up, have low self-esteem, exhibit learned helplessness, get depressed, and feel fatalistic and hopeless. Not coincidentally, people who exhibit these traits are more likely to turn to drugs and alcohol to alleviate these negative feelings.

I wanted Finn to be able to talk to me about all his fears and anxiety around the move, and I knew that self-efficacy could help with that, too. It promotes open parent-child communication while helping kids resist peer pressure both directly and indirectly. Research shows that when a child believes he has the ability to resist peer pressure, he will be a lot more likely to do so, and further, he will be more likely to talk to his parents about those episodes of peer pressure when they arise. On the other hand, kids who don’t feel as if they can resist peer pressure don’t tend to talk to their parents about the things they do outside the home.

Lack of self-efficacy is a risk factor for substance abuse and other negative health outcomes, but when converted into its opposite and equal force, a strong sense of self-efficacy, it can be one of the most powerful protective factors we can give our children. Here are some practical ways parents can boost kids’ perceptions of their own self-efficacy and help kids with low self-efficacy get back on the right path:

Start with yourself.

Model, model, model self-efficacy for your kids. Start questioning your own assertions of “I can’t” with “I can’t yet,” then turn that perspective outward, toward your children. That helps kids believe competence is not congenital, it is learned, and often hard-won.

Give kids skills.

Praise alone won’t give your child a sense of self-efficacy or competence; these things come from the actual experience of trying, doing, failing, trying again, and succeeding. Give kids age-appropriate tasks that help them stay engaged and challenged while granting opportunities to taste success. Teach them how to make dinner from start to finish and see what they create on their own. Encourage your teen to take the family car to the garage and have that rattle behind the dash fixed.

Project optimism.

Optimism is about more than seeing a glass as half full; it’s a mind-set that has a very real impact on physical and mental health. Optimistic children are better able to resist learned helplessness and depression, whereas pessimists are much more likely to give in to feelings of helplessness and are consequently at much higher risk of suffering from a wide range of negative mental and physical health outcomes. According to the psychologist Martin Seligman, author of “The Optimistic Child,” pessimistic kids see obstacles as permanent, pervasive, and their fault. Optimistic children, on the other hand, view setbacks as temporary, specific and attributable to behaviors that can be changed. As Dr. Seligman explains: “Children learn their pessimism, in part, from their parents and teachers, so it is very important that you model optimism for your children as a first step.”

Make failures specific, but generalize success.

Guide children toward optimism by framing their success as generally as possible. If your daughter has a good day in math class, help her globalize that success. Instead of “I did well in math class because I paid attention,” move toward “School

is going well because I am doing all my assignments on time.” Help her expand her success beyond the boundaries of one class or one day.

Be specific in your praise.

General praise, such as “Good job!” is useless when it comes to bolstering self-efficacy in kids because it has no real meaning. Aim for behavior-specific praise that reinforces practices you want to encourage, such as, “I’m so proud of you for sticking with that project even when you got frustrated.” Behavior-specific praise describes the desired behavior, is specific to the child, and offers a positive, clear, statement.

Don’t go overboard with your praise.

Experts on the use of behavior-specific praise in the classroom recommend a 3:1 or 4:1 ratio of praise to correction, a ratio I have tried to maintain with my own students and children. I teach and parent older teens, but this guideline is effective for kids of any age. Research shows it not only boosts good behavior, but also creates a sense of community and positivity that helps kids hear our constructive criticism when it inevitably comes.

A belief in self-efficacy, Dr. Bandura writes in his book “Self-Efficacy: The Exercise of Control,” is “the foundation of human motivation, well-being, and accomplishments.” That might have been what my son needed most to get started in a new school, and not just as a protection against substance abuse. It could help him set and achieve goals, view obstacles as surmountable, have a lower fear of failure and approach new challenges with the assumption that he could succeed.

While I can’t know which, if any, of the preventions I’ve heaped on Finn during his adolescence will inoculate him against developing a substance use disorder, I do know that boosting his self-efficacy has been essential to building up his sense of competence, well-being and happiness.

One year after the move, Finn and I hiked up to the top of the mountain behind our house to pick wild huckleberries. We’d spent an hour or so crawling around on our hands and knees talking about whatever drifted through our minds, when Finn sat back on his heels, dumped a handful of berries into his mouth and admitted to being happy. What’s more, he was looking forward to his second year of high school. As we sat together, eating huckleberries and looking out over the Vermont landscape, I felt the weight of his risk ease from my shoulders, at least for a while.

Jessica Lahey is a former teacher and the author, most recently, of “The Addiction Inoculation,” from which this article is adapted.

Family Travel Gets Complicated Without a Covid Vaccine for Kids

Amid the chatter of travel’s long-awaited rebound one year into the pandemic, many families with children feel largely left out of the conversation.

Nearly every summer, Ada Ayala, a teacher, and her husband, Oscar Cesar Pleguezeulos, travel with their children to visit Mr. Cesar Pleguezeulos’s parents in Spain. But this year, even though they will both soon be fully vaccinated in their home state of Florida, they are changing their plans. The reason? There is still no pediatric Covid-19 vaccine available for their kids.

The travel industry, buoyed by news of vaccine rollouts, is anticipating a summer rush after a year of devastation. But amid the chatter of travel’s long-awaited rebound, many families with children — who comprise roughly 30 percent of the global travel market — say they are largely being left out of the conversation.

In a March survey on Bébé Voyage, an online community for traveling families, 90 percent of respondents said that amid unclear guidelines on Covid-19 testing, they were searching for flexible bookings. The topic also comes up often on Bébé Voyage’s Facebook page, particularly among parents in the United States. “It’s the Americans in the group that are the most nervous traveling with kids,” said the Bébé Voyage chief executive, Marianne Perez de Fransius.

Ms. Ayala, 44, is among those nervous parents. “If it wasn’t for the kids, we would definitely be flying this summer,” she said. Ms. Ayala already received her shot as a teacher. Her husband, also 44, will soon receive his shots, too, because Florida recently opened vaccinations to those age 40 and up. But their children, Charlise, 6, and Oscar, 2, will have to wait many more months to be inoculated.

“My 2-year-old isn’t going to wear a mask for 10 hours on a flight, and I don’t know if I want to expose him for a 16-hour trip with layovers,” Ms. Ayala said. “I’ll feel more confident when vaccination reaches more people worldwide, or at least in the destinations we want to go.”

Nearly one in three adults in the United States have now received at least one dose of the Covid-19 vaccine. But a full pediatric Covid-19 vaccine currently isn’t expected until the end of 2021 at the earliest, and while they wait, parents are struggling to figure out how they, too, can travel safely this summer, and even where their children are welcome as rules on quarantine and testing continue to shift.

“This is the elephant in the room right now,” said Cate Caruso, an adviser for Virtuoso, a network of luxury travel agencies, who also owns her own travel planning company, True Places Travel. The potential that a child could become infected with Covid-19 while abroad and not be allowed on a return flight, she said, is a major deterrent for parents. “Anywhere you go outside of the U.S. right now, you’ve got to think about how you’re going to get back in,” she said. “It’s leaving behind a whole bunch of people who are ready to go.”

In Ms. Ayala’s case, a compromise has been struck: If and when Spain — which is currently closed to American travelers — opens its borders, Mr. Cesar will travel to Spain with their daughter, Charlise, while Ms. Ayala will remain in Florida with Oscar. “She goes to school and is very good with wearing her mask, cleaning her hands and keeping distance,” Ms. Ayala said of her daughter. “So I think she can be safe. But it’s just not possible with a baby.”

But she doesn’t plan to stay home all summer. Whether or not her husband and daughter make it to Spain, Ms. Ayala is planning a family road trip at some point this summer, likely within Florida.

After a year of road trips, R.V.s and rental cottages, many Americans are now ready to fly again: Online searches for late-summer flights are up as much as 75 percent, and hotels on both coasts are reporting that they are sold out through October. But families, more than any other travel sector, continue to play it safe.

Family travel plans for this summer are more low-key than two years ago, with bookings to Mount Rushmore National Memorial, in the Black Hills of South Dakota, reported to be significantly up.
Family travel plans for this summer are more low-key than two years ago, with bookings to Mount Rushmore National Memorial, in the Black Hills of South Dakota, reported to be significantly up.Tannen Maury/EPA, via Shutterstock

Rovia, a membership-based global travel agency that works with both travelers and travel agents, reports that beach and camping destinations within driving distance are the most popular choices for families this summer. An exception? Disney World, which is seeing an uptick in reservations for summer from families looking to visit while capacity remains limited (and lines, as a result, remain shorter).

“The rate of couples traveling by air has increased faster, whereas families are still leaning toward travel by car and R.V. rentals,” said Jeff Gwynn, Rovia’s director of communications.

Montoya and Phil Hudson, who showcase their travels as a Black family on their popular blog, The Spring Break Family, are among them. “Most years we go pretty far — Spain, Italy, France, as far as we can go. This year it was about what’s reachable by car,” Ms. Hudson said. She and Mr. Hudson, who both work in the health care industry, are vaccinated, but admit they probably won’t be willing to fly with their two daughters, Leilah, 11, and Layla, 8, for several more months.

That’s because they want to wait for herd immunity to help keep their daughters safe. “The goal is to wait until the majority of the population is vaccinated, or has at least had the opportunity to become vaccinated,” Ms. Hudson said.

In addition to preferring driving over flying this summer, travel analysts say families with children will also continue to opt for rental homes over hotel rooms.

In fact, when it comes to the vacation cottage market, parents are booking faster than anyone else. “Families are the number one group expected to travel in 2021,” said Vered Schwarz, the president and chief operating officer of Guesty, a short-term property management platform which reports that its summer reservations are already 110 percent higher than 2020, with families comprising more than 30 percent of those booking. “For families with unvaccinated children, private rentals are appealing — they are comfortable and they avoid hotels chock-full of crowded common areas,” she said.

The question of how to treat unvaccinated children who may be traveling with their parents is also presenting a legal and ethical minefield for American travel operators.

The European Union is considering a vaccine passport that will allow free travel within the bloc for those who can show proof of inoculation. In Israel, a green pass has been established for those who have been vaccinated, granting holders not just the ability to cross a border but also check into a hotel or eat inside a restaurant, but children are not exempt — so parents with unvaccinated children must dine outside at restaurants and find babysitters before heading to the gym or a show.

But in the United States, such policies are unlikely to take hold, said Chuck Abbott, the general manager of the InterContinental San Diego. “Most hotels would not ask for that information, because it violates the privacy of the guest,” he said. “Even putting vaccinated guests on a different floor than other guests would likely present a legal issue.”

Compared with summer 2019, families’ plans for summer 2021 are more low-key: Travelocity reports that bookings to Mount Rushmore and Nashville are significantly up over two years ago; internationally, family bookings to London, Paris and Rome, destinations that were top family sites in 2019, but have still not reopened to U.S. travel, are way down, while Cancún, which is currently open to American travelers without quarantine requirements, is up nearly 50 percent.

Some European countries, like Iceland, have begun inching open their borders, but only to passengers who are vaccinated. That means individuals who can present proof of the Covid-19 jab can bypass quarantine when they arrive — unless they are parents traveling with children.

“Unvaccinated children would still need to quarantine for five days, and the parents, of course, must stay with the child,” said Eric Newman, who owns the travel blog Iceland With Kids. “Iceland’s brand-new travel regulations are not friendly to families hoping to visit with children.”

After a year of virtual schooling and working from home, parents have no desire to quarantine with their kids, said Anthony Berklich, the founder of the travel platform Inspired Citizen. “What these destinations are basically saying is you can come but your children can’t,” he said.

Instead, families are opting for warm-weather destinations closer to home.

When the Centers for Disease Control and Prevention announced in January that proof of a negative PCR test would be required of all air passengers arriving in the United States, many tropical resorts — including more than a dozen Hyatt properties — began offering not just free on-site testing, but a deeply discounted room in which to quarantine in case that test comes back positive. That move, said Rebecca Alesia, a travel consultant with SmartFlyer, has been a boon for family travel business.

“What happens if the morning you’re supposed to come home, you get up and Junior has a surprise positive test?” she said. “A lot of my clients have booked this summer because of this policy.”

For parents struggling to decide how and when to return to travel, there is good news on the horizon, said Dr. Shruti Gohil, the medical director of infection prevention at the University of California, Irvine.

“The chances of a good pediatric vaccine coming soon are high,” she said, noting that both Pfizer and Moderna are already running pediatric trials on their vaccines. “There is no reason to think that the vaccine will have any untoward effects on children that we haven’t already noted in adults.”

In the meantime, she said, parents with children need to continue to be cautious. That doesn’t mean families shouldn’t travel at all, but she recommends choosing to drive rather than fly; to not allow unvaccinated children to play unmasked with children from other households; and to remain vigilant about wearing masks and regularly washing hands while on the road.

“We can’t keep saying that you can’t go anywhere,” she said. “At some point we have to have some kind of nuance around this. But this is a game we are all still playing until the virus is gone.”

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Weighing the Use of Growth Hormones for Children

New research has linked growth hormone treatment to serious adverse health effects years later.

An 8-year-old boy I know is small for his age, shorter and slighter than his friends, even smaller than his 5-year-old sister. Concerned about the increasing use and possible risks of growth hormone, I asked his mother if she’d considered treating him with it. She replied, “Not really. He’s built like his father, who was short and slight as a boy and didn’t shoot up until college.”

Their son, she said, has no sign of a hormone deficiency. “He’s in the third percentile for height and has maintained the same growth trajectory for years, so there’s no reason to do something about it,” she said. “He’s very athletic, physically capable and can keep up with his friends in other ways.”

His father, at 41, is now 6 feet tall, though still very slender. He recalls being a reasonably athletic child but without the physical power of his friends, making up for what he lacked in mass with speed and agility. “I enjoyed competitive sports and worked on skills others didn’t have,” he told me, and said he encourages his son to recognize and capitalize on the skills he has.

If only every parent with a short but healthy child approached the matter as sensibly. Experts estimate that 60 percent to 80 percent of children who are short for their age do not have a growth hormone deficiency or other medical condition that limits growth. But knowing there’s a therapy available to increase height, some parents seek a medical solution for a perceived problem, even when there is no medical abnormality. They should also know, however, that new research has linked growth hormone treatment to serious adverse health effects years later.

Undue shortness may have many causes in addition to a deficiency of growth hormone, including malnutrition, Crohn’s disease or celiac disease, and potential medical conditions should be ruled out or, if present, treated. But height is most often related to the child’s genetics. Like father or mother, like son or daughter. Given the height of my parents — a 5-foot-1 mother and a 5-foot-6 father — I was not likely to become a forward for the Knicks at 4 feet 11.

Dr. Adda Grimberg, a pediatric endocrinologist at Children’s Hospital of Philadelphia, recalled that “20 years ago, families were focused on health. They came in with a child who was not growing right and wanted to know if there was an underlying disease. Now, more and more, they’re focused on height. They want growth hormone, looking for a specific height. But this is not like Amazon; you can’t just place an order and make a child the height you want.”

Originally, growth hormone was used to treat children with an established deficiency, which can result in a host of serious health problems. Cadavers were the initial limited source of the hormone until 1985, when scientists succeeded in producing recombinant human growth hormone in the laboratory, greatly increasing the supply and its use to treat growth hormone deficiency.

Estimates of the incidence of this deficiency range from one in 3,000 to one in 10,000 children. According to the Pediatric Endocrine Society, those affected are usually much shorter than their peers — well below the third percentile — and over time fall increasingly behind.

In 2003, the Food and Drug Administration approved use of recombinant human growth hormone for the condition known as “idiopathic short stature,” or short stature of unknown cause, which is not a disease. But it has prompted a growing number of parents to consider using the hormone to boost the height of their children. The resulting rush to therapy reflects concerns about a widespread societal bias against shortness, rather than a true medical need, Dr. Grimberg said.

Parents considering treatment for this otherwise medically benign condition should know what it entails: daily injections for years until the child’s growth is completed, rotating injection sites in the body to minimize scarring. Although few children experience side effects, which can include severe headaches and hip problems, treatment requires repeated doctor visits, X-rays and blood work and, Dr. Grimberg said, “gives the child a powerful message that there’s something wrong with him that needs fixing.”

According to the Pediatric Endocrine Society, the decision to administer growth hormone for idiopathic short stature should be made on a case-by-case basis in which benefits and risks are carefully considered for each child.

What, then, are the benefits and risks? Although manufacturers have supported monitoring drug safety beyond the 10 years mandated by the U.S. government, reporting is voluntary and necessarily incomplete. However, a far more reliable assessment is available from Sweden, where population-wide data are routinely collected.

In JAMA Pediatrics in December, pediatric endocrinologists from Karolinska University Hospital reported that among 3,408 patients who were treated with recombinant growth hormone as children and adolescents and followed for up to 25 years, the risk of developing a cardiovascular event like a heart attack or stroke was two-thirds higher for men and twice as high for women than among 50,036 untreated but otherwise similar people.

The Swedish finding follows a report last June from a research team in Tokyo that growth hormone promotes biomedical pathways that stimulate the development of atherosclerosis, the basis for most cardiovascular events.

Not yet known is whether other long-term adverse effects will become apparent in the years ahead. Based on its known action, giving growth hormone when no deficiency exists might raise the risk of cancer, respiratory disease and diabetes. In an editorial in JAMA Pediatrics, Dr. Grimberg wrote that “indirect evidence suggests that the potential for untoward effects of growth hormone treatment is sufficiently plausible” to warrant further study.

Equally important for parents to know is how much height their children might gain from years of daily hormone injections. Though impossible to predict in advance for an individual child, the average benefit for children with idiopathic short stature is about two inches in adult height. Dr. Grimberg suggested that if there is no measurable benefit within a year of therapy, parents should consider stopping it.

In discussing the psychological aspects of growth hormone therapy when no deficiency exists, experts have noted that the practice perpetuates the notion that short stature is unacceptable, leading to a spiraling demand for therapy. It is far better, one group suggested, to help a short child develop coping skills than to buy inches through pharmacological means.

In a report in Hormone Research in Pediatrics, Dr. Talia Hitt and colleagues at Children’s Hospital of Philadelphia and the University of Pennsylvania wrote that parents’ high expectations that growth hormone therapy will improve the quality of life for their children are unlikely to be met if the children are not hormone deficient. They urged clinicians to “support families in other ways that promote positive development in children with short stature.”

Dr. Philippa Gordon, a pediatrician in Brooklyn, N.Y., urges parents to make sure their children know “that people can be all different sizes and shapes and that their love for them is unconditional.”

Your Pandemic Baby’s Coming Out Party

Haven’t seen your family in a while? Have a grandchild you’ve never met? Visiting may be awkward at first but you can get through it.

No one in Deena Al Mahbuba’s family has met her daughter, Aara. She was born at the end of 2019, extremely premature. By the time Aara left the hospital for her home outside Boston in mid-June, the world was already months into Covid-19 lockdowns. Ms. Mahbuba’s close relatives, along with her husband’s, all live in Bangladesh. The couple moved from there in 2013.

Family members have done their best to stay connected, but Ms. Mahbuba, a graduate student at the Massachusetts Institute of Technology, wishes her relatives were nearby. Her older siblings have kids of their own and could help her soothe Aara when she’s sleepless.

Or they could show her how they introduced foods to their own babies; Aara, now 15 months old, struggles with new foods after having been tube-fed in her early life. Ms. Mahbuba also hopes Aara will learn to speak Bengali, but worries she needs exposure to the language from people besides her parents.

“Sometimes I feel really sad,” Ms. Mahbuba said. “I feel like there is a gap happening, and sometimes I worry this gap is going to be stretched out day by day.”

Even grandparents, aunts or uncles in the same country as babies born during Covid-19 have been kept away by travel restrictions and other precautions. Darby Saxbe, an associate professor at the University of Southern California, said her lab started following 760 expectant parents in the spring of 2020 to study their mental health, social connection and other factors. In open-ended survey responses, many participants reported that they hadn’t been able to see extended family.

The first pandemic babies are becoming toddlers this spring, which means entire infancies have passed while children and their parents were isolated from their loved ones. Even as families mourn the missed cuddles, though, experts say the gap isn’t likely to have any long-term effects. Kids and their relatives can make up for lost time when they reunite. In the meantime, families can take steps to keep those missing relatives present in a child’s mind.

Reaching Across the Gap

Infancy is an important window of time for bonding, said Sarah Schoppe-Sullivan, an Ohio State University child psychology professor, and not just because it’s your only chance to catch those squishy cheeks and sniffable heads. “Infancy is the period during which children are biologically predisposed to form close relationships with important caregivers,” Dr. Schoppe-Sullivan said.

This is an element of attachment theory, an area of psychology research that’s been around for several decades. (Not to be confused with attachment parenting, a philosophy from the 1980s that espouses a whole lot of baby-wearing.) Studies suggest that babies are primed to bond tightly with one or more caregivers. Once a child has a strong attachment to someone, that person becomes a “secure base,” the theory goes. The child looks to that person for reassurance in moments of distress. In calmer times, secure attachments give kids confidence to explore and learn from their environments.

But relatives who miss this window don’t need to worry, Dr. Schoppe-Sullivan said. The theory says that when infants form secure attachments, they’re also forming the capacity for relationships in the future. That means the bonds parents have built with their babies during coronavirus-induced isolation may help those babies connect with relatives who live far away — whenever they finally visit.

And today’s infants and toddlers won’t recall these absences. The older siblings of the pandemic babies may not remember a gap in visits from Nana, either. Because of what’s known as childhood amnesia, most people remember few events that occur before age 3 or so. Even though grandparents may be grieving for the milestones they missed this year, “The child will not remember who attended their first or second birthday party,” said Lorinda Kiyama, a psychologist and associate professor at Tokyo Institute of Technology.

As an American living in Japan, Dr. Kiyama often counsels couples who come from different countries or international couples who are adopting a Japanese child. She pointed out that separation from relatives isn’t always a bad thing. “The distance is often a relief when relationships are fraught,” she said. However, “it can be agonizing when you want to be close.”

She suggested building familiarity by talking about absent relatives while pointing to photos of them. Babies as young as nine months may be able to recognize an object they’ve seen in a picture. And even if children seem too young to grasp what you’re saying, Dr. Kiyama said, they usually understand more language than they can produce.

With a parent’s help, a distant family member can use video chat to play peekaboo, sing songs with a child, do pretend play, or show off their pets. (And don’t worry if you’re trying to limit screen time: The American Academy of Pediatrics says video chatting doesn’t count.)

Ms. Mahbuba uses FaceTime to keep Aara in touch with her family in Bangladesh, though the time difference is a challenge. When Aara is alert and playful after her nap, it’s 2 a.m. for her grandparents.

Ms. Mahbuba said the enforced separation of the pandemic has given some of her friends and co-workers a window into what her life is like as an immigrant living far from her family. “They kind of understand now how it feels to be stuck,” she said.

Jumping the Gap

When long-absent family members finally get to meet those babies — or toddlers — it will be important to take their time building a relationship, said Carola Suárez-Orozco, a professor of counseling psychology at the University of Massachusetts, Boston, who has studied the effects of family separation on immigrant children. “Help the adults slow it down when they first encounter the baby.”

First, prime relatives for some amount of rejection from the child, Dr. Suárez-Orozco said. From a child’s point of view, “They’re meeting strangers.” Although younger infants might happily go from one set of arms to another, stranger anxiety develops by eight months or so. This fear of new people usually lasts well into the child’s second year.

“If a child is reluctant to hug an extended family member they just met, that should be seen as a healthy sign,” Dr. Kiyama said.

She suggested preparing toddlers for meeting relatives by using toys or stuffed animals to act out scenes like picking them up from the airport. You could also keep an empty chair at your kitchen table, or leave out a bath towel or other object, and tell the child it’s going to be Grandma’s when she visits, Dr. Kiyama said.

Older toddlers, or preschool-aged siblings who will be seeing relatives after a long absence, might like practicing what they’re going to say. “Give the child a script to follow, with some variations for flexibility,” Dr. Kiyama said. Or share memories of that relative from your own childhood.

For grown-ups who are connecting or reconnecting with a toddler or preschooler, parents are an important source of information, Dr. Schoppe-Sullivan said. Parents can help relatives get on a kid’s good side by updating them on the child’s temperament, interests and weird obsessions of the moment.

“From the emotional point of view of the adults, they have connected to an abstraction. They haven’t been bonding in those moment-to-moment interactions,” Dr. Suárez-Orozco said. In her study of immigrant children who had been apart from their parents for months or years — a much more extreme form of separation than what most families face during the pandemic — she saw that family reunifications were usually “messy.”

Even so, Dr. Suárez-Orozco and her co-authors wrote, the psychological distress these children felt after reuniting gradually ebbed, showing the “extraordinary adaptability and resilience of youth.”

Now that Ms. Mahbuba’s family in Bangladesh is in the process of getting their vaccines, she’s looking forward to her own reunion. Her mother-in-law is planning to come to the United States to help out with the baby, and Ms. Mahbuba can’t wait. “The day will come. Hopefully,” she said.

The gladness that parents feel to finally see their absent relatives will be one of the most important factors in helping a child warm up, Dr. Schoppe-Sullivan said. “Do things that are fun and that make them laugh. I think that makes a big impression on kids.”

Dr. Kiyama agreed. Young children are highly sensitive to how their caregivers feel about other people, she said. The best way to help kids accept a new family member? “Genuine joy in each other’s presence.”

Elizabeth Preston is a Boston-area science journalist and mom to a preschooler and a pandemic baby.

Pfizer Begins Testing Its Vaccine in Young Children

Other drug makers have begun similar trials of their Covid-19 vaccines. If they work in children younger than 12 as expected, it will be easier for the U.S. to reach herd immunity.

Pfizer has begun testing its Covid-19 vaccine in children under 12, a significant step in turning back the pandemic. The trial’s first participants, a pair of 9-year-old twin girls, were immunized at Duke University in North Carolina on Wednesday.

Results from the trial are expected in the second half of the year, and the company hopes to vaccinate younger children early next year, said Sharon Castillo, a spokeswoman for the pharmaceutical company.

Moderna also is beginning a trial of its vaccine in children six months to 12 years of age. Both companies have been testing their vaccines in children 12 and older, and expect those results in the next few weeks.

AstraZeneca last month began testing its vaccine in children six months and older, and Johnson & Johnson has said it plans to extend trials of its vaccine to young children after assessing its performance in older children.

Immunizing children will help schools to reopen as well as help to end the pandemic, said Dr. Emily Erbelding, an infectious diseases physician at the National Institutes of Health who oversees testing of Covid-19 vaccines in special populations.

An estimated 80 percent of the population may need to be vaccinated for the United States to reach herd immunity, the threshold at which the coronavirus runs out of people to infect. Some adults may refuse to be vaccinated, and others may not produce a robust immune response.

Children under 18 account for about 23 percent of the population in the United States, so even if a vast majority of adults opt for vaccines, “herd immunity might be hard to achieve without children being vaccinated,” Dr. Erbelding said.

Pfizer had initially said it would wait for data from older children before starting trials of its vaccine in children under 12. But “we were encouraged by the data from the 12 to 15 group,” said Ms. Castillo, who did not elaborate on the results so far.

Scientists will test three doses of the Pfizer vaccine — 10, 20 and 30 micrograms — in 144 children. Each dose will be assessed first in children 5 through 11 years of age, then in children ages 2 through 4 years, and finally in the youngest group, six months to 2 years.

After determining the most effective dose, the company will test the vaccine in 4,500 children. About two-thirds of the participants will be randomly selected to receive two doses 21 days apart; the remaining will get two placebo shots of saline. The researchers will assess the children’s immune response in blood drawn seven days after the second dose.

“It sounds like a good plan, and it’s exciting that another Covid-19 vaccine is moving forward with trials in children,” said Dr. Kristin Oliver, a pediatrician and vaccine expert at Mount Sinai Hospital in New York.

Dr. Oliver said about half of the parents she sees in practice are eagerly waiting for vaccines, and even to volunteer their children for clinical trials, while the rest are skeptical because comparatively few children become seriously ill from coronavirus infection.

Both groups of parents will benefit from knowing exactly how safe and effective the vaccines are in children, she said.

Children represent 13 percent of all reported cases in the United States. More than 3.3 million children have tested positive for the virus, at least 13,000 have been hospitalized and at least 260 have died, noted Dr. Yvonne Maldonado, who represents the American Academy of Pediatrics on the federal Advisory Committee on Immunization Practices.

The figures do not fully capture the damage to children’s health. “We don’t know what the long-term effects of Covid infection are going to be,” Dr. Maldonado said.

Other vaccines have helped to control many horrific childhood diseases that can cause long-term complications, she added: “For some of us who’ve seen that, we don’t want to go back to those days.”

Children often react more strongly to vaccines than adults do, and infants and toddlers in particular can experience high fevers. Any side effects are likely to appear soon after the shot, within the first week and certainly within the first few weeks, experts have said.

Some vaccines are tested only in animals before being assessed in children, and have to be monitored carefully for side effects.

“But this is a little different, because we’ve already had experience with tens of millions of people with these vaccines,” Dr. Maldonado said. “So there’s a higher degree of confidence now in giving this vaccine to kids.”

Some experts suggested that the Food and Drug Administration may require up to six months of safety data from studies of children before authorizing the Covid-19 vaccines. But a spokeswoman said the agency did not expect six months of safety data to support the vaccines’ authorization.

The Pfizer-BioNTech vaccine is authorized for children 16 through 18 years old, and the authorization for that age group was based on just two months of safety data, she said.

Parents will want to know how the companies and the F.D.A. plan to monitor and disclose side effects from the vaccines, and how long they will continue to follow trial participants after the vaccines’ authorization, Dr. Oliver said.

“I think everyone has learned throughout this,” she said. “The more transparent you can be, the better.”

Talking to Children About Anti-Asian Bias

“I’m not sure Asian-American families can avoid ‘the talk’ any longer,” one expert said.

My daughter was the only kid who didn’t have a separate Korean name when we signed her up for Korean classes three years ago. The blank space on the registration form looked at me, as if to say we’d forgotten something as parents.

When she was born in the United States in 2012, my spouse and I, who are both Asian-American, never thought to give her a name like Seohyun or Haeun. Though Korean was the language I spoke growing up in New York with my immigrant parents, I’ve forgotten many of the words I used to know. Yet hearing it spoken still conjures the sense of home.

I had no ambition to teach my daughter Korean, but when she turned 5, she insisted she wanted to learn so she could talk to her halmoni — her grandmother. So I conceded.

On Seollal, the Korean New Year, she and the other girls in her class sported traditional silk outfits. The floor-length skirts flapped to show their patterned leggings underneath, in a church basement that smelled of steamed rice and sesame oil.

It was familiar and reassuring.

Still, I kept asking my daughter when she would try soccer, which seemed to me the “American thing” to do on a Saturday morning. It was held at the same time as Korean School. I kept thinking about the parents on the sidelines and wondered what we were missing.

In March 2020, my daughter was in first grade, eager to talk about a school assignment that asked her to write about a problem and how to be a part of solving it. Her response was that women should be paid the same as men. I felt proud.

But then she continued. A classmate had written that coronavirus was a problem and that keeping Chinese people out of the country was the solution.

Later the other kids asked: “Are you Chinese?”

In the summer of 2020, the Stop A.A.P.I. Hate Youth Campaign interviewed 990 Asian-American young adults across the United States about their experiences during the pandemic, and found that one in four had reported experiencing racism in some way.

Kids said that they had been bullied, physically harassed and had racial slurs shouted at them. Dr. Juliana Chen, a child and adolescent psychiatrist at Mass General Brigham, said that kids who experience this kind of racism may stop going to school or speaking up in class. They might start acting out, feel unwell, have trouble sleeping or struggle with depression.

Tiffany Yip, a developmental psychologist at Fordham University, said that a child who hears a racist remark hears this: “You don’t belong. You’re other. You’re different.”

We are one of only a handful of Asian-American families in our school, which prides itself on teaching about inclusion. Earlier in the year, our daughter came home talking about Malala Yousafzai and Ruby Bridges, asking where we would have been sitting on the bus in times of segregation. Now I questioned what racial biases our progressive community might have held.

When schools closed and our country locked down, my family took daily walks, chalked the sidewalks, looked for teddy bears in windows, and tried to smile from behind our masks. But when a girl in our neighborhood pointed to my daughter and said they could not play together because of the “China virus,” I wept.

During lockdown, we devoured books with Asian-American heroines by authors like Grace Lin and Min Jin Lee. I marveled: “That’s my family’s story.” While my 7-year-old jumped from the couch, she said of one of the characters: “She likes to eat dduk guk” — Korean rice cake soup — “like me!”

Next we read about Li Keng Wong, a 7-year-old who was detained at the Angel Island immigration station in San Francisco in 1933. We admired the poems carved into the barracks there, wrote poems of our own, and taped them to our bedroom walls. But I struggled to find the words to explain to my daughter why Chinese-Americans were forced to live in these barracks; why they were separated from their families.

She doesn’t yet know about the 84-year old man who died two days after being shoved to the sidewalk in Chinatown in San Francisco last month, or about the six Asian-American women killed by a shooter in Atlanta this week. While attacks on Asian people aren’t always charged as hate crimes, many Asians feel an increasing sense of vulnerability.

And I found the answer to my daughter’s question about where we would sit on the bus. Asian-Americans have our own, less well-known place in the civil rights story. Asians also lived in the South in the 1950s, and we, too, would have been told to move to the back of the bus. In the 1860s, there were segregated schools for Chinese-American children, for families that looked like ours.

I am finding the language to share this with my daughter. I will tell her about these injustices and I will remind her of Fred Korematsu, an American civil rights activist who objected to the internment of Japanese-Americans during World War II, and others who in their bravery spoke their minds when they disagreed with what our systems condoned.

Kids begin to develop a sense of racial identity by age 3 or 4, Dr. Yip said. Once they enter grade school, they hear about race and racism from peers and the media they consume.

“By not talking about race” and what they’re hearing, Dr. Yip said, “you run the risk of intensifying stereotypes” which can then lead to racism.

As parents we fear these hard conversations, but Dr. Chen said that it’s important to ask certain questions: What have you heard? What do you worry about? What’s school like for you and your friends? Has anything like this ever happened to you or someone you know?

“We think we’re protecting our kids, by not talking about racist incidents” Dr. Chen added. “But actually not talking about it is not helping.” Building their racial identity is what helps them feel safe.

When a racist incident happens to your child, Dr. Chen said, don’t jump into solving the problem. First ask how they feel and listen. Tell them you don’t know all the answers, but you can find solutions together.

Dr. Yip also suggested telling teachers and school leaders about the incident. Parents can help start a conversation with all the kids involved. Ask: “Can you help me understand why you did this? How do you think it makes others feel?”

Make sure that the children who were targeted know it wasn’t their fault, Dr. Chen added. Role play what you will do if it happens again and tell them, Mom or Dad or your caregivers will keep you safe.

“Black families always have the racial talk,” Dr. Yip said. But many Asian-American families in past generations did not. They emphasized assimilating to what they thought was a post-racial state. Now with the surge in harassment and hate incidents, she said: “I’m not sure Asian-American families can avoid ‘the talk’ any longer.” It’s a talk that must include listening to, and coming to understand, all groups who face racial bias.

In hindsight, I now see that Korean School has done more for my family than soccer ever could. It’s a place where my daughter sees she isn’t alone. There are families who look like ours and wrestle with the same questions, about what we will forget, and what we will keep from our immigrant families’ pasts. Being in a community equips us to be resilient in the face of the racism that we will inevitably encounter. I resolved to teach my daughter about the parts of myself that I, for too long, believed were meant to be forgotten. This will anchor her in who she is becoming, as an American.

It’s been a year since the pandemic began. Ideas around race and identity have shifted in a seismic way. My daughter has gone from sewing masks for her bears, to carrying Black Lives Matter posters and voting with me in a presidential election. Her memories of these historic events will take shape over time.

But for now, she is 8. She is learning to do cartwheels and is making dioramas and writing short stories. When she grows up, she says she wants to be a writer. She’s decided already on a character for her first book. Her name will be Minjee.

Here’s what parents can do to help:

  • Read books, watch movies and consume media with racially diverse characters. Read with your children or talk with them about what they’re reading.

  • Be proactive in bringing up conversations about race with your kids. Ask them what they are hearing and experiencing.

  • Kids will hear what’s happening in the news. Discuss it with them in an age-appropriate way.

  • Role play what to do when you see a racist incident. Talk to your kids if a racist incident happens to your child or to someone in your community.

  • Read this parenting guide for parents of Asian-American teens: How are you and your children talking about racism?

  • Share these resources from the M.G.H. Center for Cross-Cultural Student Emotional Wellness with your kids.

  • Explore additional resources for talking about race with younger children such as Embrace Race and PBS Kids for Parents.

Sources: Juliana Chen, child and adolescent psychiatrist, Mass General Brigham; Josephine Kim, faculty, Harvard Graduate School of Education; Tiffany Yip, developmental psychologist, Fordham University

Heidi Shin is a journalist and a public radio and podcast producer. Follow her on Twitter @byheidishin and Instagram @shinherrie3

How Children Read Differently From Books vs. Screens

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The Checkup

How Children Read Differently From Books vs. Screens

Scrolling may work for social media, but experts say that for school assignments, kids learn better if they slow down their reading.

Credit…Cristina Spanò

  • March 16, 2021, 11:20 a.m. ET

In this pandemic year, parents have been watching — often anxiously — their children’s increasing reliance on screens for every aspect of their education. It can feel as if there’s no turning back to the time when learning involved hitting the actual books.

But the format children read in can make a difference in terms of how they absorb information.

Naomi Baron, who is professor emerita of linguistics at American University and author of a new book, “How We Read Now: Strategic Choices for Print, Screen and Audio,” said, “there are two components, the physical medium and the mind-set we bring to reading on that medium — and everything else sort of follows from that.”

Because we use screens for social purposes and for amusement, we all — adults and children — get used to absorbing online material, much of which was designed to be read quickly and casually, without much effort. And then we tend to use that same approach to on-screen reading with harder material that we need to learn from, to slow down with, to absorb more carefully. A result can be that we don’t give that material the right kind of attention.

For early readers

With younger children, Professor Baron said, it makes sense to stick with print to the extent that it is possible. (Full disclosure: As the national medical director of the program Reach Out and Read, I believe fervently in the value of reading print books to young children.) Print, she said, makes it easier for parents and children to interact with language, questions and answers, what is called “dialogic reading.” Further, many apps and e-books have too many distractions.

Dr. Jenny Radesky, a developmental behavioral pediatrician who is an assistant professor of pediatrics at Michigan Medicine C.S. Mott Children’s Hospital in Ann Arbor, said that apps designed to teach reading in the early years of school rely on “gamification meant to keep children engaged.” And though they do successfully teach core skills, she said, “what has been missing in remote schooling is the classroom context, the teacher as meaning maker, to tie it all together, helping it be more meaningful to you, not just a bunch of curricular components you’ve mastered.”

Any time that parents are able to engage with family reading time is good, using whatever medium works best for them, said Dr. Tiffany Munzer, also a developmental behavioral pediatrician at Mott Children’s Hospital, who has studied how young children use e-books. However, Dr. Munzer was the lead author on a 2019 study that found that parents and toddlers spoke less overall, and also spoke less about the story when they were looking at electronic books compared with print books, and another study that showed less social back-and-forth — the toddlers were more likely to be using the screens by themselves.

“There are some electronic books that are designed really well,” Dr. Munzer said, pointing to a study of one book (designed by PBS) that included a character who guided parents in engaging their children around the story. “On the other hand, there’s research that suggests that a lot of what you find in the most popular apps have all these visually salient features which distracts from the core content and makes it harder for kids to glean the content, harder for parents to have really rich dialogue.”

Still, she said, it’s not fair to expect parents to navigate this technology — it should be the job of the software developers to design electronic books that encourage language and interactions, tailored to a child’s developmental level.

With preschoolers as opposed to toddlers, Professor Baron said, “there are now beginning to be some smarter designs where the components of the book or the app help further the story line or encourage dialogic reading — that’s now part of the discussion.”

Dr. Radesky, who was involved in the research projects with Dr. Munzer, talked about the importance of helping children master reading that goes beyond specific remembered details — words or characters or events — so a child is “able to integrate knowledge gained from the story with life experience.” And again, she said, that isn’t what is stressed in digital design. “Stuff that makes you think, makes you slow down and process things deeply, doesn’t sell, doesn’t get the most clicks,” she said.

Parents can help with this when their children are young, Dr. Radesky said, by discussing the story and asking the questions that help children draw those connections.

For school-age kids

“When kids enter digital spaces, they have access to an infinite number of platforms and websites in addition to those e-books you’re supposed to be reading,” Dr. Radesky said. “We’ve all been on the ground helping our kids through remote learning and watching them not be able to resist opening up that tab that’s less demanding.”

“All through the fall I was constantly helping families manage getting their child off YouTube,” Dr. Radesky said. “They’re bored, it’s easy to open up a browser window,” as adults know all too well. “I’m concerned that during remote learning, kids have learned to orient toward devices with this very skimmy partial attention.”

Professor Baron said that in an ideal world, children would learn “how to read contiguous text for enjoyment, how to stop, how to reflect.”

In elementary school, she said, there’s an opportunity to start a conversation about the advantages of the different media: “It goes for print, goes for a digital screen, goes for audio, goes for video, they all have their uses — we need to make kids aware that not all media are best suited to all purposes.” Children can experiment with reading digitally and in print, and can be encouraged to talk about what they perceived and what they enjoyed.

Dr. Radesky talked about helping children develop what she called “metacognition,” in which they ask themselves questions like, “how does my brain feel, what does this do to my attention span?” Starting around the age of 8 to 10, she said, children are developing the skills to understand how they stay on task and how they get distracted. “Kids recognize when the classroom gets too busy; we want them to recognize when you go into a really busy digital space,” she said.

For older readers

In experiments with middle school and university students asked to read a passage and then be tested on it, Professor Baron said, there is a mismatch between how they feel they learn and how they actually perform.

Students who think they read better — or more efficiently — on the screen will still do better on the test if they have read the passage on the page. And college students who print out articles, she said, tend to have higher grades and better test scores. There is also research to suggest that university students who used authentic books, magazines or newspapers to write an essay wrote more sophisticated essays than those just given printouts.

With complex text in any format, slowing down helps. Professor Baron said that parents can model this at home, sitting and relaxing over a book, reading without rushing and perhaps generally de-emphasizing speed when it comes to learning. Teachers can be trained to help students develop “deep reading, mindful, focusing on the text,” she said.

For example, students can be trained in digital annotation, highlighting but also making marginal notes, so that they have to slow down and add their own words. “We’ve known that for years, we’ve done it with print, we have to realize that if you want to learn something from a digital document, annotate,” she said.

There are also studies that suggest that reading comprehension is better onscreen when readers page down — that is, when they see a page (or a screen) of text at a time, and then move to the next, rather than continuously scrolling through text.

Seeing information on the page may help a student see a book as something with a structure, rather than just text from which you grab some quick information.

No one is going to take screens out of children’s lives, or out of their learning. But the more we exploit the rich possibilities of digital reading, the more important it may be to encourage children to try out reading things in different ways, and to discuss what it feels like, and perhaps to have adults reflect on their own reading habits. Reading on digital devices can motivate recalcitrant readers, Professor Baron said, and there are many good reasons to do some of your reading on a screen.

But, of course, it’s a different experience.

“There’s a physicality,” Professor Baron said. “So many young people talk about the smell of books, talk about reading print as being ‘real’ reading.”

Why I Took a Vow of Celibacy

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Modern Love

Why I Took a Vow of Celibacy

In my life, sex and love have been twisted up with childhood trauma. Time for a break.

Credit…Brian Rea

  • March 12, 2021, 12:00 a.m. ET

Twenty months ago, I took a vow of celibacy that had nothing to do with religion. I had just come out of a two-year relationship that had ended messily, and I felt exhausted at the soul level. Not just by what it had taken to extricate my heart from this particular maelstrom of shattered promises and lingering disappointments, but by the whole thing, the dozens of relationships so much like this one that they seemed to exist in an echo chamber.

Two failed marriages. An ocean’s worth of love drama. The giddiness, hope and euphoria that invariably collapsed into conflict and doubt. And then the desperate attempts at relationship CPR, the talking and processing, anxious text messages, fighting and makeup sex, trying and failing to make something work that didn’t.

I was tired, most of all, of the voices in my head that would creep in as the latest enmeshment was disintegrating, telling me that all I needed to do was try again with the next one, the right one, somewhere out there.

This time, however, something shifted. When the voices began to whisper their usual “just keep looking” litany, I couldn’t bring myself to believe them. The jig was up. When the smoke cleared, I saw that I was lost, and that no love, no matter how profound, was going to help me find my way out.

I had been in this limbo for so long, desperate to find someone to save me, that I had lost track of where I had come from: the foster care system in Fresno, Calif. I was only 5 when my two sisters and I were sent to live with the couple at the root of all this.

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A skinny, curly-haired, quiet girl, I had already learned to read grown-ups like maps of difficult terrain and to bend myself into whatever kind of child they seemed to want. This was my job, to watch and to please, so I wouldn’t be given away again. Because I had learned that as bad as any situation was, it could always be worse.

My sisters, who were 3 and 7, must have been coping similarly. But strangely we never spoke to each other about what was happening to us in that house, or about anything that had already transpired. Not about how our mother, who had skipped town with a boyfriend the year before without saying goodbye or telling anyone where she was going. Not about our violent, shiftless father, who bounced in and out of jail and our lives. Not about our social worker, who showed up unannounced at our last placement, which had lasted only four months, and helped us pack our few things into garbage bags.

Had we done something bad? Were we not enough? No one said, and we knew better than to ask. We went without crying or even complaining, as if childhood was a kind of war, and we had been made soldiers.

There were an infinite number of rules in our new situation, which we followed without question. No sitting on the furniture, no food or water after 5 p.m., no raised voices. I must have gone to kindergarten and first grade there, but my school memories are blurry. I do remember days at home, stiff and cold as the plastic casing on the chairs and the sofas. The wife would tell us to play outside and then lock the door behind us.

At night, I shared a bed with my younger sister. We would sleep curled against each other like puppies, rubbing our feet together against the mattress to self-soothe — our oldest shared habit.

Some nights nothing happened. Other nights I would wake to a shape in the doorway, the husband’s inky silhouette. And then I would disappear inside myself, barely breathing, frozen. I vanished so expertly that I wasn’t actually in my body any longer as he peeled me away from my sister. I didn’t make a sound.

I think I was sleepwalking through those years — when I was 5, 6 and 7. That I went somewhere else, even in the daytime, far away from all the things I couldn’t control.

Do children ever belong to themselves? I didn’t. I was a chess piece, there to be moved, sacrificed. Grown-ups, and particularly my caregivers, seemed either uncaring or dangerous or both. There was nowhere to turn, and nothing to do but simply give up my body and hide far away, deep in the maze of my mind.

After two years, we eventually left that family. I was 7. I was so young, too young, but as a therapist once said to me, “The body never forgets.” Trauma leaves its imprint on you.

We were taken away because I had somehow mustered the courage to speak, telling the wife, in a shaking voice, about the molestation that had been happening. Though she never turned around or even acknowledged me, she later called our social worker to say she couldn’t take care of us anymore. We were taken to another foster home, and then another, each of them decidedly less abominable, but not without trauma.

At 18, when I aged out of the system, all I wanted was to reinvent myself as quickly as possible. Given a chance, I think I would have crawled out of my own skin, or even seared off my fingerprints. Whoever that throwaway girl was, I didn’t want to be her any longer.

I broke ties with our latest foster family, who had raised us for the last ten years, and also our biological family, the grandmother, cousins, aunts and uncles we had seen less frequently throughout the years. I let it all burn without looking back, making it a policy never to tell anyone in this new life how I had grown up. Not friends, and certainly not the boyfriends I blew through as if I were bent on revenge.

There was a desperate edge to those years. I enrolled in community college, all I could afford or even aspire to, and rented an apartment with my sisters. We lived paycheck to paycheck, well below the poverty line, but we belonged only to ourselves.

Every weekend, we went dancing, drinking Vodka Collins by the dozen. Sometimes I went home with strangers, telling myself I liked sex, when really, I would often feel myself sliding out of my body and going somewhere else during the act, like watching a mannequin going through the motions.

Sometimes I would burst into tears or flood with rage, wanting to fight back in a way I hadn’t as a child. And in these moments, which were like a terrible hijacking, I would feel embarrassed, ashamed, incapable of explaining to whomever I was with what was really happening, not even someone I cared about, a boyfriend, or later my husband.

Sex scared me, so I had more of it. Men bewildered me, so I obsessed over figuring out what they wanted and tried to become that, falling to pieces when it didn’t work. And if I was with a guy who was caring and attentive, I would feel claustrophobic and overwhelmed, poised to bolt.

This is the dance I have been caught up in for most of my adult life, through marriage and divorce, motherhood, a successful career. It’s the dark shape that is forever in the background, tracking me like my own shadow, driving me to seek what can’t be found.

“I just want to have some other argument with the universe,” I told my therapist when I made the decision to swear off relationships. “I feel like I’m fighting the same war, over and over. And the weapons are only ever pointed at me.”

Sometimes I feel as if I am broken and always will be, but I have to remind myself of an essential fact: I didn’t break myself. Maybe I can’t fully mend myself, either, but the first step must be to try to love myself as I am, though that often seems like the hardest task of all.

I want to carry what’s mine to carry, claiming my life experiences, my war wounds, instead of wishing I’d had some other story. I feel lonely now and then in this, my second year of self-imposed celibacy, but I’m hardly alone.

We’re all carrying something. In my neighborhood, I often find myself looking up and down the street in an almost sacred way, knowing that many of the men and women climbing into buses or sitting masked in coffee shops have also been damaged by sexual abuse or experienced similarly painful traumas. I marvel at how beautiful we all are, how human. And then I make my way home.

Paula McLain is the author of the novel “The Paris Wife.” Her new novel, “When the Stars Go Dark,” will be published in April.

Modern Love can be reached at modernlove@nytimes.com.

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The Year Grandparents Lost

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Generation Grandparent

The Year Grandparents Lost

The enforced separations of the pandemic have brought a particular kind of mourning to many grandparents.

Kathy Koehler of Ann Arbor, Mich., relies on Skype calls to connect with her infant grandson, Elya, who lives in London. He was born at the start of the pandemic and they have not yet been able to meet in person.
Kathy Koehler of Ann Arbor, Mich., relies on Skype calls to connect with her infant grandson, Elya, who lives in London. He was born at the start of the pandemic and they have not yet been able to meet in person.Credit…Cydni Elledge for The New York Times

  • March 11, 2021, 4:03 p.m. ET

Kathy Koehler had made elaborate plans to meet her first grandchild. Her daughter, who was expecting a baby last March, lived in London, and Ms. Koehler intended to fly there from her home in Ann Arbor, Mich.

She had collected a small stash of blankets, toys and clothes to tuck into her suitcase, and reserved a bed-and-breakfast near her daughter’s flat for the month of April.

“I’d be there every day and help out and get to know this little guy,” said Ms. Koehler, who’s 63. “I could not wait.”

That trip never took place, of course. Nor did her daughter make a planned visit home in October to introduce her new son, Elya, to the rest of the family. Covid-19 intervened.

Crushed, Ms. Koehler hoped she could at least celebrate her grandson’s first birthday in person. Friends scoffed at her pessimism, assuring her that surely international travel would safely resume before then. But Elya turns 1 on March 13, and his maternal grandmother has yet to hold or kiss him.

“It feels like a double loss,” she said. “I’m losing time with this newborn that I’ll never get back. And I didn’t get to see my daughter and son-in-law fall in love with him and become parents. I felt so cheated.”

The enforced separations of the pandemic have caused widespread sorrow for grandparents. Whether they live an ocean apart or around the corner, many have had to cancel visits, forgo holiday gatherings and give up the ordinary pleasures of reading stories and playing games. Even though distancing protects grandparents’ physical health and safety, because elders are at higher risk, it has been a painful time.

And it’s not entirely behind us. The vaccine rollout may prompt a spate of joyful reunions in coming weeks; new guidelines from the Centers for Disease Control and Prevention say that fully vaccinated grandparents can now safely visit with grandchildren.

But, in many states, older people are still scrambling for appointments and the C.D.C. has maintained its warnings against travel. Ms. Koehler, who doesn’t yet qualify for vaccination in Michigan, watched Elya’s birthday party via Zoom.

Long before the pandemic, researchers knew that social isolation afflicted many older adults. In widely cited studies, about a quarter reported feeling isolated and more than 40 percent felt lonely, states that can affect both psychological and physical health. For many people, the pandemic intensified that sense of disconnection.

The inability to spend time with grandchildren brings a particular kind of loss, however. Children change more quickly than our other relatives. As Ms. Koehler pointed out, missing time with babies means they have passed through phases and stages we will never witness, except on video screens. Grandparents were unable to attend many older kids’ milestones, too, over the last year — dance recitals, soccer games, graduations. Some special occasions did not take place at all.

Nor could they help their beleaguered children the way many wished to, as they faced uncommon economic and other pressures, often without child care or in-person school.

Ms. Koehler waves to her grandson on their daily call.Credit…Cydni Elledge for The New York Times
“He absolutely knows my face,” she said.Credit…Cydni Elledge for The New York Times

Kerry Byrne, founder of The Long Distance Grandparent, a business that helps build intergenerational connections, heard from distressed grandparents all year. After extended apartness, “they worry that the grandchildren won’t know you or you won’t know them,” she said. “They worry they won’t be able to maintain these bonds.”

Risa Nye, 69, a writer in Oakland, was able to see her four grandchildren in the Bay Area, though in some cases only outdoors. But what about the two in Syracuse, N.Y.?

Prepandemic, Ms. Nye and her husband would fly east or her daughter and family would come west several times a year. Sometimes they’d vacation together at the Jersey Shore or in Southern California near Disneyland.

Now, she wonders if Madeleine, 13, and Ezra, 7, will remember eating blue pancakes at the Rise N Shine Diner or seeing “Wonder Woman” together. “It’s been a year-plus,” Ms. Nye said. “The older one’s a teenager. I’m missing out.”

“This has been devastating,” agreed her daughter, Caitlin Nye, 43. Her parents hinted about visiting, and “it’s very hard to tell your mom, ‘There’s no logistical way to do this safely and without huge anxiety.’” But as a nurse educator hyper-aware of viral risks, that is what she told her mother.

Grandparent grief — a term used by Emma Payne, founder of a company called Grief Coach — involves another dimension: older people recognize that time with their families is growing limited. The average age for becoming a grandparent in the United States is 50, but many grandparents are older, or face health problems.

A year apart can feel more wrenching to a 75-year-old, for whom it represents a greater proportion of her remaining life span, than to her 35-year-old son or daughter.

In April, Marilee Reinertson Torres of Cedar Rapids, Iowa, met her  youngest grandchild through a hospital window.
In April, Marilee Reinertson Torres of Cedar Rapids, Iowa, met her  youngest grandchild through a hospital window. Credit…Marilee Torres

Marilee Reinertson Torres, 61, has five grandchildren within a half-hour drive of her home in Cedar Rapids, Iowa. Last April, she greeted the youngest, Salma Elaine, from outside the window of the hospital where she’d just been born. Though Ms. Torres could see her grandchildren outdoors over the summer, and hold the newcomer, those visits stopped in the November cold.

Because she undergoes chemotherapy infusions and scans every three weeks for a recurrence of cervical cancer, Ms. Torres said she is more aware of mortality than other people. “I saw Salma when she was born. Can I see her go to school? I want to see what my 10-year-old is like as an adult.” She questions whether she will.

Experts in child development are reassuring on one score: Family bonds can weather this interruption.

“Grandparents shouldn’t worry that they won’t have important roles in their grandchildren’s lives going forward,” said Dr. Dimitri Christakis, who directs the Center for Child Health, Behavior and Development at Seattle Children’s Research Institute.

“Children are resilient and they’re highly adaptable,” he said. “If a child is being reintroduced to grandparents after a year apart, they will still have a very important place in that child’s life.”

Maintaining those connections, especially with children who didn’t know their grandparents well before Covid-19, does take effort, however.

Ms. Koehler has Skyped with Elya and his mother every day. “He absolutely knows my face,” she said. She and her husband show him their dog and cats and play where’s-your-nose together. “It feels like a real relationship is being formed,” said Ms. Koehler, who also Skypes with a second grandchild in Maine.

Kathryn Hirsh-Pasek, a psychologist at Temple University, Zooms nightly with her own young grandchildren. “If there are ways that allow you to see a face or hear a voice, that can be very powerful in maintaining relationships,” she said.

“A willingness to be silly and playful is important,” Ms. Byrne added. Oh, I know.

I haven’t been separated from my granddaughter, now 4; she and her parents and I have formed a pandemic pod. We mask and distance from everyone else, but not from one another.

Since I’m lucky enough to remain her child care provider one day a week, we don’t need to FaceTime often. But when we do, I pull out the hand puppets and have been known to get cheap laughs by bonking a pesky horse puppet on the head with a banana.

Vaccination is finally allowing some grandparents to resume spending time in person with their grandchildren.

But no matter how hard all parties have worked at staying in touch, many grandparents have suffered deeply this year. Resumed visits — the real kind, in person — cannot come too soon.

“Grief” isn’t too strong a word for those grandparents who have yearned all year for a small hand in theirs, for a hug without fear.

Pandemic Raises Concerns About Childhood Lead Poisoning

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Pandemic Raises Concerns About Childhood Lead Poisoning

Lead screenings for children plummeted last spring, and stay-at-home orders may have increased household exposure to the toxic metal.

A worker scraping off lead paint. The C.D.C. estimates that more than 20 million housing units in the United States contain lead-based paint, which was essentially banned in 1978.
A worker scraping off lead paint. The C.D.C. estimates that more than 20 million housing units in the United States contain lead-based paint, which was essentially banned in 1978.Credit…Jamie Hooper/Alamy

  • March 11, 2021, 5:00 a.m. ET

Over the past half-century, public health officials have made enormous progress in protecting American children from lead poisoning and the irreversible neurological damage it can cause. Since the 1970s, the percentage of children with high levels of lead in their blood has plummeted.

But in 2020, a new health threat, the coronavirus, endangered these hard-earned gains.

When Covid-19 cases spiked last spring, lockdowns and day care closures confined young children to their homes, where lead exposure can be particularly high. The growing national emergency also delayed lead-removal efforts and disrupted routine childhood lead screenings, leaving health officials unable to identify and treat many children living in lead-laden homes.

Last month, the Centers for Disease Control and Prevention estimated that in the early months of the pandemic, roughly 10,000 children with elevated levels of lead in their blood may have gone undetected.

“Hundreds of thousands of children have missed their essential tests for lead,” said Joseph Courtney, a senior epidemiologist at the C.D.C.’s lead poisoning prevention and environmental health tracking branch, who conducted the analysis. “And it’s something that has potentially permanent lifetime effects.”

There is no safe level of exposure to lead, which can disrupt neurological and cognitive development, causing learning disabilities, behavioral problems and developmental delays.

The C.D.C. estimates that more than 20 million housing units in the United States contain lead-based paint, which was banned in 1978. When the paint flakes, cracks or peels, the lead mixes with dust, which children can ingest or inhale. Young children, whose brains are still developing, are at particular risk.

“The main route of exposure for most children is lead-contaminated dust, from paint getting on their hands or their toys,” said David Jacobs, chief scientist at the National Center for Healthy Housing. “And then normal child behavior at this age is, everything goes in the mouth.”

For that reason, many states recommend or require that children of certain ages have their blood tested for lead. (Federal guidelines require that all children who are enrolled in Medicaid receive blood lead level tests at ages one and two.) Doctors typically perform these tests as part of a child’s regular checkup.

But when the pandemic hit last March, government officials issued stay-at-home orders, and many medical offices closed. Others started conducting appointments virtually. “You can’t do a blood lead test by telemedicine,” said Dr. Stephanie Yendell, senior epidemiology supervisor at the Minnesota Department of Public Health. “You can’t get a blood sample by video call.”

That month in Minnesota, the number of tests for blood lead level fell to 70 percent of what it had been the previous year, Dr. Yendell said. “And then in April, we bottomed out at 43 percent compared to the year before.”

In New York City, which was hit by an early wave of Covid-19 cases, childhood lead screenings declined by 88 percent last April.

Anecdotal reports of these declines soon made their way to the C.D.C., which asked state and local health officials to share their lead screening data so the agency could conduct a more formal analysis. Thirty-four health departments — representing 32 states, plus New York City and Washington, D.C. — ultimately did so.

Paint is the most common cause of childhood lead poisoning, but lead pipes also pose a threat; the longer that water sits stagnant in such pipes, the more lead leeches into it.
Paint is the most common cause of childhood lead poisoning, but lead pipes also pose a threat; the longer that water sits stagnant in such pipes, the more lead leeches into it.Credit…Julio Cortez/Associated Press

Every one of those departments reported a drop-off in testing last spring, Dr. Courtney and his colleagues found. Over the first five months of 2020, roughly 500,000 fewer children had their blood lead levels tested in these districts compared with the same period of 2019. The decline was especially steep in March, April and May, when testing levels fell 50 percent compared to the previous year.

That kind of decline has no precedent, Dr. Courtney said: “There’s nothing like it before.”

Roughly 2 percent of American children have elevated blood lead levels, Dr. Courtney said. If that percentage holds for the children who missed their screenings last year, it would mean that nearly 10,000 of them had significant lead exposures. “And there were 18 states that we didn’t receive data from that probably would have added to that total,” he noted. “So that’s a conservative estimate.”

There is also reason to suspect that lead poisoning is even more prevalent among the children who missed their blood tests last year, experts said. Children of color, and those who live in low-income neighborhoods, are particularly likely to be exposed to lead. Those same communities have been among the hardest hit by the coronavirus and may have faced the biggest obstacles in receiving pediatric checkups last year.

“We’re afraid that the kids who are being missed are probably the kids at higher risk,” Dr. Courtney said. Some states reported that the dip in lead screenings was especially pronounced among children who were on Medicaid, he added.

For lead-poisoned children, the consequences could be devastating. Although there is no way to reverse lead poisoning, nutritional supplements and educational services can help mitigate the harms. Children who miss their lead screenings may not receive these essential interventions.

Moreover, in many cases, it takes an elevated blood lead level to trigger lead removal or remediation efforts. “If you don’t test, you don’t find,” said Dr. Morri Markowitz, director of the lead poisoning treatment and prevention program at the Children’s Hospital at Montefiore, in New York City. “If you don’t find, you don’t intervene, and the kid continues to be exposed, continues potentially to be ingesting lead.” He added: “And then it can progress, and by the time you check, things will have gotten worse.”

Even as lead testing rates were falling last spring, the amount of time that children were spending in their homes, where lead exposure is most likely, was rising. The pandemic, and the financial hardships that accompanied it, may also have prompted some families and property owners to postpone essential building repairs and maintenance tasks.

“I’m very concerned that we potentially may have more children who have been exposed if they’ve been in homes with peeling, chipping paint,” said Dr. Joneigh Khaldun, the chief medical executive for the state of Michigan and chief deputy director for health in the Michigan Department of Health and Human Services. “We just don’t even know it.”

Widespread building closures have created other risks. Although paint is the most common cause of childhood lead poisoning, lead pipes also pose a threat. The longer that water sits stagnant in such pipes, the more lead leeches into it; schools and day care centers that shut down last year could find their water dangerously contaminated when they reopen.

“There’s likely to be high lead levels in some taps,” said Jennifer Hoponick Redmon, a senior environmental health scientist at RTI International, a nonprofit research organization based in North Carolina. “Water needs to be flushed at schools and child care centers — and really, all places that are closed — before people start using the water again for drinking and cooking.”

There is some evidence that lead poisoning rates may have risen slightly last year. Health officials in Massachusetts said they detected a 3 percent increase in the prevalence of lead poisoning among young children between mid-March and mid-August 2020. “While this may seem like a small increase, it is concerning, as we normally see rates of lead poisoning decline each year,” said Jan Sullivan, acting director of the Bureau of Environmental Health at the Massachusetts Department of Public Health.

And in New York City, preliminary data suggests that the share of young children with elevated blood lead levels was essentially flat over the first three-quarters of 2020, after years of steady declines.But not all health departments have found these patterns, and many are still analyzing their data from last year. Of course, if the children who face the biggest lead hazards are the ones who skipped their screenings , a rise in lead poisoning may not show up in the testing data, experts said.

Early evidence suggests that blood lead testing did begin to rebound in the second half of 2020. “But it still fell below the levels of previous years and did not nearly make up for the number of children missed earlier in the year,” Dr. Courtney said.

In Michigan, where childhood lead testing was about one-third lower in 2020 than in 2019, health officials are now trying to make up lost ground. They are organizing mobile lead testing events, to be held across the state, and planning a major media campaign.

“We’re going to put some money behind it, have some commercials and a real intentional focus on making sure people are aware of the risk of lead and that they know how and where to get tested,” said Dr. Khaldun. “We are really focused on making sure we don’t have other unintended consequences of the pandemic.”

Storytime Lets Fathers Form Bonds From Behind Bars

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Storytime Lets Fathers Form Bonds From Behind Bars

Across the country, inmates are distance reading bedtime stories to their kids and finding their own paths to redemption.

Credit…Lorenzo Gritti

  • March 11, 2021, 5:00 a.m. ET

Greg Williams, 45, doesn’t remember the first book he read to his daughters in 2006, but he remembers picking the shortest book in a stack, hoping he could get to the end without crying on camera. He imagined his girls in their pajamas, tucked into bed, listening. As he turned each page, he imagined that he was there, too.

At the Descanso Detention Facility in Southern California, a dozen men waited with tough-guy facades and children’s books in hand. They were participants in a program that allowed incarcerated parents to read to their children, albeit far removed from their bed sides. An unassuming beige room at the jail became a makeshift production studio, with men taking turns in front of a tripod-mounted camera.

One by one, dads shape-shifted from guys in prison garb to dragons, wizards and even princesses. They contorted their voices, becoming heroes from faraway lands, where fairies were real and fathers weren’t locked away in dungeons.

For those who are incarcerated, parenthood can feel nearly impossible. They miss out not only on the big soccer matches, music recitals and school dances that shape childhood, but also the peanut butter and jelly sandwiches, board games and nightly bedtime stories.

While they may never be able to see that game-winning soccer goal in person, inmates across the country are at least trying to bridge the storybook gap for their families, aiding not just their kids’ development but also their own.

A New Chapter for Incarcerated Parents

While it sounds simple, reading to your child can have profound impacts. In 1985, a report by the National Academy of Education concluded that, for children, reading aloud was the most consequential factor in their educational success down the road. Since then, countless studies have touted the cognitive and behavioral benefits of reading aloud to children.

But the benefits of reading programs for incarcerated parents go beyond cognitive benefits. For many, it’s less about literacy, and more about mending and maintaining their bonds that are strained by their being behind bars. Building this bond is more crucial now, because the pandemic has limited access to family members over the past year, though restrictions are easing in some places.

At the Carol S. Vance Unit prison near Richmond, Texas, Caleb Ester chose to read “The Jungle Book” for his daughter’s 11th birthday in 2018, because she told him that she loved animals. Squeezed into an audio recording booth, Mr. Ester, 38, was participating in the inmate-run Storybook Dad program, which was started by a former inmate in the Prison Fellowship Academy.

After recording, program volunteers added sound effects and then sent the C.D., along with a copy of the book, for his kids to read along.

Because he was incarcerated before her birth, Mr. Ester said his relationship with his daughter was always different from that of other inmates. His daughter has dyslexia, which he said makes it all the more important that he encourage reading. Until he could be by her side, he said the recordings and books were “like a piece of me laying with her.”

Eventually they developed a routine during visitation. Every time she’d go to see him, she’d bring a book for them to read together.

Mr. Ester was released in November 2019 and is now living with his mother and daughter in Houston. While they are still adjusting to life under one roof, Mr. Ester said that he still reads to his daughter almost every night.

Transforming On and Off the Page

For Mr. Williams, that day he first read to his daughters was the beginning of a greater transformation. From 1993 to 2005 he’d been using methamphetamines and cycling in and out of jail.

As much as he tried to be a good father, Mr. Williams said he couldn’t escape the streets, violating his probation or committing a new felony. Then he’d find himself in a living room, explaining to his girls that Dad had to go on “time out” again.

“I had to sit them both down and tell them I was going away to where dads go when they’ve been bad,” Mr. Williams recounted. When it was too hard to say goodbye, he’d say he was going to return a movie or buy cigarettes, and disappear for months. Then, during a parenting and anger management class in jail, a classmate suggested Reading Legacies.

The San Diego-based organization was founded by a retired teacher and was originally aimed at recording deployed military parents reading to their kids. But the organization eventually saw a greater need among incarcerated parents.

There are an estimated 2.7 million children in the United States with incarcerated parents. According to a 2015 study by the nonprofit research firm Child Trends, Black children were nearly twice as likely to have a parent incarcerated than white children. Other research indicates children with incarcerated parents have an increased risk of depression, addiction and poverty, and they are six times more likely to end up incarcerated themselves.

Sociologists have found that parenting education programs in general improve inmate recidivism in parents and self-image in children. Other research suggests reading programs in particular are effective.

“We tend to define people by the worst thing they’ve ever done,” said Heath Hoffmann, a sociologist at the College of Charleston who studies the effectiveness of prison programs. “But programs like these help incarcerated people occupy a role other than ‘criminal.’”

In a survey of 387 state-run correctional facilities across the country in 2010, Dr. Hoffmann found that 75 percent of women’s facilities and 23 percent of men’s offered programs where incarcerated parents could send their children recordings of themselves reading a book. Most wardens reported in the survey that they felt the programs improved family relationships during incarceration, reduced recidivism and made re-entry into society easier for parents, though more research is needed.

Dr. Hoffmann said the bedtime story programs allow inmates to reconcile a shameful past with a positive future. “People are able to rewrite the story of their life,” he said.

Kory Russell, a utilities foreman who said he once made “an artwork of going in and out of prison,” said that the distance reading program helped him rewrite his life. When he was sentenced to 15 months in prison in 2018, he felt that his daughters “had no choice but to be a part of my incarceration, too.”

When Mr. Russell, now 40, heard about a distance reading program it soon became both a refuge and a chance to be someone new.

“It’s like putting on your absolute best performance for the ones you love most,” he said. “Every time you read a character’s line, you do your best to turn into that character, whether it’s a little girl or a big beast.”

Video player loading
Kory Russell, 40, participated in the Reading Legacies program in 2017 while incarcerated at the East Mesa Correctional Facility in San Diego.CreditCredit…Kory Russell

Looking for Happily Ever After

The distress of family separation has been exacerbated by the coronavirus pandemic. In order to reduce the risk of potential exposure in the facilities — which have been occasional hotbeds for viral outbreaks — most prisons and local jails have reduced or eliminated family visitation. In an effort to mitigate isolation, the Federal Bureau of Prisons made phone calls and video visitations free. In October, the bureau decided to reopen visitation, citing the importance for inmates to “maintain relationships with friends and family,” though most jails and state prisons continued to disallow visits.

According to a New York Times coronavirus database, there have been more than 612,000 infections and at least 2,700 deaths among inmates and guards since the start of the pandemic. Researchers at Johns Hopkins University found that infections in U.S. prisons were 5.5 times higher than in the general population. They also found that the coronavirus death rate was three times higher for prisoners.

Because of the pandemic, the Reading Legacies program now operates virtually, with inmates reading aloud to their kids over the phone and on video chats.

The silly faces and noises of reading a children’s story offered an escape from jailhouse culture, which Mr. Russell likened to that of a 12-step meeting or church service.

As for Mr. Williams, the bond he began fostering with his children through the pages of a book has only gotten stronger. His daughter, Melissa White, now 25, said that receiving those recordings from her father more than a decade ago opened her heart to the possibility of letting him back into her life.

“My dad being incarcerated was my normal,” she said.

Today, Ms. White is a teacher with a master’s degree in early childhood education and special education. When possible, she volunteered at her local library, reading books to children. And, she said, her relationship with her dad is the best it’s ever been.

“He is truly one of my idols and my best friend,” she said.

Ludwig Hurtado is a writer and video producer.

Storytime Lets Fathers Form Bonds From Behind Bars

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Storytime Lets Fathers Form Bonds From Behind Bars

Across the country, inmates are distance reading bedtime stories to their kids and finding their own paths to redemption.

Credit…Lorenzo Gritti

  • March 11, 2021, 5:00 a.m. ET

Greg Williams, 45, doesn’t remember the first book he read to his daughters in 2006, but he remembers picking the shortest book in a stack, hoping he could get to the end without crying on camera. He imagined his girls in their pajamas, tucked into bed, listening. As he turned each page, he imagined that he was there, too.

At the Descanso Detention Facility in Southern California, a dozen men waited with tough-guy facades and children’s books in hand. They were participants in a program that allowed incarcerated parents to read to their children, albeit far removed from their bed sides. An unassuming beige room at the jail became a makeshift production studio, with men taking turns in front of a tripod-mounted camera.

One by one, dads shape-shifted from guys in prison garb to dragons, wizards and even princesses. They contorted their voices, becoming heroes from faraway lands, where fairies were real and fathers weren’t locked away in dungeons.

For those who are incarcerated, parenthood can feel nearly impossible. They miss out not only on the big soccer matches, music recitals and school dances that shape childhood, but also the peanut butter and jelly sandwiches, board games and nightly bedtime stories.

While they may never be able to see that game-winning soccer goal in person, inmates across the country are at least trying to bridge the storybook gap for their families, aiding not just their kids’ development but also their own.

A New Chapter for Incarcerated Parents

While it sounds simple, reading to your child can have profound impacts. In 1985, a report by the National Academy of Education concluded that, for children, reading aloud was the most consequential factor in their educational success down the road. Since then, countless studies have touted the cognitive and behavioral benefits of reading aloud to children.

But the benefits of reading programs for incarcerated parents go beyond cognitive benefits. For many, it’s less about literacy, and more about mending and maintaining their bonds that are strained by their being behind bars. Building this bond is more crucial now, because the pandemic has limited access to family members over the past year, though restrictions are easing in some places.

At the Carol S. Vance Unit prison near Richmond, Texas, Caleb Ester chose to read “The Jungle Book” for his daughter’s 11th birthday in 2018, because she told him that she loved animals. Squeezed into an audio recording booth, Mr. Ester, 38, was participating in the inmate-run Storybook Dad program, which was started by a former inmate in the Prison Fellowship Academy.

After recording, program volunteers added sound effects and then sent the C.D., along with a copy of the book, for his kids to read along.

Because he was incarcerated before her birth, Mr. Ester said his relationship with his daughter was always different from that of other inmates. His daughter has dyslexia, which he said makes it all the more important that he encourage reading. Until he could be by her side, he said the recordings and books were “like a piece of me laying with her.”

Eventually they developed a routine during visitation. Every time she’d go to see him, she’d bring a book for them to read together.

Mr. Ester was released in November 2019 and is now living with his mother and daughter in Houston. While they are still adjusting to life under one roof, Mr. Ester said that he still reads to his daughter almost every night.

Transforming On and Off the Page

For Mr. Williams, that day he first read to his daughters was the beginning of a greater transformation. From 1993 to 2005 he’d been using methamphetamines and cycling in and out of jail.

As much as he tried to be a good father, Mr. Williams said he couldn’t escape the streets, violating his probation or committing a new felony. Then he’d find himself in a living room, explaining to his girls that Dad had to go on “time out” again.

“I had to sit them both down and tell them I was going away to where dads go when they’ve been bad,” Mr. Williams recounted. When it was too hard to say goodbye, he’d say he was going to return a movie or buy cigarettes, and disappear for months. Then, during a parenting and anger management class in jail, a classmate suggested Reading Legacies.

The San Diego-based organization was founded by a retired teacher and was originally aimed at recording deployed military parents reading to their kids. But the organization eventually saw a greater need among incarcerated parents.

There are an estimated 2.7 million children in the United States with incarcerated parents. According to a 2015 study by the nonprofit research firm Child Trends, Black children were nearly twice as likely to have a parent incarcerated than white children. Other research indicates children with incarcerated parents have an increased risk of depression, addiction and poverty, and they are six times more likely to end up incarcerated themselves.

Sociologists have found that parenting education programs in general improve inmate recidivism in parents and self-image in children. Other research suggests reading programs in particular are effective.

“We tend to define people by the worst thing they’ve ever done,” said Heath Hoffmann, a sociologist at the College of Charleston who studies the effectiveness of prison programs. “But programs like these help incarcerated people occupy a role other than ‘criminal.’”

In a survey of 387 state-run correctional facilities across the country in 2010, Dr. Hoffmann found that 75 percent of women’s facilities and 23 percent of men’s offered programs where incarcerated parents could send their children recordings of themselves reading a book. Most wardens reported in the survey that they felt the programs improved family relationships during incarceration, reduced recidivism and made re-entry into society easier for parents, though more research is needed.

Dr. Hoffmann said the bedtime story programs allow inmates to reconcile a shameful past with a positive future. “People are able to rewrite the story of their life,” he said.

Kory Russell, a utilities foreman who said he once made “an artwork of going in and out of prison,” said that the distance reading program helped him rewrite his life. When he was sentenced to 15 months in prison in 2018, he felt that his daughters “had no choice but to be a part of my incarceration, too.”

When Mr. Russell, now 40, heard about a distance reading program it soon became both a refuge and a chance to be someone new.

“It’s like putting on your absolute best performance for the ones you love most,” he said. “Every time you read a character’s line, you do your best to turn into that character, whether it’s a little girl or a big beast.”

Video player loading
Kory Russell, 40, participated in the Reading Legacies program in 2017 while incarcerated at the East Mesa Correctional Facility in San Diego.CreditCredit…Kory Russell

Looking for Happily Ever After

The distress of family separation has been exacerbated by the coronavirus pandemic. In order to reduce the risk of potential exposure in the facilities — which have been occasional hotbeds for viral outbreaks — most prisons and local jails have reduced or eliminated family visitation. In an effort to mitigate isolation, the Federal Bureau of Prisons made phone calls and video visitations free. In October, the bureau decided to reopen visitation, citing the importance for inmates to “maintain relationships with friends and family,” though most jails and state prisons continued to disallow visits.

According to a New York Times coronavirus database, there have been more than 612,000 infections and at least 2,700 deaths among inmates and guards since the start of the pandemic. Researchers at Johns Hopkins University found that infections in U.S. prisons were 5.5 times higher than in the general population. They also found that the coronavirus death rate was three times higher for prisoners.

Because of the pandemic, the Reading Legacies program now operates virtually, with inmates reading aloud to their kids over the phone and on video chats.

The silly faces and noises of reading a children’s story offered an escape from jailhouse culture, which Mr. Russell likened to that of a 12-step meeting or church service.

As for Mr. Williams, the bond he began fostering with his children through the pages of a book has only gotten stronger. His daughter, Melissa White, now 25, said that receiving those recordings from her father more than a decade ago opened her heart to the possibility of letting him back into her life.

“My dad being incarcerated was my normal,” she said.

Today, Ms. White is a teacher with a master’s degree in early childhood education and special education. When possible, she volunteered at her local library, reading books to children. And, she said, her relationship with her dad is the best it’s ever been.

“He is truly one of my idols and my best friend,” she said.

Ludwig Hurtado is a writer and video producer.

Diagnosing Autism in the Pandemic

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The Checkup

Diagnosing Autism in the Pandemic

Autism spectrum disorder is often suspected when young children stand out as being different from their peers. That can be much harder in this isolated time.

Credit…Yifan Wu

  • March 1, 2021, 5:00 a.m. ET

We talk often in pediatrics about the importance of early identification and early treatment of autism spectrum disorder, with its hallmark issues of social communication problems and restricted repetitive behavior patterns. “Early” means paying particularly close attention to the behavior and development of children between ages 1 and 3, and checking in with their parents about any concerns.

But what does that mean for young children who have now spent half their lives — or more — in the special circumstances of the pandemic?

Dr. Heidi Feldman, a professor of developmental and behavioral pediatrics at Stanford University School of Medicine, said, “We don’t know what the impact of one year of very restricted social interaction is going to be on children.” Some of the behavior patterns that children are showing now may be the result of these strange living conditions, or they may reflect stress, trauma and the social isolation that many families have experienced, she said.

Dr. Feldman said that first-time parents who have been operating in the increased isolation of the pandemic may have very limited context for appreciating where their child’s behavior falls. They’re missing the input they might usually get from teachers and child care providers.

Dr. Eileen Costello, a clinical professor of pediatrics at Boston University School of Medicine and chief of ambulatory pediatrics at Boston Medical Center, said, “Especially for the really little ones, the only eyes that are on them are their parents’. They’re not seeing uncles and aunts and cousins, not in preschool.”

Dr. Costello and I are co-authors of the book “Quirky Kids: Understanding and Supporting Your Child With Developmental Differences.” We use the word “quirky” to encompass children whose development does not follow standard patterns, whether or not they fit the criteria for a specific diagnosis. Some of these children will accumulate several different diagnoses as they grow and change — and as different demands are made on them in terms of academic performance and social life — and others will never fit the criteria for any specific formal diagnosis.

Dr. Adiaha Spinks-Franklin, a developmental behavioral pediatrician at Texas Children’s Hospital and an associate professor at Baylor College of Medicine, said that because parents right now are at home more, sometimes they are more likely to notice unusual or concerning patterns — repetitive behaviors, or communications problems like echolalia, in which a child repeats words. This can be completely normal, and is in fact part of how children learn to talk, but it can be concerning if it’s the major part of a child’s language as the child grows. By the age of 2, children should be saying lots of their own words.

When parents — or teachers or doctors — do have concerns, getting a developmental assessment done has its own complexity in the pandemic.

Catherine Lord, a professor of psychiatry and education at the University of California, Los Angeles, said, “I’m doing diagnoses right now in my back yard, which is insane.” But with the protective gear that would have to be worn at the hospital, she said, “we look like we’re from outer space,” and could be too intimidating to small children.

Dr. Lord said. “We do remote interviews with parents, we try to see videos of the kid, then have them come — we have a big back yard.” And they continue to use the Zoom technology, even across the yard.

The standardized assessment for autism spectrum disorder can’t be done masked, because it depends on interpreting the child’s expressions and observing reactions to the examiner’s facial expressions. Dr. Lord said there is a shorter version that children can do with their parents — everyone unmasked — while the clinicians watch without being in the room. This may not be as accurate — researchers are still analyzing the data — but they are hopeful that it will be helpful in many cases.

“When we see kids in clinic, we have to be masked, and if they’re over 2, they have to be masked,” Dr. Feldman said. Earlier in the pandemic, a family that was convinced that their child had autism came to the clinic. “This kid had not seen anybody other than his parents and had not been anyplace other than his home — he was so terrified — the in-person visit was very, very hard.” They used a room with a one-way mirror, so the parents could be alone with the child, and could take their masks off, but “even with that, he had such a hard time settling down.”

Dr. Lord was the lead author on a review paper on autism spectrum disorder published in Nature Reviews in 2020. She emphasized the importance of early diagnosis so that children can get early help with communication: “Kids who are going to become fluent speakers, their language starts to change between 2 and 3, and 3 and 4, and 4 and 5,” Dr. Lord said. “We want to be sure we optimize what happens in those years and that’s very hard to do if people are stuck at home.”

She recommended that parents request the free assessments that can be done through early intervention, in many cases now being done remotely.

Developmental assessments can include remote visits. “We have gotten quite good at doing telehealth evaluations,” Dr. Feldman said. “We get the kids in their own environments and their own toys, we get to see what they do at home.”

“Sometimes making the diagnosis of autism over telehealth in a very young child is incredibly challenging,” Dr. Spinks-Franklin said. “Families that don’t have access to consistent reliable high-speed internet are also impacted — a video visit may not be possible or may be interrupted.”

Even before the pandemic, many families faced long waits to get those developmental assessments. “Those who are vulnerable already are always going to be more severely affected — families who already had more limited access to primary care providers or are underinsured or uninsured already had a harder time,” Dr. Spinks-Franklin said.

Now, she said, the pandemic is placing those families even more at risk, because of the likelihood of economic hardship from jobs loss, underemployment or lost health care benefits. The disparities are exacerbated, and the chance of getting to the right clinic and the right health care professional go down.

Right now, because families are isolated or may not have good access to medical care, neurodevelopmental problems may be being missed in these critical early years, when getting diagnosed would help children get therapy. On the other hand, some children who don’t have these underlying problems and are just reacting to the strange and often anxiety-provoking circumstances of pandemic life may mistakenly be thought to be showing signs of autism.

Parents and even doctors may worry about autism spectrum disorder in children who have attention deficit hyperactivity disorder or anxiety, and who are being seen in unusual situations — in a parking lot, for example. “I’ve been undoing diagnoses,” Dr. Lord said. “It’s not surprising that a kid is looking a bit less relaxed.”

Dr. Spinks-Franklin said that the pressures of the pandemic may act on children as other stresses do, and show up as more extreme behavior, such as more frequent tantrums or increased irritability.

“All that bounces is not A.D.H.D.; all that flaps is not autism,” Dr. Spinks-Franklin said.

What Parents Can Do

To understand whether a child’s extreme behavior represents chronic stress and increased frustration related to the hardships that families are living through, or is a sign of a neurodevelopmental disorder, it’s important to figure out whether these behaviors were present before the pandemic, Dr. Spinks-Franklin said.

If parents have concerns about a child’s development or behavior, a good place to start is to talk the question through with the child’s primary care provider, who can also review the record with the parents and talk about the child’s early developmental course.

If parents still have concerns, it’s reasonable to request a referral for a full developmental assessment. Early intervention, a federally mandated program, offers help and therapy if a child seems to be significantly delayed in any developmental domain, but does not make diagnoses.

Some developmental markers reflect a child’s early progress with speech and language, and with social interactions. The following are adapted from “Quirky Kids.”

  • A baby babbles by 6 months, and the babble increases in complexity

  • By 9 months, a baby responds to his or her name

  • By 15 to 18 months, a child can say some words and follow simple directions

  • By 18 months, a child can put two words together

  • By 2 ½ to 3, a child can speak in simple sentences with some fluency and inflection — a question sounds like a question

  • By 4 months, babies make eye contact and respond with social smiles

  • By 1 year, they can point to show interest, and wave goodbye

  • From about 2, they respond to other children and can interact in games with some back-and-forth

Navigating My Son’s A.D.H.D. Made Me Realize I Had It, Too

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Navigating My Son’s A.D.H.D. Made Me Realize I Had It, Too

Experts say some symptoms, especially in women, are mistaken for other conditions such as mood disorders or depression.

Credit…Natalia Ramos

  • Feb. 25, 2021, 2:25 p.m. ET

I heard my 7-year-old son’s cries of frustration loud and clear despite the closed door between us. Seconds earlier, I’d left him stationed at a desk in my bedroom, hoping he’d complete at least a portion of his virtual school assignments without me at his side while I left to wash the dishes.

“This is so BORING,” he groaned. Finishing each of his math problems required enduring an animated character’s long-winded ovations and cheers. The work was easy for him, but the system didn’t allow him to zip through it. Pulling up a chair, I sat with him in solidarity as he finished up.

Remote learning is daunting for most parents; it’s particularly thorny when your child has attention deficit hyperactivity disorder. As I tried to guide my son through his online lessons over the course of the pandemic, I began to see parallels between his struggles and my own. While hyperactivity was never an issue for me, we had many other traits in common: impulsivity, distractibility, lack of organization and low frustration tolerance — all key signs of A.D.H.D.

Primary school was easy for me; from third grade on, I was enrolled in gifted classes and earned straight A’s. Nonetheless, I recall many tear-laden homework sessions where exasperation over a tricky math problem threw me into emotional overload. During study sessions, I often became disinterested and zoned out, rereading sections of text until I could focus enough to absorb the information. I attributed my difficulties to character flaws: I was spacey and forgetful, a master procrastinator lacking drive and ambition.

Though I received an academic scholarship and entered college with a 4.2 grade point average and 15 credits from Advanced Placement classes, my performance at university was subpar. Lacking structure, it was tough for me to stick to any semblance of routine. In large lecture halls where I was an unknown in a sea of students, I floundered. I changed my major five times and eventually lost my scholarship. I never imagined an underlying neurological disorder was at play.

People who have A.D.H.D. but who do relatively well in school often don’t get diagnosed until later in life, said Lidia Zylowska, associate professor of psychiatry at the University of Minnesota Medical School and author of “Mindfulness for Adult A.D.H.D.” She said the expression of A.D.H.D. symptoms can change as life gets more complex, becoming more overwhelming as responsibilities increase in adulthood. For those who have advantages such as intelligence and family support, “school may be a place where you thrive. But when you don’t have that support, whether it’s in college, or you get your first job,” or if you become a parent, Dr. Zylowska said, “that’s when the impairment really starts showing up.”

No one in my family (nor my husband’s) had been given an A.D.H.D. diagnosis, yet research suggests a strong genetic component to the disorder. “We’ve known for many years that A.D.H.D. runs in families; it’s not just a childhood disorder,” said Mark Stein, director of A.D.H.D. and related disorders at Seattle Children’s Hospital. He said 20 percent to 30 percent of children with A.D.H.D. will have another family member who has it. “A big part of it is genetics, but it’s also awareness. Once you’re aware of what A.D.H.D. is, you’re more likely to recognize it in others,” he said.

Dr. Stein said it’s not unusual for parents to realize they have A.D.H.D. after their child is diagnosed, as in my case. “That’s a real common pathway,” he said. “A child has symptoms and problems and is being evaluated, and then the parent for the first time looks at their life and views it from the frame of, ‘Well, maybe I have this, and this is why I had those difficulties.’”

As a 3-year-old, my son was evaluated by a school psychologist because of hyperactive, disruptive behavior in preschool. He was formally given an A.D.H.D. diagnosis at age 5; by then I’d become his tireless advocate, collaborating with our school district to ensure he was set up for success in the classroom. In 2020, I reached out to my doctor about my concerns about my own symptoms and received a preliminary diagnosis of A.D.H.D; I’ll undergo a comprehensive neurological evaluation this spring.

When I was in elementary school in the ’80s, no one ever brought up the possibility that I had A.D.H.D. Experts say that’s not uncommon. Because men tend to exhibit more disruptive symptoms than women, they’re far more likely to be given diagnoses early on, said Russell Barkley, a psychiatry professor at Virginia Commonwealth University Medical School and author of “12 Principles for Raising a Child With A.D.H.D.”

Dr. Stein noted: “For 10 or 15 years now we’ve been talking about how it’s not identified in females, and that it’s often missed, and even though we’ve improved somewhat it’s still much more likely to be missed in females, especially in moms.”

Research shows girls with A.D.H.D. tend to internalize their struggles rather than acting out. “Girls tend to be a little bit more inattentive and less hyperactive,” Dr. Barkley said. “If they’re disruptive, it’s mainly talking too much and socializing, whereas the boys, if they’re disruptive, it tends to be more reactive emotion and aggression, as well as defiance and oppositional behavior.”

Dr. Stein said the increasing stressors and external demands of motherhood can worsen A.D.H.D. symptoms. “I think of A.D.H.D. women as typically suffering in silence,” he said. They may seek care for something like being demoralized or having low self-esteem, or feeling overwhelmed, he said. “It’s often assumed this is a mood disorder or depression.” He added, “We’re treating the effects and the aftereffects” of A.D.H.D., “but not the underlying cause.”

I’ve had anxiety for most of my adult life; experts say the longer A.D.H.D. goes untreated, the more likely people are to experience comorbidities like anxiety, depression, substance abuse, and bulimia/binge eating. About 30 percent of children with A.D.H.D. have an anxiety disorder, a statistic that increases in adulthood. While many women do have depression and anxiety, Dr. Barkley said, “It’s just that it’s being picked up as the primary problem without looking behind the curtain, so to speak, to see what else might be there that could also be contributing to these difficulties.”

Dr. Zylowska said treatment tools for adult A.D.H.D. are very similar to those for children, but newly diagnosed adults often have an additional problem of struggling with feelings of self-doubt and shame. “You sort of have this long-life experience of getting in your own way, of having good intentions, but not being able to deliver, and that can be really demoralizing,” she said. Part of the treatment is to “help develop this less judgmental, less negative view of yourself, understanding A.D.H.D. as a neurobiological difference and developing self-acceptance and self-compassion, which can really be important,” Dr. Zylowska said.

Mindfulness-based therapy is a helpful self-regulation tool for working through feelings of inadequacy and shame, and developing self-compassion, she said.

Medication can play a role in managing A.D.H.D. symptoms for many people, but Dr. Stein said it’s part of an individualized treatment plan that may also include good nutrition and sleep. While A.D.H.D. can be a big problem for kids in school, adults often have more control about choosing to be in an environment that suits the way their brains work. “It’s less of a problem if you have the right fit with your occupation,” he said, because it’s easier to focus if you find a career you’re passionate about.

This diagnosis has been eye-opening for me. My treatment plan will most likely include medication, but my doctor is waiting for data from my scheduled neurological evaluation before she prescribes me anything. There are so many options when it comes to A.D.H.D. medications; testing will ensure that I receive the most effective one based on my individual needs. Experiencing the improvement medication may have on my daily functioning will allow me to make a more informed decision if and when the time comes to medicate my son. Thus far, it hasn’t been recommended for him.

Meanwhile, I’m able to more deeply empathize with my son when he is frustrated; after all, I’ve been there too.

Heidi Borst is a freelance writer and mother of one based in Wilmington, N.C.

New Findings on 2 Ways Children Become Seriously Ill from the Coronavirus

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New Findings on 2 Ways Children Become Seriously Ill from the Coronavirus

A large study found that young people hospitalized with acute Covid-19 infection have symptoms and characteristics that differ from those with a Covid-linked inflammatory syndrome.

Kindergartners this month at a Catholic school in Boyle Heights, Los Angeles. The study analyzed 1,116 cases in 31 states, with participants ranging from infants to 20-year-olds.
Kindergartners this month at a Catholic school in Boyle Heights, Los Angeles. The study analyzed 1,116 cases in 31 states, with participants ranging from infants to 20-year-olds.Credit…Etienne Laurent/EPA, via Shutterstock
Pam Belluck

  • Feb. 24, 2021, 4:32 p.m. ET

A large nationwide study has found important differences in the two major ways in which children have become seriously ill from the coronavirus, findings that may help doctors and parents better recognize the conditions and understand more about the children at risk for each one.

The study, published on Wednesday in the journal JAMA, analyzed 1,116 cases of young people who were treated at 66 hospitals in 31 states. Slightly more than half the patients had acute Covid-19, the predominantly lung-related illness that afflicts most adults who get sick from the virus, while 539 patients had the inflammatory syndrome that has erupted in some children weeks after they have had a typically mild initial infection.

The researchers found some similarities, but also significant differences in the symptoms and characteristics of the patients, who ranged from infants to 20-year-olds and were hospitalized last year between March 15 and October 31.

Young people with the syndrome, called Multisystem Inflammatory Syndrome in Children or MIS-C, were more likely to be between 6 and 12 years of age, while more than 80 percent of the patients with acute Covid-19 were either younger than 6 or older than 12.

More than two-thirds of patients with either condition were Black or Hispanic, which experts say most likely reflects socioeconomic and other factors that have disproportionately exposed some communities to the virus.

“It’s still shocking that the overwhelming majority of the patients are nonwhite and that is true for MIS-C and for acute Covid,” said Dr. Jean A. Ballweg, medical director of pediatric heart transplant and advanced heart failure at Children’s Hospital & Medical Center in Omaha, who was not involved in the study. “There’s clearly racial disparity there.”

For reasons that are unclear, while Hispanic young people seemed equally likely to be at risk for both conditions, Black children appeared to be at greater risk for developing the inflammatory syndrome than the acute illness, said Dr. Adrienne Randolph, the senior author of the study and a pediatric critical care specialist at Boston Children’s Hospital.

One potential clue mentioned by the authors is that with Kawasaki disease, a rare childhood inflammatory syndrome that has similarities with some aspects of MIS-C, Black children appear to have greater frequency of heart abnormalities and are less responsive to one of the standard treatments: intravenous immunoglobulin.

The researchers found that young people with the inflammatory syndrome were significantly more likely to have had no underlying medical conditions than those with acute Covid. Still, more than a third of patients with acute Covid had no previous medical condition. “It’s not like previously healthy kids are completely scot-free here,” Dr. Randolph said.

The study evaluated obesity separately from other underlying health conditions and only in patients who were age 2 or older, finding that a somewhat higher percentage of the young people with acute Covid had obesity.

Dr. Srinivas Murthy, an associate professor of pediatrics at the University of British Columbia, who was not involved in the study, said he was not convinced that the findings established that healthy children were at higher risk for MIS-C. It could be “mostly a numbers game, with the proportion of kids infected and the proportion of healthy kids out there, rather than saying that there’s something immune in healthy kids that puts them at a disproportionately higher risk,” he said.

Overall, he said, the study’s documentation of the differences between the two conditions was useful, especially because it reflected “a reasonably representative set of hospitals across the U.S.”

Young people with the inflammatory syndrome were more likely to need to be treated in intensive care units. Their symptoms were much more likely to include gastrointestinal problems, inflammation and to involve the skin and mucous membranes. They were also much more likely to have heart-related issues, although many of the acute Covid patients did not receive detailed cardiac assessments, the study noted.

Roughly the same large proportion of patients with each condition — more than half — needed respiratory support, with slightly less than a third of those needing mechanical ventilation. Roughly the same small number of patients in each group died: 10 with MIS-C and eight with acute Covid-19.

The data does not reflect a recent surge in cases of the inflammatory syndrome that followed a rise in overall Covid-19 infections across the country during the winter holiday season. Some hospitals have reported that there have been a greater number of seriously ill MIS-C patients in the current wave compared with previous waves.

“I am going to be fascinated to see comparison from Nov. 1 forward versus this group because I think we all felt that the kids with MIS-C have been even more sick recently,” Dr. Ballweg said.

An optimistic sign from the study was that most of the severe cardiac problems in young people with the inflammatory syndrome improved to normal condition within 30 days. Still, Dr. Randolph said any residual effects were still unknown, which is why one of her co-authors, Dr. Jane Newburger, associate chief for academic affairs in Boston Children’s Hospital’s cardiology department, is leading a nationwide study to follow children with the inflammatory syndrome for up to five years.

“We can’t say 100 percent for sure that everything’s going to be normal long-term,” Dr. Randolph said.

Exercise vs. Diet? What Children of the Amazon Can Teach Us About Weight Gain

A young girl carries harvested food, part of the traditional hunting and gathering lifestyle of the Shuar of Amazonian Ecuador.
A young girl carries harvested food, part of the traditional hunting and gathering lifestyle of the Shuar of Amazonian Ecuador.Credit…Samuel S. Urlacher, Ph.D.

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Phys Ed

Exercise vs. Diet? What Children of the Amazon Can Teach Us About Weight Gain

What we eat may be more important than how much we move when it comes to fighting obesity.

A young girl carries harvested food, part of the traditional hunting and gathering lifestyle of the Shuar of Amazonian Ecuador.Credit…Samuel S. Urlacher, Ph.D.

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Gretchen Reynolds

  • Feb. 24, 2021, 5:00 a.m. ET

When children gain excess weight, the culprit is more likely to be eating too much than moving too little, according to a fascinating new study of children in Ecuador. The study compared the lifestyles, diets and body compositions of Amazonian children who live in rural, foraging communities with those of other Indigenous children living in nearby towns, and the results have implications for the rising rates of obesity in both children and adults worldwide.

The in-depth study found that the rural children, who run, play and forage for hours, are leaner and more active than their urban counterparts. But they do not burn more calories day-to-day, a surprising finding that implicates the urban children’s modernized diets in their weight gain. The findings also raise provocative questions about the interplay of physical activity and metabolism and why exercise helps so little with weight loss, not only in children but the rest of us, too.

The issue of childhood obesity is of pressing global interest, since the incidence keeps rising, including in communities where it once was uncommon. Researchers variously point to increasing childhood inactivity and junk food diets as drivers of youthful weight gain. But which of those concerns might be more important — inactivity or overeating — remains murky and matters, as obesity researchers point out, because we cannot effectively respond to a health crisis unless we know its causes.

That question drew the interest of Sam Urlacher, an assistant professor of anthropology at Baylor University in Waco, Texas, who for some time has been working among and studying the Shuar people. An Indigenous population in Amazonian Ecuador, the traditional Shuar live primarily by foraging, hunting, fishing and subsistence farming. Their days are hardscrabble and physically demanding, their diets heavy on bananas, plantains and similar starches, and their bodies slight. The Shuar, especially the children, are rarely overweight. They also are not often malnourished.

But were their wiry frames a result mostly of their active lives, Dr. Urlacher wondered? As a postgraduate student, he had worked with Herman Pontzer, an associate professor of evolutionary anthropology at Duke University, whose research focuses on how evolution may have shaped our metabolisms and vice versa.

In Dr. Pontzer’s pioneering research with the Hadza, a tribe of hunter-gatherers in Tanzania, he found that, although the tribespeople moved frequently during the day, hunting, digging, dragging, carrying and cooking, they burned about the same number of total calories daily as much-more-sedentary Westerners.

Dr. Pontzer concluded that, during evolution, we humans must have developed an innate, unconscious ability to reallocate our body’s energy usage. If we burn lots of calories with, for instance, physical activity, we burn fewer with some other biological system, such as reproduction or immune responses. The result is that our average, daily energy expenditure remains within a narrow band of total calories, helpful for avoiding starvation among active hunter-gatherers, but disheartening for those of us in the modern world who find that more exercise does not equate to much, if any, weight loss. (Dr. Pontzer’s highly readable new book on this topic, “Burn,” will be published on March 2. )

A young Shuar boy fills a water gourd in the river.
A young Shuar boy fills a water gourd in the river.Credit…Samuel S. Urlacher, Ph.D.

Dr. Pontzer’s work focuses primarily on Hadza adults, but Dr. Urlacher wondered if similar metabolic trade-offs might also exist in children, including among the traditional Shuar. So, for a 2019 study, he precisely measured energy expenditure in some of the young Shuar and compared the total number of calories they incinerated with existing data about the daily calories burned by relatively sedentary (and much heavier) children in the United States and Britain. And the totals matched. Although the young Shuar were far more active, they did not burn more calories, over all.

Young Shuar differ from most Western children in so many ways, though, including their genetics, that interpreting that study’s findings was challenging, Dr. Urlacher knew. But he also was aware of a more-comparable group of children only a longish canoe ride away, among Shuar families that had moved to a nearby market town. Their children regularly attended school and ate purchased foods but remained Shuar.

So, for the newest study, which was published in January in The Journal of Nutrition, he and his colleagues gained permission from Shuar families, both rural and relatively urban, to precisely measure the body compositions and energy expenditure of 77 of their children between the ages of 4 and 12, while also tracking their activities with accelerometers and gathering data about what they ate.

The urban Shuar children proved to be considerably heavier than their rural counterparts. About a third were overweight by World Health Organization criteria. None of the rural children were. The urban kids also generally were more sedentary. But all of the children, rural or urban, active or not, burned about the same number of calories every day.

What differed most were their diets. The children in the market town ate far more meat and dairy products than the rural children, along with new starches, like white rice, and highly processed foods, like candy. In general, they ate more and in a more-modern way than the rural children, and it was this diet, Dr. Urlacher and his colleagues conclude, that contributed most to their higher weight.

These findings should not romanticize the forager or hunter-gatherer lifestyle, Dr. Urlacher cautions. Rural, traditional Shuar children face frequent parasitic and other infections, as well as stunted growth, in large part because their bodies seem to shunt available calories to other vital functions and away from growing, Dr. Urlacher believes.

But the results do indicate that how much children eat influences their body weight more than how much they move, he says, an insight that should start to guide any efforts to confront childhood obesity.

“Exercise is still very important for children, for all sorts of reasons,” Dr. Urlacher says. “But keeping physical activity up may not be enough to deal with childhood obesity.”

Got a Pandemic Puppy? Learn How to Prevent Dog Bites

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The Checkup

Got a Pandemic Puppy? Learn How to Prevent Dog Bites

With new puppies and kids at home, doctors are worried about treating more children for dog bites.

Credit…Manon Cezaro

  • Feb. 23, 2021, 2:33 p.m. ET

The surge in pet adoptions during the pandemic brought much-needed joy to many families, but doctors are worrying about a downside as well: more dog bites.

A commentary published in October in The Journal of Pediatrics noted an almost threefold increase in children with dog bites coming into the pediatric emergency room at Children’s Hospital Colorado after the stay-at-home order went into effect.

The lead author, Dr. Cinnamon Dixon, a medical officer in the Pediatric Trauma and Critical Illness Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, said: “If someone were to tell me they were going to get a new dog during Covid, I would first and foremost want to make sure that family is prepared to have a new entity in their household, a new family member.”

Dr. Dixon said that as a pediatric emergency room doctor, taking care of children who get bitten had been a priority for her. Still, she said, from the stories she heard, she often felt “that dogs are victims in this as well.”

Brooke Goff, a partner in the personal-injury law firm the Goff Law Group in Hartford, Conn., said, “We’re definitely seeing a huge uptick in dog bite cases.”

Ms. Goff said that dog bites harm children in ways that go well beyond the physical damage. “It creates major emotional issues and PTSD,” she said. “If you’ve ever spoken to a dog bite victim as an adult that was bitten as a child, they are deathly afraid of dogs.”

Dog bites are “an underrepresented public health problem” in the United States, said Dr. Dixon, the daughter of a veterinarian who grew up around animals. The Centers for Disease Control and Prevention’s best estimates from old research put the number of dog bites at 4.5 million a year. There are over 300,000 nonfatal emergency department visits a year related to dog bites, and among children, the greatest incidence is in school age children, aged 5 to 9, but the most severe injuries are among infants and young children, presumably because they are less mobile, and lower to the ground, with their heads and faces closer to the dogs.

Dr. Robert McLoughlin, a general surgery resident at the University of Massachusetts Medical School in Worcester, was the first author on a 2020 study of hospitalizations for pediatric dog bite injuries in the United States. He said that his research grew out of an interest in pediatric surgery and pediatric injury prevention. “I had seen a lot of cases of toddlers with head and neck injuries,” he said.

The study showed that younger children, ages 1 to 4 and 5 to 10, were much more likely to need hospitalization than those over 11. In the youngest children, most injuries are to the head and neck, and beyond the age of 6, extremity wounds (arms, legs, hands) become increasingly prevalent and predominate after the age of 11, Dr. McLoughlin said.

The bites that require hospitalization and surgical repair are the most serious injuries, such as toddlers bitten in the face and neck, where many critical structures can be damaged, including eyes and ears, and there can be devastating cosmetic damage done as well. But hand injuries can also have a very lasting impact and need expert repair.

For dog bite prevention, Dr. Dixon said, “the No. 1 strategy remains supervision.” Children should learn to leave dogs alone when they are eating, when they are sleeping with a favorite toy, when they are caring for their puppies. They should not reach out to unfamiliar dogs. And dog owners should keep their dogs healthy and should socialize and train them from an early age.

“It’s important we take responsibility for our animals,” said Ms. Goff, who has a dog named Daisy that she brings with her to the office. “Most dogs don’t bite to attack, they bite because they’re scared or provoked.”

Ms. Goff also emphasized that from the point of view of liability, anyone who owns a dog should have insurance coverage. In her state, Connecticut, a strict liability state, “I don’t have to prove anybody was at fault,” she said, and the dog owner is responsible for the damages. “If you can afford the dog, you can afford the insurance,” she said.

She said that it’s important as well that dog bites be reported because of the need to track dogs who bite multiple times, but reassured those who were worried that a dog might be destroyed that, at least in Connecticut, unless there is a catastrophic or fatal injury, “our forgiveness about animals extends quite heavily.”

When dogs do show aggressive behavior, Dr. Dixon said, owners should seek expert help from a veterinarian or “a behavioral expert in canine aggression — ideally before something bad happens.”

Dr. Judy Schaechter, a professor of pediatrics and public health at the University of Miami, said that given the increase in puppy buying during the Covid epidemic, “We’re now a year into this; puppies may be big, strong dogs at this point.” And with many parents juggling work from home with their children’s school issues, it can be difficult for them to supervise all the children (and pets) all the time.

Bites often occur, Dr. Schaechter said, “around playing and feeding behaviors.” Small children are particularly at risk, in part because they may be close to the dog’s food dish, or on the ground when food falls, and the dog may see the child as competition. “Any dog can bite, any breed can bite, and that can be horrific,” she said, but a medium or large dog, or a dog with a very strong jaw, “can quickly do a lot more damage.”

When Dr. Dixon saw children who had been bitten in the emergency room, “the most common story I would hear over and over,” she said, involved “resource guarding,” in which the child seemed to be encroaching on something that belonged to the dog. “The child was next to the dog’s food or had gone next to a dog’s toy or was playing with the dog and the dog jumped up and grabbed the arm instead of the bone,” she said.

Dr. McLoughlin sees opportunities for programs to address dog bite prevention, perhaps drawing lessons from programs that discuss “stranger danger.” It’s important to teach children not to approach strange dogs, he said, but also to help them interpret dogs’ behavior, “to identify when a dog is saying leave me alone, give me some space.” He is interested in the possibility of taking dogs into schools in order to educate children about dogs they may encounter outside their homes, but emphasized that parents should be teaching even very young children about how to approach a dog — including that they should always ask the owner first.

Dr. Schaechter pointed to research on the benefits of having a dog in the family, from the joys of companionship and the lessons children learn from caring for a pet to the medical evidence that children may be at lower risk of allergy and asthma if they are exposed early to animals. The bond between children and their pets is the substance of so many books and movies, Dr. Schaechter said. “It’s real — but don’t let that be so romantic that a child ends up being hurt or scarred.”

[Get the C.D.C.’s advice on dogs, the A.A.P.’s advice on dog bite prevention, and more tips from the American Veterinary Medical Association]

My Mother Died When I Was 7. I’m Grieving 37 Years Later.

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Feb. 17, 2021

My Mother Died When I Was 7. I’m Grieving 37 Years Later.

Delayed grief is sometimes triggered by an event later in life, experts say.

I’m in my basement looking for a file when I stumble upon the cards and pictures — a small manila envelope containing what is left of my mother. She died at 30 in an apartment in Van Nuys, Calif., in April 1983. I don’t even know the exact date.

My brother and I were told that her biker boyfriend, a guy named Eddie, found her dead in the shower. I was 7.

I lived with my grandparents, my state-appointed guardians in my mother’s absence, in a city 15 minutes outside of Boston. After school and on many weekends, I was also cared for by my foster mother, Esther. The state paid for her to help my grandparents. It was also the state that had removed my brother and me from the apartment we shared with my mother, Denise, just before my first birthday. Denise was an addict.

Her fall in the shower, I later learned, actually happened during a seizure brought on by constant drug use. She died of an overdose.

One of the few images the author has of her mother.
One of the few images the author has of her mother.Credit…via Nicole Johnson

Back in the present, I pour over the relics: a letter my mother wrote to me and my brother, another to my grandmother just before my mother was about to enter the rehab she never made it to, a picture of her on her 21st birthday and some things from high school. The pieces of my mother’s life are spread in front of me like a mixed-up jigsaw puzzle. I wipe at my eyes, surprised to find tears. I never cry about my mother so I wonder, why now? I am a 44-year-old woman, a mother to four children. The woman I never actually called “Mom” has been dead for more than 37 years. That is longer than she was alive.

A few days later while reading an article online, I stumble across a term that’s new to me: delayed grief. It is a grief response that does not happen at the time of loss, but at some point later and is sometimes triggered by an event, like me discovering the artifacts of my mother’s life.

Hope Edelman, author of “The AfterGrief: Finding Your Way Along the Long Arc of Loss,” said that it was not surprising that meeting my mother as an adult, through her belongings, elicited a grief response. Ms. Edelman has been writing about grief for over 20 years, having lost her own mother at 17.

I read these letters when my mother initially sent them to me back in 1983 and have seen the pictures before. But the loss feels different now. I understand her death as a mother, instead of as her daughter. I understand the grief she must have felt without her children. The Strawberry Shortcake card that arrived just around the time of my birthday declared, “I love you very much.” She signed the card with two more declarations of love and X’s and O’s until she ran out of white space. I felt gutted as I read it.

Credit…via Nicole Johnson

“You grieved all that you could at the time,” Ms. Edelman said. “We revisit loss and make different meaning of it at different times in our lives.”

Ms. Edelman said certain milestones or life events cause complicated grief to bubble up again. Andrea Warnick, a psychotherapist based in Toronto and Guelph, Ontario, who specializes in grief therapy, refers to these as grief bursts.

Nadine Melhem, associate professor of psychiatry at the University of Pittsburgh School of Medicine, has studied childhood grief related to sudden parental death. She said that the nature of the relationship with the person who died has been shown to be an important factor in how people grieve. Additional losses and ongoing stressors may trigger grief, she said, which certainly could have been part of the reason for my recent grief response.

As the world is grappling with the Covid-19 pandemic, many people are losing their loved ones without being able to be with them at the end of their lives or in some cases, even to see their bodies for a while after death. The pandemic is also affecting funeral and memorial rituals, which usually celebrate a person’s life.

Dr. Melhem said she expects complicated, or prolonged, grief reactions in a subset of those grieving a loss in the pandemic. She is conducting an online study assessing stress and grief responses among those who lost someone to Covid-19. Among the sample of 7,353 respondents, she has found 55 percent of those who lost someone to the coronavirus reported intense grief reactions that could predict prolonged, unrelenting grief in the future. Interestingly, similar rates were reported for both adolescents and adults.

Complicating things, Ms. Edelman said, is that the initial grief process of children is colored by the way those around them handle their grief. When my mother died, my grandmother plowed through her loss by checking boxes on her to-do list. Ship body on Delta flight. Funeral mass. Thank you cards. She believed overcoming loss meant being strong.

Dr. Melhem agreed, saying that her research found the surviving parent or caregiver’s grief to be an important factor predicting children’s grief reactions as it can affect “whether there was an environment that facilitated grieving.”

Ms. Warnick said my grandmother might have been trying to protect me from grief. What I recall in the days and months following my mother’s death were my own feelings of guilt about grieving for her. If I cried for the woman who walked out on me, I was afraid the women who stayed behind to raise me, my grandmother and foster mother, would feel hurt. I also didn’t feel as though I had the right to mourn a woman I didn’t know.

My grief lacked validity. Indeed, in the early ’80s, there was typically even less support for the grieving process than there is now, especially for children.

Dr. Melhem said that when I was a child, there had not been much attention given to childhood grief in research. When she and colleagues published a study of bereaved children in 2011, she said, not only did it address a gap in grief research, but it addressed how grief presented itself and progressed in children over time. Additionally, a study she and her colleagues published in 2018 shined a light on the impact that childhood grief can have on a child’s mental health.

We’ve come a long way when it comes to understanding and processing grief, for many kinds of losses. I finally understand the relevance of my grief in the past and in the present. I’ve allowed myself permission to grieve.

“Grief is a very healthy experience and we have every right to it,” Ms. Warnick said.

Nicole Johnson is a freelance writer who is working on a memoir about addiction, abandonment, and the pop culture that colored her GenX childhood.

Covid-Linked Syndrome in Children Is Growing and Cases Are More Severe

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Covid-Linked Syndrome in Children Is Growing and Cases Are More Severe

The condition, which usually emerges several weeks after infection, is still rare, but can be dangerous. “A higher percentage of them are really critically ill,” one doctor said.

Braden Wilson, of Simi Valley, Calif., with his mother, Amanda. He was hospitalized and placed on a ventilator and a heart-lung bypass machine, but he died on Jan. 5. “My boy was gone,” his mother recalled.
Braden Wilson, of Simi Valley, Calif., with his mother, Amanda. He was hospitalized and placed on a ventilator and a heart-lung bypass machine, but he died on Jan. 5. “My boy was gone,” his mother recalled.Credit…via Amanda Wilson
Pam Belluck

  • Feb. 16, 2021, 3:00 a.m. ET

Fifteen-year-old Braden Wilson was frightened of Covid-19. He was careful to wear masks and only left his house, in Simi Valley, Calif., for things like orthodontist checkups and visits with his grandparents nearby.

But somehow, the virus found Braden. It wreaked ruthless damage in the form of an inflammatory syndrome that, for unknown reasons, strikes some young people, usually several weeks after infection by the coronavirus.

Doctors at Children’s Hospital Los Angeles put the teenager on a ventilator and a heart-lung bypass machine. But they could not stop his major organs from failing. On Jan. 5, “they officially said he was brain dead,” his mother, Amanda Wilson, recounted, sobbing. “My boy was gone.”

Doctors across the country have been seeing a striking increase in the number of young people with the condition Braden had, which is called Multisystem Inflammatory Syndrome in Children or MIS-C. Even more worrisome, they say, is that more patients are now very sick than during the first wave of cases, which alarmed doctors and parents around the world last spring.

“We’re now getting more of these MIS-C kids, but this time, it just seems that a higher percentage of them are really critically ill,” said Dr. Roberta DeBiasi, chief of infectious diseases at Children’s National Hospital in Washington, D.C. During the hospital’s first wave, about half the patients needed treatment in the intensive care unit, she said, but now 80 to 90 percent do.

The reasons are unclear. The surge follows the overall spike of Covid cases in the United States after the winter holiday season, and more cases may simply increase chances for severe disease to emerge. So far, there’s no evidence that recent coronavirus variants are responsible, and experts say it is too early to speculate about any impact of variants on the syndrome.

The condition remains rare. The latest numbers from the Centers for Disease Control and Prevention show 2,060 cases in 48 states, Puerto Rico and the District of Columbia, including 30 deaths. The median age was 9, but infants to 20-year-olds have been afflicted. The data, which is complete only through mid-December, shows the rate of cases has been increasing since mid-October.

While most young people, even those who became seriously ill, have survived and gone home in relatively healthy condition, doctors are uncertain whether any will experience lingering heart issues or other problems.

“We really don’t know what will happen in the long term,” said Dr. Jean Ballweg, medical director of pediatric heart transplant and advanced heart failure at Children’s Hospital & Medical Center in Omaha, Neb., where from April through October, the hospital treated about two cases a month, about 30 percent of them in the I.C.U. That rose to 10 cases in December and 12 in January, with 60 percent needing I.C.U. care — most requiring ventilators. “Clearly, they seem to be more sick,” she said.

Symptoms of the syndrome can include fever, rash, red eyes or gastrointestinal problems. Those can progress to heart dysfunction, including cardiogenic shock, in which the heart cannot squeeze enough to pump blood sufficiently. Some patients develop cardiomyopathy, which stiffens the heart muscle, or abnormal rhythm. Dr. Ballweg said one 15-year-old at her hospital needed a procedure that functioned as a temporary pacemaker.

Jude Knott, 4, at home with his mother, Ashley Knott, was hospitalized for 10 days after developing a headache, fever, vomiting, red eyes and a rapid heart rate.
Jude Knott, 4, at home with his mother, Ashley Knott, was hospitalized for 10 days after developing a headache, fever, vomiting, red eyes and a rapid heart rate.Credit…Kathryn Gamble for The New York Times

Hospitals say most patients test positive for Covid antibodies that indicate previous infection, but some patients also test positive for active coronavirus infection. Many children were previously healthy and had few or no symptoms from their initial Covid infection. Doctors are uncertain which factors predispose children to the syndrome. Dr. Jane Newburger, associate chief for academic affairs in Boston Children’s Hospital’s cardiology department, who is a leader of a nationwide study, said patients with obesity and some older children seem to fare worse.

Sixty-nine percent of reported cases have affected Latino or Black young people, which experts believe stems from socioeconomic and other factors that have disproportionately exposed those communities to the virus. But Omaha’s hospital, where early cases were largely among children of Latino parents working in the meatpacking industry, is now “seeing a much more broad spectrum and every ethnicity,” Dr. Ballweg said.

Jude Knott, 4, was hospitalized in Omaha for 10 days after developing a headache, fever, vomiting, red eyes and a rapid heart rate.

“It was just a roller coaster,” said his mother, Ashley Knott, a career coach at an Omaha nonprofit helping low-income teenagers.

To explain to Jude the infusions of intravenous immunoglobulin doctors were giving him, she said they were “‘putting Ninjas in your blood so they can fight.’” For blood thinner injections, which he hated, she said, “‘Buddy, they’re making your blood go from a milkshake to water because we need it to be water.’ Anything to help him make sense of it.”

Jude recently returned to preschool full time. He has some dilation of a coronary artery, but is improving, his mother said.

“He’s definitely experiencing some anxiety,” Ms. Knott said. “I just worry that he’s kind of been saddled with some adult worries at 4.”

Doctors said they’ve learned effective treatment approaches, which, besides steroids, immunoglobulin and blood thinners, can include blood pressure medications, an immunomodulator called anakinra and supplemental oxygen. Some hospitals use ventilators more than others, experts said.

But though doctors are learning more, pediatricians can miss the syndrome initially because early symptoms can mimic some common ailments.

Mayson Barillas, 11, was hospitalized for eight days at Children’s National Hospital, where his doctors said he exhibited cardiogenic shock.Credit…Rosem Morton for The New York Times

On New Year’s Day, Mayson Barillas, 11, of Damascus, Md., started feeling sick. “My stomach started hurting, and then I went to my soccer game and then I got a fever,” he said.

His mother, Sandy Barillas, a medical assistant at a women’s health practice, gave him Alka Seltzer, Pepto Bismol and Tylenol. Several days later, he developed shortness of breath and they went to an urgent care clinic.

There, a rapid Covid-19 test was negative, as were evaluations for strep, influenza and appendicitis. Ms. Barillas said she was told, “It was just like a stomach flu.”

But the next day, Mayson had swollen eyes and lips with red blisters. “He started developing really bad body aches and he couldn’t walk anymore,” she said. She took him to an emergency room, which transferred him to Children’s National Hospital, where doctors said he exhibited cardiogenic shock.

“It was very scary,” Ms. Barillas said. “I’d never heard of this syndrome before.”

Mayson spent eight days in the hospital, four in the I.C.U. Since leaving, he has seen a hematologist, a rheumatologist and a cardiologist and is on blood thinners for now. The hardest part, said Mayson, a star local soccer player, is being temporarily sidelined from sports, as doctors advise for most patients for several months.

“It was very shocking for everybody in the community: ‘Wow, how did this happen to someone very healthy?’” Ms. Barillas said.

At a memorial service on Feb. 5, Braden Wilson was remembered as a kindhearted, creative teenager who loved filmmaking and fashion. His color-splashed oil paintings were displayed.

His mother read a poem he wrote that hangs on the refrigerator of his grandparents, Fabian and Joe Wilson, with whom he was close: “Hold fast to dreams/ for if dreams create/ life is a beautiful canvas/ a masterpiece painted great.”

Braden at his eighth-grade graduation with his grandparents, Fabian and Joe Wilson, with whom he was close.Credit…via Amanda Wilson

It’s unclear why the syndrome hit Braden so hard. Ms. Wilson said he did not have serious health issues. She said he was overweight but active, swimming three times a week and taking dance and yoga at his arts-and-science high school.

Symptoms started New Year’s Eve, when he began vomiting and spiking a fever. Ms. Wilson took him to an emergency room, where he tested positive for the coronavirus, received treatment that included a new monoclonal antibody drug and was sent home.

But his fever persisted and two days later, he developed diarrhea and his lips and fingers turned blue. Ms. Wilson called 911. When paramedics arrived, she said, he was “lying in his bed, like almost lifeless.”

At the hospital, he was hooked to a ventilator and transferred to Children’s Hospital Los Angeles, which like several hospitals has established a MIS-C clinic with various specialists.

“Braden was one of our most ill patients,” said Dr. Jacqueline Szmuszkovicz, a pediatric cardiologist there.

Doctors placed him on the heart-lung bypass machine, put him on dialysis and performed a heart procedure to relieve pressure. “He had what we would term severe multisystem organ failure: his lungs, his heart, his kidneys,” Dr. Szmuszkovicz said.

Through tears, Ms. Wilson said that after a few days, Braden began bleeding from his mouth, eyes and nose, and doctors ultimately could not detect brain activity. “I asked them specifically: ‘Is there any chance for him to recover from this?’” she recounted. “And they said no.”

Family members FaceTimed to say goodbye before life support was withdrawn. Ms. Wilson gave consent for doctors to take blood samples from his body for research studies.

Ms. Wilson had never written poetry before, but since Braden’s death, it has spilled out of her.

“Now your heart no longer beats / and I can’t hold you in my arms,” reads one. “But I remember back to those days / When my womb protected you from harm/ You lived a life of beauty/ of laughter, and of grace/ I hold you now inside my heart / We’ll always share that space.”

The Influence of a Perfect Teacher

Credit…Isabel Seliger

The Checkup

The Influence of a Perfect Teacher

Perhaps because I had a teacher who made reading aloud into ceremony, ritual and compelling drama, I grew up to find my cause in pediatricians’ promoting reading aloud at checkups.

Credit…Isabel Seliger

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  • Feb. 15, 2021, 5:00 a.m. ET

“Charlie and the Chocolate Factory” was published in 1964, so when my teacher read it aloud to my fourth-grade class, it was only a couple of years old. She had a good eye for a classic-to-be, did my fourth-grade teacher.

And she made a ceremony out of reading: She would light a special reading candle while she read us the day’s chapter, and then we would blow it out together, and she would say, “There go your wishes up in the smoke — may they all come true.”

Nowadays, I guess, you wouldn’t be allowed to have a candle in a classroom. I’m not even sure I should tell you about the magic pills: She had some jars of candies — red hots, I remember in particular, and M&M’s — that were labeled for different subjects, so that if you needed help with math, you could ask for a “math pill.” (Yes, I know, it wouldn’t be allowed now, between the worries about sugar and pill culture — but I do have to tell you, those math pills worked.)

As you can tell, in fourth grade, I had the perfect teacher. Her name was Miriam Marecek — and I am writing this because she died last October, after a long and difficult struggle with multiple sclerosis, but of course, I wish I had written it sooner, when she was still here to read it.

Actually, she became Dr. Miriam Marecek in the 1970s when she earned a doctorate in education, but in my mind, she was always Miss Marecek, because I had spent fourth grade in Miss Marecek’s class and it had changed my life.

I had lucked into what was probably the perfect school for me; my education had been jump-started during a year my family spent in rural India, in which I attended a convent school. By the time I was 6, the missionary nuns, by dint of rigorous pedagogy (and the fear of corporal punishment) managed to teach me the reading and writing and arithmetic that I would have learned in the first several grades of an American school.

When we returned from India, my parents sent me to the Agnes Russell School, a “lab” school associated with Teachers College at Columbia (my father taught at Barnard), where they were promised that I wouldn’t have to learn to read all over again; it was a “progressive” school and I would be able to go at my own rate.

I spent four very happy years in that school. I have pleasant memories of student teachers trying out all kinds of new educational techniques on us (hands up, everyone who learned math on Cuisenaire rods — and how about those SRA cards for reading?).

It was a small school and, as I remember it, full of faculty children whose educational trajectories had been interesting in one way or another; my mixture of convent education and familiarity with the Hindu deities whose ceremonies my anthropologist father had been studying in West Bengal fit right in with the intellectual odds and ends that my classmates had accumulated as they had trailed their parents from graduate school to research trip to junior faculty post.

We had a terrific school library where you could go read on the couch if you got your work done early, and a terrific school librarian, always ready with book recommendations. We also had classroom white rats who probably came our way via the college science labs, and big gallon jars in which we raised mealworms. But fourth grade was without question the best, because in fourth grade, as I said, I had the perfect teacher.

Miriam Marecek found me again, a couple of decades later; she read something that I had published and called me up. I know what I said when she asked if I remembered her, because I wrote a story about it at the time: “Miss Marecek! The reading candle! ‘A Wrinkle in Time!’” As I said, she had a good eye for a future classic.

Miriam Marecek was born in Prague, during the Second World War. She later wrote about her childhood in a memoir, “Escape From Prague.” Her mother was a debutante and an opera singer and later a teacher, and her father, she wrote, was a “journalist, scholar and diplomat” who was in danger as a dissident. In 1948, the U.S. ambassador helped the family get to the United States.

When I was in fourth grade, I don’t think I understood that teachers had past histories, or, indeed, that they would go on to live complicated and individual lives after I moved on to the next grade. It was only decades later — after that phone call — that I learned that Miss Marecek had gone on to graduate school, had become a professor of education, and that children’s literature was still her great love and her specialty.

I didn’t know how lucky I was, of course, to have a teacher who could choose such amazing books, and make reading aloud into ceremony, ritual and compelling drama, and I didn’t know I would grow up to find my cause in pediatrics working with Reach Out and Read, a national literacy organization through which doctors talk with parents at checkups about the importance of reading aloud and provide them with books. When I reconnected with that teacher, she became an early member of the advisory board, and helped choose the books.

I’d like to draw a moral here about teachers, and how young children take what their teachers have to offer with a kind of matter-of-fact greediness, without stopping to marvel at what is being transmitted, to wonder how the knowledge was acquired, or to examine the teacher’s own passions.

And given the times we’re living through, I’d like to say something in appreciation of all the teachers who are managing to convey their passions remotely this year, and maybe to mourn the days that children are missing in what would have been exciting or even magical classrooms. But really, all I want to say is, when you get lucky with a teacher, you really get lucky.

Miriam Marecek spent the rest of her life deeply engaged with children’s literature — teaching it to college students and graduate students in education, advising school districts on books and literacy, maintaining a website as the “Children’s Book Lady,” corresponding with authors and illustrators — in her memoir she reproduces communications from Maurice Sendak and Uri Shulevitz.

After that phone call, I learned that she lived not far from me, in a house filled (of course) with children’s books, in the town of Winchester. I never quite got over the feeling that it was a magical house, as it had been a magical classroom. She sent books to my children, and to my brother’s children. I met her own three children, and when her daughter eventually became a pediatrician, I felt a strong sense of pride and delight.

In the last part of her life, as multiple sclerosis gradually took her mobility, staying in that house became her cause. Thanks to her family and to devoted friends, she managed it, tended by a succession of remarkable caretakers, reading stories to her grandchildren in person and long-distance, and continuing to read and to think and to connect.

I’m so glad she found me, when I was a grown-up, so I got to know more of her story and spend more time with her. I miss her, and I wish I’d written this when she was still here to read it. But here’s to Miriam Marecek, and to teachers, and all that they can mean, and to everything good that a classroom can hold.

Covid Vaccines for Kids Are Coming, but Not for Many Months

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Covid Vaccines for Kids Are Coming, but Not for Many Months

Pfizer and Moderna are testing their vaccines on children 12 and older and hope to have results by the summer.

A 15-year-old participating in Moderna’s teen Covid vaccine trial received a shot in Houston this month.
A 15-year-old participating in Moderna’s teen Covid vaccine trial received a shot in Houston this month.Credit…Brandon Thibodeaux for The New York Times
Apoorva Mandavilli

  • Feb. 12, 2021, 5:00 a.m. ET

As adults at high risk for Covid-19 line up to be immunized against the coronavirus, many parents want to know: When will my child get a vaccine?

The short answer: Not before late summer.

Pfizer and Moderna have enrolled children 12 and older in clinical trials of their vaccines and hope to have results by the summer. Depending on how the vaccines perform in that age group, the companies may then test them in younger children. The Food and Drug Administration usually takes a few weeks to review data from a clinical trial and authorize a vaccine.

Three other companies — Johnson & Johnson, Novavax and AstraZeneca — also plan to test their vaccines in children, but are further behind.

When researchers test drugs or vaccines in adults first, they typically then move down the age brackets, watching for any changes in the effective dose and for unexpected side effects.

“It would be pretty unusual to start going down into children at an early stage,” said Dr. Emily Erbelding, an infectious diseases physician at the National Institutes of Health who oversees testing of Covid-19 vaccines in special populations.

Some vaccines — those that protect against pneumococcal or meningococcal bacteria or rotavirus, for example — were tested in children first because they prevent pediatric diseases. But it made sense for coronavirus vaccines to be first tested in and authorized for adults because the risk of severe illness and death from Covid-19 increases sharply with age, said Paul Offit, a professor at the University of Pennsylvania and a member of the F.D.A.’s vaccine advisory panel.

“We’re trying to save lives, keep people out of the I.C.U., keep them from dying,” Dr. Offit said. That means prioritizing vaccines for the oldest people and for those with underlying conditions.

People younger than 21 account for about one-quarter of the population in the United States, but they make up less than 1 percent of deaths from Covid-19. Still, about 2 percent of children who get Covid-19 require hospital care, and at least 227 children in the United States have died of the disease.

“It is a significant disease in children, just not necessarily when you compare it to adults,” said Dr. Kristin Oliver, a pediatrician and vaccine expert at Mount Sinai Hospital in New York.

Children will also need to be vaccinated in order for the United States to approach herd immunity — that long-promised goal at which the pandemic slows to a halt because the virus runs out of people to infect.

Scientists have estimated that 70 to 90 percent of the population might need to be immunized against the coronavirus to reach herd immunity, especially with more contagious variants expected to circulate widely in the country.

“Not all adults can get the vaccine because there’s some reluctance, or there’s maybe even some vulnerable immune systems that just don’t respond,” Dr. Erbelding said. “I think we have to include children if we’re going to get to herd immunity.”

It will also be important to immunize children in racial and ethnic populations that are hit hardest by the pandemic, she added.

Abhinav, 12, a participant in the Pfizer vaccine trial at Cincinnati Children’s Hospital last month.
Abhinav, 12, a participant in the Pfizer vaccine trial at Cincinnati Children’s Hospital last month.Credit…Cincinnati Children’s Hospital

Pfizer and Moderna’s clinical trials in adults each enrolled about 50,000 participants. They had to be that large in order to show significant differences between the volunteers who received a vaccine and those who got a placebo. But because it is rarer for children to become seriously ill with Covid-19, that kind of trial design in children would not be feasible, because it would require many more participants to show an effect.

Instead, the companies will look at vaccinated children for signs of a strong immune response that would protect them from the coronavirus.

The Pfizer-BioNTech vaccine was authorized in December for anyone 16 and older. The company has continued its trial with younger volunteers, recruiting 2,259 adolescents from 12 to 15 years of age. Teenagers are roughly twice as likely to be infected with the coronavirus as younger children, according to the Centers for Disease Control and Prevention.

Results from that trial should be available by summer, said Keanna Ghazvini, a spokeswoman for Pfizer.

“Moving below 12 years of age will require a new study and potentially a modified formulation or dosing schedule,” Ms. Ghazvini said. Those trials will most likely start later in the year, but the plans will be made final after the company has data from older children, she added.

Moderna’s vaccine, which was also authorized in December, is on a similar track for pediatric testing. In December, the company began testing adolescents ages 12 through 17, and plans to enroll 3,000 volunteers in this age group. The company expects results “around midyear 2021,” said Colleen Hussey, a spokeswoman for Moderna.

Based on the results, Moderna plans to assess the vaccine later this year in children between the ages of 6 months and 11 years.

Infants may have some antibodies at birth from vaccinated or infected mothers, but that maternal protection is unlikely to last through the first year of age. And with their relatively weak immune systems, babies might be particularly susceptible to infection if community transmission is high.

The trials will also assess the vaccine’s safety in children — and hopefully ease any fears that parents have. One-third of adults in the United States have said they do not plan to have their children immunized against the coronavirus, according to a recent poll conducted by Verywell Health.

Given the low risk of Covid-19 in children, some parents might be skeptical of the urgency to inoculate their children with a brand-new jab, Dr. Offit said. “For that reason, the vaccine would have to be held to a very high standard of safety,” he said.

More than 42 million people in the United States have been immunized so far, with few lasting side effects. And the F.D.A. has set up multiple systems to carefully monitor any serious reactions to the vaccine.

“They’re really looking at the data very, very closely,” Dr. Oliver said. “As a pediatrician and a mom, I have really good confidence that those systems work.”

Once a vaccine for children is available, schools can reintroduce extracurricular activities that involve close contact, like band practice, team sports and choir. But in the meantime, there is ample evidence that schools can reopen with other precautions in place, Dr. Oliver said.

“I don’t think we need to anticipate having a vaccine in order to open schools in the fall,” she said. “We should be planning now for opening schools.”

Dr. Oliver also urged parents to make sure children are immunized for other diseases. According to the C.D.C., orders for non-flu childhood vaccines through the Vaccines for Children Program are down approximately 10.3 million doses over all.

“Now’s the time to really catch up on missed doses of those vaccines,” she said. “Measles, HPV, tetanus boosters, pertussis boosters — all of that is really important.”