This article was produced in partnership with the Institute for Public Service Reporting at the University of Memphis, a non-profit newsroom specializing in investigative and explanatory journalism.

Are children better off at school or at home in the middle of a pandemic?

“For a lot of kids in our community, there’s a risk either way,” said Dr. Jason Yaun, a pediatrician at Le Bonheur Children’s Hospital.

Yaun, director of Le Bonheur’s Family Resilience Initiative, calls it the COVID-19 Catch-22.

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Kids who go to school risk exposing themselves and others (teachers, fellow students, their families) to the coronavirus.

But many kids who stay home risk being exposed to more “adverse childhood experiences,” or ACEs, chronic stress and trauma, which are further aggravated by the coronavirus.

A new study shows that families enrolled in Le Bonheur’s Family Resilience Initiative (FRI) in May and June experienced more than three times the number of ACEs and other “social determinants of health” as those who were enrolled a year ago.

The COVID-19 Catch-22 is further complicated by the geography and demographics of Memphis.

Exposure to ACEs, which has been called a “public health epidemic” in economically distressed homes and neighborhoods in Memphis, makes kids more vulnerable to illness and disease in general, not to mention acts of violence. Homicides are up 30% this year.

But those “social determinants of health,” such as higher levels of obesity, diabetes, asthma, poor nutrition and other byproducts of poverty, make children, families and schools in those distressed neighborhoods more vulnerable to the public health pandemic of COVID-19.

“Going to school can expose children to greater health risks, but so can staying home,” Yaun said. “Many parents are facing very difficult choices.”

So are physicians, educators, policymakers and others who are weighing the economic and academic, physical and emotional trade-offs of reopening schools.

And they’re making those decisions in a whirlwind.

The number of COVID-19 cases and hospitalizations are rising faster to ever more precarious levels.

It took 63 days for Shelby County to record its first 100 COVID-19 deaths. It took 40 days to record its second 100 earlier this week.

Shelby County is averaging nearly 300 new COVID-19 cases a day over the past two weeks with a 12.6% positivity rate. Daily hospitalizations for COVID-19 are more than double what they were a month ago.

“We know there are some significant issues that point out to us that we have ongoing community transmission,” Alisa Haushalter, Shelby County Health Department director, said earlier this week.

Children represent an increasing number of COVID-19 cases nationally, rising from 2% to 7% since March.

Tennessee now ranks second highest, with children representing 14% of all cases. In Shelby County, children represent about 9% of all cases.

But studies around the world have shown that children have been much less likely than adults to contract and spread the virus.

In New South Wales, Australia, for example, nine students and nine staff members infected with coronavirus across 15 schools had close contact with 735 students and 128 staff members.

Only two secondary infections were identified. One student in primary school was potentially infected by a staff member, and one student in high school was potentially infected by exposure to two infected schoolmates.

“Almost six months into the pandemic, accumulating evidence and collective experience argue that children, particularly school-aged children, are far less important drivers of coronavirus transmission than adults,” according to a study published last month by the American Academy of Pediatrics.

“Therefore, serious consideration should be paid towards strategies that allow schools to remain open, even during periods of COVID-19 spread. In doing so, we could minimize the potentially profound adverse social, developmental, and health costs that our children will continue to suffer until an effective treatment or vaccine can be developed and distributed, or failing that, until we reach herd immunity.”

Despite all of the questions and challenges, Yaun and his colleagues believe most children are better off going back to school.

“We are encouraging kids to get back to school, although maybe in a hybrid learning environment,” said Dr. Jon McCullers, pediatrician-in-chief at Le Bonheur and chair of pediatrics at UTHSC. ”It’s better for learning, socio-emotional health, and many families rely on schools as a safe haven and for things like nutrition and supervision.”

The American Academy of Pediatrics continues to recommend that students be “physically present in school” as much as possible.

“Lengthy time away from school and associated interruption of supportive services often results in social isolation, making it difficult for schools to identify and address important learning deficits as well as child and adolescent physical or sexual abuse, substance use, depression, and suicidal ideation,” the Academy stated.

“This, in turn, places children and adolescents at considerable risk of morbidity and, in some cases, mortality. Beyond the educational impact and social impact of school closures, there has been substantial impact on food security and physical activity for children and families.”

Yaun and his colleagues at Le Bonheur are seeing that impact every day.

Le Bonheur’s Family Resilience Initiative opened in May 2018. Nearly all of the more than 250 families enrolled in FRI qualify for TennCare. Seven in 10 report a household income of less than $15,000 a year.

Doctors and nurses don’t just assess the weight, length and reflexes of a child’s body, and the size and shape of a child’s head. They also check the physical, social and emotional support system of the child’s brain.

They don’t just screen children for sickle-cell disease, hypothyroidism or other inherited disorders. They also screen for chronic stress, trauma and poverty.

“Because poverty so strongly influences a child’s health and development, pediatricians are asking about poverty-related stress, so we can connect families to resources in their communities,” Yaun said.

In May and June, FRI clients reported experiencing more violence, food and housing insecurity, trauma and stress than a year ago.

And the FRI clinic made more referrals than ever to food banks, legal clinics, and psychological counseling services at the University of Tennessee Health Science Services.

In May 2019, only one parent asked for a counseling referral. Last May, 14 did.

“A lot of times, families have been reluctant to accept referrals for counseling,” Yaun said. “Not now. May was the highest rate of psychiatric referrals we’ve ever had.”

The four local Universal Parenting Places are seeing similar increases.

“We’re providing our highest level of counseling ever, even though it’s all done remotely,” said Dr. Renee Wilson-Simmons, executive director of the ACE Awareness Foundation. “Some of our parents are seeking counseling from their cars. It’s the only place they can find privacy.”

Like FRI and UPP, local law enforcement and other social agencies have seen a sharp increase in the number of domestic violence calls.

“With bars closed, more people are drinking at home, and they’re dealing with a lot of stress, economic and otherwise,” Wilson-Simmons said. “And isolation is part of an abuser’s power and control.”

Conversely, family isolation has resulted in a sharp decline in the number of calls to child abuse hotlines across the Mid-South.

“We don’t think kids are being abused less,” Simmons-Wilson said. “It’s just that when kids are in school, there are more adults to keep an eye on them and report concerns.”

Family stress and trauma likely will be increasing in coming weeks.

The state Supreme Court lifted the moratorium on evictions effective June 1. Thousands of eviction notices are pending in Shelby County.

Meanwhile, about 30% of MLGW customers are behind on paying their utility bills, and service cutoffs are expected to resume next month.

“Parents are under so much pressure,” Wilson-Simmons said. “They’re worried about sending their kids back to school, because of COVID, because they’ve had family who were sick, but they need to work and can’t be at home. They need to pay the mortgage or the rent. But they know the online thing didn’t work.”

When schools closed in March and lessons resumed online, many schools lost touch with as many as a third of their students.

Parents were at work. Families moved. Cellphone numbers changed or didn’t work. A lot of kids didn’t have the motivational or technical support they needed to get online and stay online.

“It was chaos,” said Jamie Jones, executive director of Asha’s Refuge, which aids dozens of refugee families. “Computer viruses popped up. Kids spilled milk or juice on keyboards. Screens froze for no reason. Password security questions were culturally tone-deaf.”

What was the name of the street you lived on when you were a child?

“If you’re from a refugee camp, you didn’t live on a street,” Jones said.

What was your grandmother’s maiden name?

“Names don’t work that way in a lot of cultures,” said Jones. “We are having to help kids make up answers to these questions. It’s very confusing to them.”

Nearly 90% of SCS students are African-American or Hispanic/Latino. More than half are economically disadvantaged.

“In order to serve our children well, we must go back to school,” SCS Superintendent Joris Ray said earlier this week as he announced the district’s plan to reopen schools next month.

The district is planning to provide digital devices (tablets or laptops) and access to all of its more than 110,000 students.

Schools also will provide temperature checks, scheduled hand-washing and sanitizing, and social distancing.

“We’ve allocated resources to keep students as safe as possible from a virus that has no vaccine, and to ensure they have a device to continue their learning if we have to close schools,” Ray wrote in a guest column for the Daily Memphian.

There are other challenges.

By some estimates, as many as a third of all Shelby County Schools teachers and staff are over age 55 or have one or more chronic conditions that put them in high-risk categories for COVID-19.

“The individual needs and concerns of school professionals should be addressed with accommodations made as needed (eg, for a classroom educator who is pregnant, has a medical condition that confers a higher risk of serious illness with COVID-19, resides with a family member who is at higher risk, or has a mental health condition that compromises the ability to cope with the additional stress),” the American Academy of Pediatrics recommends.

Evidence suggests that the virus spreads more easily and quickly in crowded indoor settings. People who spend long periods of time indoors in crowded settings may be at greater risk of becoming infected, the World Health Organization formally acknowledged Thursday.

Many older public schools are poorly ventilated. Windows don’t open. HVAC systems don’t work properly.

“The district cannot afford one teacher for every 10 students and it does not have space in buildings to spread students 6 feet apart,” Ray said this week.

The CDC also estimates that 4.2 million kids under the age of 18 already are immunosuppressed for various reasons.

And routine vaccinations are down 40% since early March, according to state and federal officials. That includes flu shots.

Doses of the vaccine against measles, mumps, and rubella were down 75% in eight U.S. health care organizations. To reach herd immunity for measles, more than 90% of the population must be vaccinated.

“You’ve got to wonder how many children will be up-to-date in their vaccinations by the time school starts,” Yaun said. “We don’t need to be worrying about another epidemic on top of this one.”