A major U.S. cohort study suggests long COVID in children may reach far beyond lingering symptoms, affecting how they learn, focus, and connect with friends at school.
Study: School Difficulties and Long COVID in Children and Adolescents. Image Credit: Niphon Subsri / Shutterstock
A recent study published in the journal Academic Pediatrics highlights the broader impact of long coronavirus disease 2019 (COVID-19, long COVID, LC) in children, extending beyond physical symptoms to academic and social functioning.
Using data from the National Institutes of Health (NIH)-funded Researching COVID to Enhance Recovery (RECOVER)-Pediatrics cohort of nearly 2,000 participants, researchers examined outcomes in school-aged children and teenagers.
They found that children with LC were significantly more likely to experience declining grades, attention difficulties, and reduced peer engagement, raising concerns about longer-term educational and developmental consequences.
Pediatric Long COVID and Developmental Concerns
LC in children represents a complex, infection-associated chronic condition that can affect multiple organ systems and present with age-specific symptoms. Despite growing recognition of its clinical burden, researchers have only recently begun to examine its influence on everyday functioning.
School performance and peer relationships, both central to cognitive, social, and emotional development, may be particularly vulnerable. While most studies in the United States have focused on pandemic-related disruptions, there is limited evidence directly linking the virus itself to educational and social outcomes, leaving a critical gap in understanding the broader developmental impact of pediatric LC.
RECOVER-Pediatrics Study Design
In this study, researchers evaluated RECOVER-Pediatrics data to assess the association between LC and functional outcomes in children and teenagers. The study included school-aged children aged 6 to 11 years and teenagers aged 12–17 years, recruited between February 2022 and November 2024.
Participants had a confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at least 90 days before study enrollment. None had enrollment within 30 days of a known reinfection or a history of multisystem inflammatory syndrome in children (MIS-C). All outcome data were based on caregiver-completed surveys.
The investigators used age-specific RECOVER symptom-based indices validated for pediatric populations to define long COVID (LC). They selected worsening academic performance as the primary study outcome of interest.
As secondary outcomes, they evaluated attention difficulties, reduced enjoyment in peer interactions, and whether a child was receiving or being assessed for an Individualized Education Program (IEP).
The authors measured attention difficulties using the DSM-5 Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure and assessed social engagement through the Patient-Reported Outcomes Measurement Information System (PROMIS)-based questionnaires.
The researchers applied an age-stratified matching approach to compare participants with LC and those below the LC research threshold. They matched children on key factors including age, sex, timing of SARS-CoV-2 infection, and study enrollment period.
Using multivariable modified Poisson regression models, they calculated effect estimates in the form of risk ratios (RRs) for each association. These models adjusted for caregiver education, food insecurity, and vaccination status.
In addition, among school-aged children, the team conducted a sensitivity analysis to account for the potential influence of school refusal on LC classification. Because the study was cross-sectional, it could identify associations but could not establish causation.
Academic and Social Outcome Findings
The final analysis comprised 1,976 participants, comprising 406 school-aged children and 1,570 teenagers. Across both groups, LC was consistently associated with poorer academic and social outcomes. Children with LC reported worsening grades more frequently than their peers below the LC research threshold (18% vs. 7.0%; RR, 2.2).
A similar pattern emerged among teenagers, with 29% of those with LC reporting declining grades compared with 11% below the LC research threshold (RR, 2.4). The primary academic outcome was that caregivers reported that the pandemic had made grades "a lot worse."
Beyond academic performance, LC was linked to marked difficulties in attention and social functioning. Children with LC experienced moderate-to-severe attention difficulties more often than those below the LC research threshold (38% vs. 14%; RR 2.5). They also reported significantly lower enjoyment in peer interactions (28% vs. 9.0%, RR 2.8).
In addition, 35% of children with LC were either receiving or undergoing evaluation for an Individualized Education Program (IEP), compared with 22% of those below the LC research threshold, although this association was less certain after adjustment.
Among teenagers, similar disparities were observed. Attention difficulties were reported by 37% of teenagers with LC, compared with 11% below the LC research threshold, while reduced peer interaction was reported by 43% compared with 21%. IEP involvement was also higher in the LC group (27% vs. 15%; RR, 1.7). Sensitivity analyses in younger children produced consistent results, reinforcing the robustness of these findings.
School Support and Long-Term Implications
The findings underscore that long COVID in children extends beyond clinical symptoms to disrupt learning, attention, and peer relationships during key developmental stages.
These results highlight an urgent need for targeted, school-based support systems, including individualized education plans, classroom accommodations, and strategies to foster social engagement. However, the authors noted that IEP findings may reflect both pre-existing vulnerabilities and new or worsened difficulties after LC onset.
Looking ahead, longitudinal research is essential to track recovery trajectories and clarify underlying mechanisms, including neurocognitive effects. Future studies integrating objective assessments and educator input may help refine interventions.
As evidence evolves, coordinated efforts across healthcare, education, and policy will be critical to mitigate long-term academic and social consequences and support affected children into adulthood.
The authors also noted that the LC index used here was a research tool rather than a clinical diagnostic standard, and that scores below the threshold were not intended to rule out LC clinically.
Nearly 70 weeks after infection, long COVID patients show no detectable inflammation in blood tests