DEVELOPMENTAL NEEDS OF CHILDREN AND YOUTH

Before examining how summer affects their development, it is worth considering children's and youth's basic developmental needs, those that must be met in order for them to thrive. Maslow (1943) identified a basic set of needs: physiological (e.g., to satisfy hunger), followed by safety, and then by love/belonging (Maslow, 1943; see Figure 3-1). Each set of needs is conditioned upon meeting the ones before it, and motivation to meet these needs helps shape human behavior. If the more basic needs such as physiological ones are not met, a person cannot focus on higher-level needs, such as self-actualization. Once each set of needs is met, “other (and higher) needs emerge (p. 375).”

FIGURE 3-1

Maslow's hierarchy of needs. SOURCE: Maslow (1943).

We know that children need adequate nutrition and safety for health and social/emotional stimulation to support psychological and cognitive development (Hoynes et al., 2016; Malin et al., 2018). Basic needs for food and safety are year-round needs and, of course, do not pause during the summer.

Research also shows that settings are critical to the development of physical, intellectual, psychological, social, and emotional skills and competencies (i.e., internal assets). In 2002, a National Research Council committee identified eight features of settings that support positive youth development (see Box 3-2). That committee highlighted that “exposure to positive experiences, settings, and people, as well as opportunities to gain and refine life skills, supports young people in the acquisition and growth of [their] assets” (National Research Council and Institute of Medicine, 2002, p. 7).

BOX 3-2

Features of Positive Developmental Settings.

Optimal implementation of the features of settings that promote positive development will vary across different types of settings (e.g., home vs. summer camps) and for youth of different ages (e.g., elementary vs. high school age students) and backgrounds. For example, appropriate structure for elementary school students will include greater adult oversight and supervision than for high school age youth. With this in mind, we provide a brief overview of the major developmental needs of youth across different age ranges. Because the committee's statement of task focused on children and youth from the summer prior to kindergarten through grade 12, we focus our overview on these age groups.

DEVELOPMENTAL STAGES OF SCHOOL-AGE CHILDREN AND YOUTH

Physical, neurological, cognitive, and social and emotional changes occur within each child across time. Thus, what is both engaging and developmentally matched to the needs of a child at early elementary school age will differ from what engages and is developmentally appropriate for a child in later childhood and in different phases of adolescence. This is important, because when a youth's environment is mismatched with his or her developmental needs it will not be able to optimally support youth outcomes (Eccles et al., 1993).¹ To promote thriving, developmental assets should be aligned with youth's specific needs in each stage of their development. Importantly, skill development is not linear. Rather, it is extremely malleable and dependent on context, and it demonstrates both within- and between-youth variability (Cantor et al., 2018). How skills develop within particular contexts will depend on both individual susceptibility to environmental influences and the timing of different periods of brain development. Further, children come into settings with existing skills, competencies, and experiences that they can draw on to promote further development (Ambrose and Lovett, 2014; Deans for Impact, 2015).

HOW DOES SUMMER AFFECT DEVELOPMENTAL TRAJECTORIES?

The committee found little systematic research concerning the impact of summer on the developmental trajectories of school-age children and youth across all four areas of well-being. In most cases, what we were able to find were sources of data pointing to seasonal differences in the rates of incidence. We identified far more information on how summer influences academic learning and obesity relative to other developmental outcomes of interest. It is also important to note that a number of the gaps in developmental outcomes between children and youth from higher and lower socioeconomic backgrounds and from different racial and ethnic groups are present before school entry, including gaps in the academic, social and emotional, and health domains. Thus, it must be acknowledged that it may be challenging for a single, standalone summer program to redress such gaps.

In the following, for each of the four domains we provide data and research on what is known about how summer influences these areas. Where no summer-specific information exists, we also look to what is known about out-of-school time generally (which includes summer and after school) that may be applicable to summer as well.

Safety and Pro- and Anti-Social Behaviors

As highlighted by the sections above, safety is foundational to physical and psychological health, well-being, and healthy development. We know that appropriate supervision is a key condition to ensure the safety of children and youth (Persson et al., 2007). Indeed, being unsupervised during out-of-school hours is associated with significant risks (Resiner et al., 2007). Summer is a potentially risky time for youth in that the amount of unsupervised time may be greater during the summer months than during the school year. While safety does not have developmental trends, per se, the characteristics of safe environments that are needed to support healthy development change as children's motor, cognitive, and social skills develop. As such, some risks to safety are inextricably linked to other characteristics associated with children's physical, psychological, cognitive, and social development.

We next discuss three key areas where we identified evidence of seasonal differences in relation to this domain: crime, pro- and anti-social behaviors, and substance use. Whereas we separate these areas for this discussion, there is some overlap. Certain risks to safety (e.g., peer victimization, exposure to violent crime) can result from other youth's anti-social behaviors. Further, substance use, generally defined as a risk-taking behavior, is also an act of delinquency, because youth are under the legal age for use even for substances that are legal for adults.

Crime

Seasonal patterns of crime exist and persist, despite overall reductions in crime over time. A study tracking violent and household property crimes from 1993 to 2010 found that victimization rates were higher during the summer than during any other season for most crimes, including household property crimes and violent crimes, with the exception of robbery and simple assault. However, among youth ages 12–17, simple assault victimization rates were lowest during the summer, starting when the school year ended, and were highest in the fall when the school year began, suggesting that violence may be occurring en route to or during school (Lauritsen and White, 2014).

Exposure to violent crime can damage children's health and development (Osofsky, 1999), and it should be noted that juvenile crime also has implications for the youth who are the potential victims of it—when crime rates increase, so does the risk of victimization. Children and youth in low-income families and those in neighborhoods with concentrated disadvantage are affected by violent crime at higher rates than others. A recent report, using data from the National Crime Victimization Survey, found that people in households below the federal poverty level experienced more than double the rate of violent victimization as high-income households (Harrell et al., 2014). Neighborhoods with more concentrated disadvantage and greater segregation by race and ethnicity tend to experience higher levels of violent crime (U.S. Department of Housing and Urban Development, Office of Policy Research and Development, 2016).

Overall engagement in delinquency, defined by the U.S. Department of Justice's Office of Juvenile Justice and Delinquency Prevention as “an act committed by a juvenile that would be criminal if committed by an adult” (Office of Juvenile Justice and Delinquency Prevention, 2019), typically increases from childhood to adolescence. Rates then decline with age, even for persistent offenders, with peaks in adolescence or during young to middle adulthood for different types of offenses (Sampson and Laub, 2003). National trends show that rates of juvenile crime and violence-related behaviors, such as carrying a weapon or being in or being injured in a fight, have declined overall since 1990 (Arnett, 2018).

Yet patterns of crime associated with in-school versus out-of-school hours also differ by type of crime. One study found that property crimes decreased by 14 percent on days when school was in session, suggesting a decrease in anti-social behavior when youth are supervised; it found further that violent crimes increased by 28 percent on school days, suggesting that opportunities for youth to interact with each other are linked to juvenile violence (Jacob and Lefgren, 2003). Violent crime peaks in the immediate afterschool hours on school days and in evenings on nonschool days (Jacob and Lefgren, 2003).

Although most of what is known about the relationship of policing or police interactions to health and well-being has been based on adult experiences (although see Legewie and Fagan, 2018), the salience of adolescence as a critical developmental stage (Steinberg, 2014) suggests that experiences with the police may be particularly influential at younger ages and among school-age youth. Police interaction with youth have increased in recent decades due to their increase in schools (National Academies of Sciences, Engineering, and Medicine, 2019a). Negative interactions between police and youth “may produce cynicism and undermine legal socialization” (National Research Council, 2013, p. 194). Police are increasingly recognized as a significant social force shaping the development and well-being of youth, yet much remains to be learned about police-youth interactions at a population level. These unknowns include our currently limited understanding of how the unique context of summertime, and the associated time that students have off from school, may shape interactions between young people and the police (Geller, 2019).

Pro- and Anti-Social Behaviors

Both pro-social behaviors, those aimed at helping others (Eisenberg and Spinrad, 2014), and anti-social behaviors, such as aggression and delinquency, skipping school, and lying (Light et al., 2013) demonstrate some developmental and seasonal trends. Pro-social behaviors appear to increase from early childhood into elementary school (Eisenberg and Spinrad, 2014). However, varying trajectories of pro-social behavior from childhood into and through adolescence have been documented (Eisenberg and Spinrad, 2014). Some report a decline in the positive behaviors associated with social emotional and character development from middle childhood into adolescence, despite increased cognitive abilities that should, in theory, lead to increased moral reasoning and thereby pro-social behaviors (Luengo Kanacri et al., 2013; Washburn et al., 2011).

Others have documented increases or stability in pro-social behavior into and across adolescence (Eisenberg and Spinrad, 2014). Thus, different developmental patterns of pro-social trajectories have been found, yet overall, with some exceptions for particular types of behavior, prosocial behavior appears to decrease in early adolescence but then increase again in late adolescence (Eisenberg and Spinrad, 2014). Concurrently, increases in anti-social behaviors have been documented from ages 12–16 (Jessor and Jessor, 1977; Loeber and Burke, 2011; Nagin and Tremblay, 1999; Patterson and Yoerger, 2002; all as cited by Light et al., 2013). General patterns of anti-social behavior demonstrate that the vast majority of individuals desist from such behaviors in adulthood. Rates of anti-social behavior (i.e., arrests, delinquency) tend to increase across early to middle adolescence. These rates peak in late adolescence, and then decline; while for a smaller group of individuals—who have often tended to show earlier, more frequent, and more extreme anti-social behavior—anti-social behavior persists into and through adulthood (Moffitt, 1993).

In terms of seasonal patterns, in a longitudinal study of students (n = 5,742) from 11 rural and suburban middle schools across the western United States, Light and colleagues (2013) found decreases in anti-social behavior during each school year across grades 6–8, with increases between school years. The researchers could not conclusively say whether the increase in anti-social behavior that marked the beginning of the school year occurred over the summer or at the start of school year, or both. In a study of students (n = 5,581) from 37 middle schools across four communities, in which all the schools served a high proportion of students on free or reduced lunch, Farrell and colleagues (2011) found the opposite pattern for aggression. In this study, aggression demonstrated increases during the school year from sixth to seventh grade, but both physical and relational aggression decreased during the summers throughout the middle school years. They hypothesized that the pattern found by Light and colleagues (2013) was due to the start of the school year, because students attempt to re-establish peer social hierarchies after the summer. This research is consistent with crime statistics reported earlier, which find reduced rates of assault victimization for youth during the summer.

As noted earlier, participation in afterschool activities may be protective for youth at high risk of engagement in anti-social behaviors. Mahoney and Cairns (1997), in a longitudinal study of students (n = 392) from two middle schools that followed students into high school, documented that participation in an extracurricular activity was protective for students with the highest risk for school dropout. Mahoney (2000) then found that participation in extracurricular activity was associated with decreased school dropout and arrests among youth with multiple risk factors. Importantly, this depended on others in the youth's peer group also participating in activities. In another study by Martin and colleagues (2007), Black males ages 13–17 who had previously been expelled or suspended from school showed improved school attendance and academic skills and a reduction in disciplinary actions after attending a 5-day-a-week afterschool program for 2 years. Of note, the program comprised a variety of components including tutoring, cultural and recreational activities, and nutritious meals. As discussed later in Chapter 5, youth involved in the juvenile justice system and other youth considered at risk for anti-social behaviors can benefit from programming that supports their needs for skills that help them transition to adulthood (Ananthakrishnan, 2019).

Substance Use

National trend data reveal steady declines in adolescent substance use, including alcohol and cigarettes, between 1990 and 2017 (Arnett, 2018). Rates of drug use differ, with rates of marijuana use fluctuating over the years and rates of other drug use increasing in the 1990s and declining since then (Arnett, 2018). Use of e-cigarettes has increased in recent years for both middle school and high school age adolescents (Cullen et al., 2018).

Among youth, substance use, including use of alcohol, cigarettes, and drugs, generally increases from early to late adolescence (e.g., Farrell et al., 2005; Warren et al., 2016). Whereas we might expect substance use to increase during the summer, when adolescents may have more unsupervised time, the evidence is complicated. The National Survey on Drug Use and Health found that first-time use of alcohol, tobacco, marijuana, hallucinogens, and inhalants peaks in June and July (Substance Abuse and Mental Health Services Administration, 2012). However, a national survey examining overall past-month use of illicit substances found that past-month use of any illicit drug except marijuana is lower during the period when most students are on summer vacation and that fewer adolescents reported being approached by drug dealers in the summer than during other times of the year. However, alcohol use was higher in July (along with holidays and winter recess) than at other times of the year (Huang et al., 1999). Similarly, one study of middle school students at three urban public middle schools serving a predominantly Black student population from low-income families (Farrell et al., 2017) found that substance use decreases in the summers from grades 6–8.

Physical and Mental Health

Whereas there has not been much research focused on the relationship between children's summertime experiences and their overall physical and mental health trajectories, there are several common health conditions in children where seasonality is known to play a role. There are also particular circumstances that children experience during summertime that may affect physical and mental health outcomes. In addition, the extent to which youth are managing an ongoing or emergent health issue can impact their engagement in summertime opportunities.

The three most common causes of mortality among children ages 5–14 are unintentional injuries, cancer, and suicide (Kochanek et al., 2019). The three most common causes of mortality for adolescents and youth ages 15–19 are unintentional injuries, suicide, and homicide (Heron, 2019). A study of the 10 leading causes of death and injury in the United States from 1980 to 2016 found a distinct seasonal pattern of mortality from unintended injuries in males ages 5–14 that was similar across all regions (Parks et al., 2018). Seasonal variation also has been reported in common childhood conditions, including asthma, obesity, and mental and behavioral health conditions.

Injuries

Physical activity-related trauma, such as sprains, fractures, and contusions, sustained while engaging in sports or recreational activities is a primary cause of summertime pediatric injuries in western countries (Jespersen et al., 2014). A study in the United States of temporal variation in injuries associated with seven common recreational activities in children under age 18 examined emergency room visits logged into the National Electronic Injury Surveillance System (NEISS) between 2002 and 2006. It found that emergency room visits peaked in June for injuries from trampolines and scooters and in July for injuries from cycling and water activities. Injuries related to skating and playground activities peaked in April and September (Loder and Abrams, 2011).

A study of childhood trauma from injury found a similar pattern, with the highest number of childhood trauma victims seen in the emergency room in July, and twice as many children admitted from May to August as were admitted from November to February (Groh et al., 2018). A retrospective study of children (mean age of 5.9 years) with humeral fractures requiring surgery in Indiana also documented a significant increase in fractures in the summer, peaking in early July, with injuries occurring from playground equipment, furniture, climbing activities, sports, trampolines, bicycles, and all-terrain vehicles (Loder et al., 2012). Injuries from moped accidents in the United States were twice as common in youth under age 18 than adults in the summer, with the highest frequency in youth ages 14–18 (Johnson et al., 2016). Drowning is the leading cause of death by unintentional injury in children ages 1–4 and the second leading cause of death by unintentional injury in children ages 5–9 (Centers for Disease Control and Prevention, 2017). Whereas children who drown between ages 1–4 tend to drown in swimming pools, hot tubs, or spas, older children and adolescents who drown tend to do so in outdoor natural water settings. Males and Black children have higher rates of drowning. Swimming skills are associated with reduced rates of drowning. More Blacks report limited swimming skills than Whites, which may account for the disparity in rates of drowning (Gilchrist and Parker, 2014; Irwin et al., 2009). In a study of adolescents over age 16, reasons for higher rates of drowning among males than females were swimming in high-risk situations, overestimation of swimming ability, and use of alcohol while swimming (Howland et al., 1996).

A study of heat-related injuries in Florida found that the rate of non-work-related emergency room visits was highest for adolescents ages 15–19 (60.41 per 100,000 person-years) and that the rate decreased as age increased, while the lowest rate of non-work-related heat-related injuries was among children under age 10 (9.83 per 100,000 person-years). However, the highest heat-related-injury death rates were for the elderly and those under age 5 (Harduar Morano et al., 2016).

Asthma

In the northern hemisphere, asthma episodes peak in the early fall, a trend hypothesized to be due to respiratory viruses (Johnston and Sears, 2006). However, this peak varies by geographic region in the United States, where it ranges from early fall to early spring (Wisniewski et al., 2016). In a 15-year study of prescription fill rates for asthma medication, the lowest fill rates were found to be in July, increasing in the autumn and through the winter, suggesting that prescription filling is reactive and follows disease exacerbation (Turi et al., 2018). However, deaths from asthma are more common in the summer months (Campbell et al., 1997; Weiss, 1990).

Obesity

Numerous studies have found an increase of childhood obesity in the summer. An analysis from the Early Childhood Longitudinal Study of body-mass index (BMI) measurements at the beginning and end of kindergarten and first grade showed that BMI increases more rapidly and more variably during the summer than during the school year. The same study found that the disparities in obesity prevalence between Black or Hispanic children and White children were largely due to increases in their BMI during the summer (von Hippel et al., 2007). In 2016, von Hippel and colleagues published an updated study, which found a similar gain in summertime BMI. However, this second study found no significant differences in summer weight gain by race or ethnicity. There were also no differences in summer weight gain between boys and girls, between children based on their families' higher versus lower incomes, or between children based on maternal education or employment status (von Hippel and Workman, 2016). Similarly, in a five-year longitudinal study conducted in southeast Texas, children generally lost weight during the school year and gained weight during the summer without any racial or ethnic variation (Moreno et al., 2013).

However, other studies have found that summer affects childhood obesity differentially across groups of children and youth. Children who are in the highest BMI percentiles have been found to gain significantly more weight during the summer than children in lower BMI percentiles (Downey and Boughton, 2007), placing children with severe obesity at the greatest risk for summer weight gain. One study of third-, fourth-, fifth-, seventh-, and eighth-grade American Indian school children found that those who were at or above the 85th percentile for BMI experienced an increase in BMI during the summer, while for children below the 85th percentile there was no change (Smith et al., 2009). However, another study of American Indian children between kindergarten and first grade found no change in the velocity of BMI increase in the summer as compared to the school year (Zhang et al., 2011).

Various explanations have been advanced to account for increased weight gain among children and adolescents in summertime. Factors that have been proposed include decreased physical activity and increased sedentary behaviors, poorer nutrition, and lack of access to school interventions. We discuss these factors below, many of which disproportionately affect children and youth in disadvantaged neighborhoods. Many of these factors fit within the “structured day” hypothesis (Brazendale et al., 2017). During the school year, children and adolescents generally experience a more highly structured, consistent, compulsory, and supervised day than in the summer. During the summer, there may be greater nutritional, activity, and sedentary activity choices and more discretionary time to engage in media use and alter sleep times (Avery et al., 2017). In one study, adolescents who regularly participated in organized activities were at less risk for obesity than those who did not (Mahoney, 2011).

Physical activity and sedentary behavior. A review of the research on seasonal variation and physical activity among children and youth by Carson and Spence (2010) suggests that summer may be associated with increased physical activity for some children and youth in certain contexts, but the evidence is mixed. Furthermore, the relationship between seasonality and physical activity may vary based on geography, urbanicity, and climate. For example, in different parts of the world, rural youth may be more active in the warmer months and urban youth were more active in the colder months (Carson and Spence, 2010).

Lower physical activity and increased sedentary time in the winter have been found across all ages, ethnicities, and climates (Atkin et al., 2016; Kornides et al., 2018; Stalsberg and Pederson, 2010). Atkin and colleagues (2016) analyzed seasonal accelerometer data from 705 seven-year-olds in the Millenium Cohort Study in the United Kingdom and found that in all children moderately vigorous physical activity (MVPA) was lower in autumn and winter compared with spring. MVPA was lower in summer compared with spring in boys, children of normal weight, those living in urban areas, those from high-income families, and on weekends. Sedentary time was greater in autumn and winter than in spring, and the seasonal effect was stronger during the weekend. Relative to spring, sedentary time in summer was lower on weekdays but higher during the weekend. Summer seems to be a time when activity and sedentary behavior are more variable between groups and during the week when compared to the school year (Atkin et al., 2015). No matter what the season, adolescents are not meeting daily physical activity requirements.

A prospective study of self-reported activity in adolescents (Kornides et al., 2018) found that 85 percent of adolescents did not meet the recommendation for MVPA (recommendation of 4 hours/week), and 91 percent did not meet the recommendation for vigorous physical activity (VPA; recommendation of 3 hours/week) for one or more seasons over the four study years. However, they were more likely to meet the MVPA requirements during the summer than in the winter. Even so, 60 percent of adolescents did not meet the moderate to vigorous physical activity requirements in the summer. Those least likely to meet these physical activity requirements were females, adolescents who had overweight or obesity, and older adolescents. When they compare the school year as a whole versus summer, many studies find a lower percentage of light-intensity physical activity and greater sedentary time, screen time, and sleep time during summer compared to the school year (Brazendale et al., 2018).

Zinkel and colleagues (2013) studied 162 school-age, sedentary Black and White youth based in or near the District of Columbia who were at risk for adult obesity to assess the potential impact of seasonal differences in total energy expenditure (TEE) on summer weight gain. When total and resting energy expenditure were measured throughout the year, no differences in energy expenditure were detected between summer and the school year, and the authors suggested that increased calorie intake through food and drinks may be the primary driver of summer weight gain (Zinkel et al., 2013).

Nutrition. Children and youth ages 6–19 engage in higher consumption of sugar-sweetened beverages and slightly lower intake of vegetables during school break (see Box 3-3), according to an analysis of the National Health and Nutrition Examination Survey (NHANES)⁵ for 2003–2008. Consumption of sugar-sweetened beverages and added sugar was higher for males, higher on weekends, and higher for older children (Wang et al., 2015b). Another study found that consumption of sugar from more fruits, sweets, and desserts during summer resulted in an unhealthier high-sugar intake during the season (Brazendale et al., 2018).

BOX 3-3

Addressing Food Insecurity in the Summer: USDA Programs.

Disruption of school interventions. School-based interventions for obesity have been successful during the school year (Wang et al., 2015a), but improvements in fitness, metabolic status, and percentage of body fat have been found to be reversed during the summer, with measurements returning to pre-intervention levels by the beginning of the next school year (Carrel et al., 2007). A small study of children in rural Wisconsin whose BMI was above the 95th percentile showed that positive results of a school-based obesity intervention (improvements in percent body fat, cardiovascular fitness, and fasting insulin) were lost during the summer break (Carrel et al., 2007). In two studies of school-based fitness interventions, improvements in fitness and body composition were lost during the summer (Gutin et al., 2008; Yin et al., 2012). In a 2-year community intervention involving more than 1,000 children in grades 1–3, BMIz⁶ decreased in children in the intervention community compared to children in the control groups. The next summer, when the intervention was less intense, there was no change in the BMIz scores between the intervention and control groups, possibly indicating a dose-response effect (Economos et al., 2013). Thus, it appears that interventions being continued into the summer may be important for maintaining obesity-related outcomes.

Neighborhood characteristics, physical activity, and weight gain. Although the associations between neighborhood characteristics and obesity in childhood are largely inconclusive, it is possible that neighborhood characteristics may influence children's physical activity and eating during the summer in particular ways. High-poverty neighborhoods often lack basic infrastructure, with substandard housing stock, more abandoned and boarded-up buildings, inadequate municipal services, fewer retail facilities (e.g., supermarkets), more bars and taverns (Evans, 2004), and high levels of joblessness and crime, especially violent crime (Meade, 2014). Confronted with such conditions, many parents in distressed neighborhoods shield their children from the streets by limiting their outdoor time (e.g., DeLuca et al., 2011). One result is that between 0–6, children from higher-income families spend an average of 1,300 more hours in “novel contexts”—meaning contexts other than home, school, or in the care of another parent or a day care provider—than do children from lower-income families (Phillips, 2011, p. 207).

A study of the link between neighborhood environments and weight gain of almost 3,000 children in a midsized city in the South from predominantly Black elementary-schools and from lower-income families demonstrated that females and older children gained more weight in the summer compared to males and younger children. These patterns did not vary by race with respect to summer weight gain. As in other studies, children who were overweight or had obesity gained more weight in the summer than children with normal weight. The study also showed that overweight children living near two or more small grocery stores gained less weight than overweight children who lived near just one or no stores; whereas whether or not the children lived within one mile of an active park was not associated with summer weight gain (Miles et al., 2018). Another study found that a lack of neighborhood safety is associated with a small reduction (8 minutes/week) in physical activity and a small BMI gain that did not change obesity status (An et al., 2017).

Mental Health

The only data regarding seasonal variations in mental health we identified involved mental health emergency visits. Emergency department (ED) data show fewer mental health–related emergency visits in the summer than in other seasons. Data from more than 20,000 children under age 17 in Alberta, Canada, from 2002 to 2008 document decreased presentations to EDs in urban and rural areas throughout Alberta for mental illness, substance use, or intentional self-harm in the summer. Visits for neurotic/stress-related disorders, mood disorders, intentional self-harm, substance abuse, and behavioral/emotional disorders decreased from May to July and then increased in August, September, and October (Ali et al., 2012). A retrospective study of psychiatric ED visits of children and youth ages 5–18 to a hospital in upstate South Carolina also demonstrated this seasonal pattern, with less frequent visits occurring in June, July, and August. The top reasons for admissions defined as mental health visits during the 5-year study period were aggressive behaviors (68%) and thoughts/actions of self-harm (27%); and the most common diagnoses were anxiety disorders (28%), disorders first usually diagnosed in infancy, childhood or adolescence (27%), mood disorders (19%), and substance-related disorders (10%) (Holder et al., 2017).

One review of the Nationwide Emergency Sample Department database (the largest all-payer ED database in the United States) examined suicide attempt–related ED visits from 2006 to 2013 for persons ages 10 and older, and found that such visits peaked for females ages 15–19 and males ages 20–24. Visits for attempted suicide were highest in the spring and fall. The largest number of visits occurred in May, and they were more common among persons in the lower-income quartiles (Canner et al., 2018). During an 8-year study of suicide ideation and suicide attempts in children, the lowest frequency occurred in the summer months, with the highest peaks in fall and spring (Plemmons et al., 2018).

CONCLUSIONS

CONCLUSION 3-1: Ensuring optimal nutrition, physical activity, and continuation of effective school-year programs for all children and youth in the summer would reduce health risks related to obesity and food insecurity that children and youth experience in the summer months.

CONCLUSION 3-2: More research is needed to understand the full impact of summertime experiences on outcomes and trajectories related to child and youth safety; pro- and anti-social, risk-taking, and delinquency-related behaviors; mental health; and social and emotional development. This need is especially great for underserved populations, which have been underrepresented in the research literature to date, including children who are American Indian, Alaska Native, Native Hawaiian, Pacific Islander, immigrant, migrant and refugee, homeless, child welfare- or justice-system involved, and LGBTQ+, as well as those with special health care or developmental needs.

CONCLUSION 3-3: The Summer Food Service Program and the Summer Electronic Benefits Transfer for Children program play crucial roles in reducing food insecurity and increasing access to healthy foods during the summer.

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