Mitigating the Impacts of the COVID-19 Pandemic Response on At-Risk Children

Children With Behavioral Health Needs

The ∼1 in 6 children with behavioral health conditions whose treatments involve regular and frequent therapist contact are at especially high risk of exacerbations during disasters.² In-person behavioral health care access during the pandemic has been reduced in medical, community, and school settings, where proportionally more low-income, minority students accessed care pre-pandemic.³ Strategies to maintain access include the promotion and reimbursement of telehealth behavioral health visits by the full range of licensed providers, promotion of mental health parity, and use of evidence-based systems (eg, statewide telehealth mental health service) to support behavioral health care in primary care. Intense and frightening pandemic media coverage may trigger behavioral health conditions in children; developmentally appropriate materials can help parents communicate transparently about COVID-19 with their children. Additionally, physical isolation from peers and support networks may exacerbate underlying behavioral health issues. Online programs and group teletherapy visits that provide emotional support while maintaining physical distance are novel mitigating strategies that should be considered for reimbursement. Importantly, parents also need support and access for their own behavioral health needs.

Children in Foster Care or at Risk for Maltreatment

As psychosocial and financial stresses build during the pandemic, children are vulnerable to new or additional abuse or neglect, similar to the increased interpersonal violence in China during the quarantine periods.⁴⁴ Strategies outlined for children with behavioral health conditions will also benefit the >400 000 US children in foster care and all children at risk for maltreatment in this stressful time. The added stress and school closures may lead foster parents to determine that they are unable to provide foster care, resulting in placement disruptions. Broad-reaching paid leave, economic relief programs, and virtual emotional support for caregivers could reduce household stress and in turn, maltreatment rates. University closures and other economic hardships may leave many older current and former foster youth without stable housing. In response, funding from the John H. Chafee Foster Care Independence Program, which promotes current and former foster youth self-sufficiency, can support room and board assistance for these youth.²⁵ For new maltreatment reports and families receiving child welfare services, case workers may be unavailable to complete important safety checks because of social distancing mandates, and biological parents may be unable to comply with court-ordered plans (eg, substance use testing). New virtual options are therefore needed for making child welfare visits, meeting court requirements, and maintaining birth family rights. For candidates for foster care, the Family First Prevention Services Act allows states to use title IV-E funds for child and family services (eg, mental health, substance use, and parenting programs) that could potentially be delivered virtually.

Children With Medical Complexity

The risk for COVID-19 among CMC is unclear but presumed to be higher than among children without medical complexity. CMC typically have multiple chronic conditions, functional limitations, medical technology dependence (eg, feeding tubes), and a complex network of service providers and caregivers critical to maintain day-to-day health.⁴⁵ Care network disruptions could generate outsized adverse consequences for CMC. As primary and specialty health care access is reduced, novel guidance for home health and medical equipment agencies is needed on in-home practices, including on conserving personal protective equipment and augmenting the home health workforce.³⁰ Telehealth reimbursable services are essential to preserve access to tertiary care center–based multispecialty medical care and school-based ancillary services (eg, physical and/or occupational therapy). Novel ancillary service telehealth visits can educate parents on how to deliver the therapies at home. Telehealth medical visits can be strengthened with remote monitoring integration and interstate health care support. Like caregivers of other at-risk child groups, CMC caregivers will need support as their usual care networks shrink because of social distancing and/or COVID-19 illness. For these families, mutual aid resource groups, family resource centers, respite child care, and caregiver support groups with expertise in CMC care and supply needs can help mitigate increased psychosocial and financial stress.

Looking Ahead

Beyond the risk of illness from COVID-19, the social and medical consequences of the unprecedented public health measures needed to slow the viral spread may pose an even greater threat to children, particularly those with behavioral health needs, in foster care or at risk for maltreatment, or with medical complexity. Common across the recommended risk mitigation strategies is the need for rapid implementation and reimbursement for virtual services, including cross-sector collaboration to maintain continuity of necessary supports and services (eg, in schools, child welfare, and child care settings). Many community-based and smaller agencies (eg, child welfare, home health agencies, therapy practices) will require technical assistance to implement virtual services. Flexibility of roles across sectors can also be leveraged (eg, teachers in China contacted students daily for education as well as for health and safety screening). Also common across strategies is support at the family level. Primary care providers, who already engage with the family unit, can enact or promote the recommended strategies, including proactively reaching out to these at-risk populations and sharing local resources with families.

The pandemic response has forced the development of strategic relationships, policy reforms, and new practices, which will accelerate care integration and payment redesigns that at-risk children need now and in the future. The redesign will require determining which strategies (eg, expanded telehealth) are working and what can be continued as part of routine care delivery. Existing pediatric care transformation learning networks can lead the way in making such recommendations, which will improve disaster preparedness for child-serving systems.

The social and health systems for children will be fundamentally transformed because of this pandemic. Clinicians, teachers, and social service providers are stepping out of their brick-and-mortar institutions to reach children in their homes and communities to deliver critical health and well-being services. The innovations in the systems that support at-risk children and families are long overdue and needed now more than ever; such innovations will position us to deliver higher value and better integrated care in the future for all children.