TABLE 1

Selected Health Risks for Vulnerable Child Subpopulations From the COVID-19 Pandemic Response Initiatives and Recommended Mitigation Strategies

Risks From COVID-19 Pandemic ResponseRecommended Mitigation Strategies
Children with behavioral health needs
 Reduced health care access and school closures: behavioral health treatments involve frequent contact with therapists and regular follow-up. Children now face reduced access in medical, community, and school settings. For example, among adolescents who use mental health services, 58% received these services in an educational setting, with higher rates among low-income, minority students.3• Promote, reimburse with mental health parity, and provide technical guidance for telehealth and telephonic mental health visits, including by school counselors (school counseling resources and recommendations4) and existing mental health providers with various licenses (eg, doctoral, LCSW, LPC, LMFT, LCAS) to promote continuity of care and parental mental health care accessa,b
• Develop and promote the use of statewide telehealth programs (eg, NC-PAL5) to provide consultative services to address child mental health needs during school closurea,b,c
 Pandemic public health messaging: the high volume of intense and potentially frightening messaging consumed by children can exacerbate or trigger behavioral health conditions in children.6• Develop and distribute developmentally appropriate guidelines7 and materials to help parents communicate clearly and honestly about COVID-19. Examples include #COVIBOOK,8 an interactive book to explain COVID-19 to children; parent resources (SAHMSA,9 Association for Child Psychoanalysis,10 National Association of School Psychologists11).a,b,c
• Encourage the media to provide child- and teenager-targeted news12 reporting for transparent information that is not fear based (eg, Newsela13 for current news that can be modified by grade level)a,b,c
 Social distancing: physical isolation from support systems and peers can exacerbate underlying behavioral health issues, particularly children with developmental disabilities for whom community supports are critical and for children with mood disorders (eg, depression and anxiety).• Develop and distribute recommended lists of best practices14 and virtual programs that allow for physical distancing and emotional support among children. Examples include social media with a family media use plan,15 mindfulness activities for the whole family (Growga16), or virtual volunteer opportunities for youth (Do Something17).a,b,c
• Explore the feasibility (regulatory, technology) and reimbursement strategy for telehealth group therapy visits to support child mental healtha,b
Children in foster care and/or at risk for maltreatment
 School closure: families of all children may be taxed by added parenting demands, which places children at risk. School personnel, a key reporter of maltreatment, will be unavailable. Foster parents18 may reevaluate their ability to financially and socially support children who are not in school, resulting in placement disruption. Kinship families may be particularly stressed because they are provided fewer resources than other foster parents.• Heighten awareness among other reporters (eg, primary care, police officers, faith-based organizations, public) of the enhanced risk for maltreatment and provide trauma-informed training19 in how to responda,b,c
• Provide paid leave20 and economic assistance to allow caregivers to provide adequate and safe child carea
• Enhance and connect parents and caregivers with online support resources,21 parenting education (eg, Incredible Years, Triple P), best practices22 for child and self-care (eg, setting and maintaining routines), and hotlines23 for crisisc
 College and university closures: closures of institutions of postsecondary education may leave current or former foster youth without stable housing options; one-fourth to one-third24 of homeless youth have been in foster care.• Provide funding for room and board assistance to foster children between the ages of 18 and 21 (eg, Chafee Foster Care Program for Successful Transition to Adulthood funds25)a
 Social distancing: for new reports of maltreatment and families receiving in-home child welfare services, case workers may be unavailable to complete important safety checks, biological parents may be unable to comply with court-ordered plans (eg, substance use testing), especially if courts close, and foster children may be isolated from birth families.• Develop and promote virtual visits26 and other strategies for child welfare workers to safely conduct assessments and investigations and to allow contact between foster homes, group homes, and birth parentsa
• Provide alternative strategies for parents who have court-ordered substance use treatment plans to meet requirements (eg, Online Intergroup of Alcoholics Anonymous27)a,b
• States can fund28 evidence-based family preservation services, such as parenting skills, mental health and substance use, and kinship navigator servicesa
Children with medical complexity
 Reduced health care access: CMC are often dependent on medical technology (eg, feeding tubes, respiratory equipment) and need continuous care from multiple service providers (eg, home health, primary and specialty providers).• Provide additional guidance29 for pediatric home health30 and durable medical equipment agencies on in-home care practices, isolation procedures, preservation of personal protective equipment used for daily in-home care (eg, gloves, masks); augmentation of home health workforce (eg, pediatric nurses with reduced in-person clinical responsibilities during the emergency response); and increased training for home health workforce on coordinating with remote medical providersa
• Proactive outreach to families of CMC through regularly scheduled touch points, use of remote monitoring,31 or reimbursable telehealth virtual visits to provide early and expanded medication,32 supplies (special consideration for face masks and respiratory equipment), and nutritional supportb
• Support formation of family mutual aid33 resource groups for critical medical supplies34 for CMC (eg, specialty compounding pharmacies, pediatric formulas, specialized pediatric equipment such as tracheostomies and feeding tubes)c
 School closure: CMC often receive medical (eg, medication administration, feeding and/or nutrition) and other services (eg, physical and/or occupational therapy) at school. School provides a regular source of respite for families.• Develop and promote a strategy for telehealth reimbursable ancillary services (eg, physical therapy35), including online resource libraries36 for common pediatric therapy modules (eg, core strengthening exercises) that caregivers can deliver at homea,b
• Develop policies for emergency respite services,37 potentially using closed school38 spaces or other facilities,39 such as medical support shelters,40 for children with complex medical technology dependence (eg, tracheostomy, ventilator dependence) and caregivers or family members that are illa,b
 Social distancing: parents of CMC at baseline carry tremendous responsibilities to provide complicated medical care, often while concurrently maintaining their own health employment and health for other family members; all of these challenges are exacerbated by physical distancing.• Implement family resource centers or promote maintaining selected child care centers41 open42 for vulnerable families, including on-site routine services for children with complex medical needsa,b,c
• Connect families of CMC through existing organizations (eg, Family Voices43) for emotional and resource supporta,b,c
  • LCAS, licensed clinical addition specialist; LCSW, licensed clinical social worker; LMFT, licensed marriage and family therapist; LPC, licensed professional counselor; NC-PAL, NC Psychiatry Access Line; SAMHSA, Substance Abuse and Mental Health Services Administration; Triple P, Positive Parenting Program.

  • a Directed for policy makers.

  • b Directed for health systems.

  • c Directed for community organizations.