Mitigating the Impacts of the COVID-19 Pandemic Response on At-Risk Children Charlene A. Wong, MD, MSHP,a,b,c,d David Ming, MD,a,d,e Gary Maslow, MD, MPH,a,d,f Elizabeth J. Gifford, PhDa,b,c,d

Although children are not at the highest risk for coronavirus disease 2019 (COVID-19)1 severe illness, necessary pandemic public health measures will have unintended consequences for the health and well-being of the nation’s at-risk children. School closures, social distancing, reduction in This article has an accompanying video summary. health care services (eg, canceling nonurgent health care visits), and ubiquitous public health messaging are just some of the measures aDuke Children’s Health and Discovery Initiative, Durham, North intended to slow the COVID-19 spread. Here, we (1) highlight the Carolina; bDuke-Margolis Center for Health Policy, Durham, North health risks of the pandemic response measures to vulnerable pediatric Carolina; cSanford School of Public Policy, Duke University, Durham, d e subpopulations and (2) propose risk mitigation strategies that can be North Carolina; and Departments of Pediatrics, Medicine, and fPsychiatry, Duke University School of Medicine, Durham, North enacted by policy makers, health care providers and systems, and Carolina communities (Table 1). The selected risks and proposed mitigation Dr Wong conceptualized, coordinated, drafted, reviewed, and strategies are based on existing evidence and opinions of expert revised the manuscript; Drs Ming and Maslow drafted, stakeholders, including clinicians, academicians, frontline service reviewed, and revised the manuscript; Dr Gifford providers (eg, social workers), and public health leaders. conceptualized, drafted, reviewed, and revised the manuscript; and all authors approved the final manuscript We focus on risks and mitigation strategies for 3 at-risk subpopulations of as submitted and agree to be accountable for all aspects children: (1) children with behavioral health needs, (2) children in foster of the work. care or at risk for maltreatment, and (3) children with medical complexity DOI: https://doi.org/10.1542/peds.2020-0973 (CMC). Mitigation strategies delineated for these at-risk populations are Accepted for publication Apr 17, 2020 also likely beneficial for any child and family. Importantly, children not already in these groups are at risk for facing new medical, behavioral, or Address correspondence to Charlene A. Wong, MD, MSHP, School of Medicine, Duke University, 4020 N Roxboro St, social challenges that develop during the pandemic. In particular, children Durham, NC 27704. E-mail: [email protected] in households of low socioeconomic status are likely at the highest risk for PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098- new or worsening issues, underscoring the critical leadership role of 4275). Medicaid programs in these risk mitigation strategies. Copyright © 2020 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have CHILDREN WITH BEHAVIORAL HEALTH NEEDS no financial relationships relevant to this article to disclose. The ∼1 in 6 children with behavioral health conditions whose treatments FUNDING: No external funding. involve regular and frequent therapist contact are at especially high risk of POTENTIAL CONFLICT OF INTEREST: The authors have exacerbations during disasters.2 In-person behavioral health care access indicated they have no potential conflicts of interest to during the pandemic has been reduced in medical, community, and school disclose. settings, where proportionally more low-income, minority students accessed care pre-pandemic.3 Strategies to maintain access include the To cite: Wong CA, Ming D, Maslow G, et al. Mitigating the promotion and reimbursement of telehealth behavioral health visits by the Impacts of the COVID-19 Pandemic Response on At-Risk full range of licensed providers, promotion of mental health parity, and use Children. Pediatrics. 2020;146(1):e20200973

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 146, number 1, July 2020:e20200973 PEDIATRICS PERSPECTIVES 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 Response Recommended Mitigation Strategies Children with behavioral health needs Reduced health care access and school closures: behavioral health • Promote, reimburse with mental health parity, and provide technical treatments involve frequent contact with therapists and regular follow- guidance for telehealth and telephonic mental health visits, including by up. Children now face reduced access in medical, community, and school school counselors (school counseling resources and recommendations4) and settings. For example, among adolescents who use mental health existing mental health providers with various licenses (eg, doctoral, LCSW, services, 58% received these services in an educational setting, with LPC, LMFT, LCAS) to promote continuity of care and parental mental health higher rates among low-income, minority students.3 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 • Develop and distribute developmentally appropriate guidelines7 and potentially frightening messaging consumed by children can exacerbate materials to help parents communicate clearly and honestly about COVID-19. or trigger behavioral health conditions in children.6 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 • Develop and distribute recommended lists of best practices14 and virtual exacerbate underlying behavioral health issues, particularly children programs that allow for physical distancing and emotional support among with developmental disabilities for whom community supports are children. Examples include social media with a family media use plan,15 critical and for children with mood disorders (eg, depression and mindfulness activities for the whole family (Growga16), or virtual volunteer anxiety). 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 • Heighten awareness among other reporters (eg, primary care, police demands, which places children at risk. School personnel, a key reporter officers, faith-based organizations, public) of the enhanced risk for of maltreatment, will be unavailable. Foster parents18 may reevaluate maltreatment and provide trauma-informed training19 in how to responda,b,c their ability to financially and socially support children who are not in • Provide paid leave20 and economic assistance to allow caregivers to provide school, resulting in placement disruption. Kinship families may be adequate and safe child carea particularly stressed because they are provided fewer resources than • Enhance and connect parents and caregivers with online support other foster parents. 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 • Provide funding for room and board assistance to foster children between education may leave current or former foster youth without stable the ages of 18 and 21 (eg, Chafee Foster Care Program for Successful housing options; one-fourth to one-third24 of homeless youth have been Transition to Adulthood funds25)a in foster care. Social distancing: for new reports of maltreatment and families receiving • Develop and promote virtual visits26 and other strategies for child welfare in-home child welfare services, case workers may be unavailable to workers to safely conduct assessments and investigations and to allow complete important safety checks, biological parents may be unable to contact between foster homes, group homes, and birth parentsa comply with court-ordered plans (eg, substance use testing), especially if • Provide alternative strategies for parents who have court-ordered substance courts close, and foster children may be isolated from birth families. 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 • Provide additional guidance29 for pediatric home health30 and durable technology (eg, feeding tubes, respiratory equipment) and need medical equipment agencies on in-home care practices, isolation procedures, continuous care from multiple service providers (eg, home health, preservation of personal protective equipment used for daily in-home care primary and specialty providers). (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

Downloaded from www.aappublications.org/news by guest on September 25, 2021 2 WONG et al TABLE 1 Continued Risks From COVID-19 Pandemic Response Recommended Mitigation Strategies 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, • Develop and promote a strategy for telehealth reimbursable ancillary feeding and/or nutrition) and other services (eg, physical and/or services (eg, physical therapy35), including online resource libraries36 for occupational therapy) at school. School provides a regular source of common pediatric therapy modules (eg, core strengthening exercises) that respite for families. 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 • Implement family resource centers or promote maintaining selected child responsibilities to provide complicated medical care, often while care centers41 open42 for vulnerable families, including on-site routine concurrently maintaining their own health employment and health for services for children with complex medical needsa,b,c other family members; all of these challenges are exacerbated by • Connect families of CMC through existing organizations (eg, Family Voices43) physical distancing. 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. of evidence-based systems (eg, China during the quarantine mandates, and biological parents may statewide telehealth mental health periods.44 Strategies outlined for be unable to comply with court- service) to support behavioral health children with behavioral health ordered plans (eg, substance use care in primary care. Intense and conditions will also benefit the testing). New virtual options are frightening pandemic media .400 000 US children in foster therefore needed for making child coverage may trigger behavioral care and all children at risk for welfare visits, meeting court health conditions in children; maltreatment in this stressful time. requirements, and maintaining birth developmentally appropriate The added stress and school closures family rights. For candidates for materials can help parents may lead foster parents to determine foster care, the Family First communicate transparently about that they are unable to provide foster Prevention Services Act allows states COVID-19 with their children. care, resulting in placement to use title IV-E funds for child and Additionally, physical isolation from disruptions. Broad-reaching paid family services (eg, mental health, peers and support networks may leave, economic relief programs, and substance use, and parenting exacerbate underlying behavioral virtual emotional support for programs) that could potentially be health issues. Online programs and caregivers could reduce household delivered virtually. group teletherapy visits that provide stress and in turn, maltreatment emotional support while maintaining rates. University closures and other physical distance are novel mitigating economic hardships may leave many CHILDREN WITH MEDICAL COMPLEXITY strategies that should be considered older current and former foster youth The risk for COVID-19 among CMC is for reimbursement. Importantly, without stable housing. In response, unclear but presumed to be higher parents also need support and access funding from the John H. Chafee than among children without medical for their own behavioral health needs. Foster Care Independence Program, complexity. CMC typically have which promotes current and former multiple chronic conditions, foster youth self-sufficiency, can functional limitations, medical CHILDREN IN FOSTER CARE OR AT RISK support room and board assistance technology dependence (eg, feeding FOR MALTREATMENT for these youth.25 For new tubes), and a complex network of As psychosocial and financial stresses maltreatment reports and families service providers and caregivers build during the pandemic, children receiving child welfare services, case critical to maintain day-to-day are vulnerable to new or additional workers may be unavailable to health.45 Care network disruptions abuse or neglect, similar to the complete important safety checks could generate outsized adverse increased interpersonal violence in because of social distancing consequences for CMC. As primary

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 146, number 1, July 2020 3 and specialty health care access is will require technical assistance to University School of Medicine); Jillian reduced, novel guidance for home implement virtual services. Flexibility Hurst, PhD (Duke Children’s Health health and medical equipment of roles across sectors can also be and Discovery Initiative and Duke agencies is needed on in-home leveraged (eg, teachers in China University School of Medicine); Kyle practices, including on conserving contacted students daily for Walsh, PhD (Duke Children’s Health personal protective equipment and education as well as for health and and Discovery Initiative and Duke augmenting the home health safety screening). Also common University School of Medicine); workforce.30 Telehealth reimbursable across strategies is support at the Rebecca Whitaker, PhD (Duke- services are essential to preserve family level. Primary care providers, Margolis Center for Health Policy); access to tertiary care center–based who already engage with the family Taruni Santanam (Duke-Margolis multispecialty medical care and unit, can enact or promote the Center for Health Policy); Sahil school-based ancillary services (eg, recommended strategies, including Sandhu (Duke-Margolis Center for physical and/or occupational proactively reaching out to these at- Health Policy); Megan Jiao (Duke- therapy). Novel ancillary service risk populations and sharing local Margolis Center for Health Policy); telehealth visits can educate parents resources with families. William Song (Duke-Margolis Center on how to deliver the therapies at for Health Policy); Carter Crew, MPH The pandemic response has forced home. Telehealth medical visits can (Duke Children’s Health and the development of strategic be strengthened with remote Discovery Initiative); Kelby Brown relationships, policy reforms, and monitoring integration and interstate (Duke-Margolis Center for Health new practices, which will accelerate health care support. Like caregivers Policy and Duke University School of care integration and payment of other at-risk child groups, CMC Medicine); Laura Stilwell (Duke redesigns that at-risk children need caregivers will need support as their Children’s Health and Discovery now and in the future. The redesign usual care networks shrink because Initiative and Duke University School will require determining which of social distancing and/or COVID-19 of Medicine); Naomi Duke, MD, PhD strategies (eg, expanded telehealth) illness. For these families, mutual aid (Duke Children’s Health and are working and what can be resource groups, family resource Discovery Initiative and Duke continued as part of routine care centers, respite child care, and University School of Medicine); delivery. Existing pediatric care caregiver support groups with Megan Golonka, PhD (Duke transformation learning networks can expertise in CMC care and supply University Sanford School of Public lead the way in making such needs can help mitigate increased Policy); Yuerong Liu, PhD (Duke recommendations, which will psychosocial and financial stress. Children’s Health and Discovery improve disaster preparedness for Initiative and Duke University child-serving systems. Sanford School of Public Policy); LOOKING AHEAD The social and health systems for Makenzie Beaman (Duke University Beyond the risk of illness from children will be fundamentally School of Medicine); Chelsea COVID-19, the social and medical transformed because of this Swanson, MPH (Duke University consequences of the unprecedented pandemic. Clinicians, teachers, and School of Medicine); Richard Chung, public health measures needed to social service providers are stepping MD (Duke Children’s Health and slow the viral spread may pose an out of their brick-and-mortar Discovery Initiative and Duke even greater threat to children, institutions to reach children in their University School of Medicine); Mark particularly those with behavioral homes and communities to deliver McClellan, MD, PhD (Duke-Margolis health needs, in foster care or at risk critical health and well-being Center for Health Policy); Rushina for maltreatment, or with medical services. The innovations in the Cholera, MD, PhD (Duke Children’s complexity. Common across the systems that support at-risk children Health and Discovery Initiative, Duke- recommended risk mitigation and families are long overdue and Margolis Center for Health Policy, and strategies is the need for rapid needed now more than ever; such Duke University School of Medicine); implementation and reimbursement innovations will position us to deliver Kenneth A. Dodge, PhD (Duke for virtual services, including cross- higher value and better integrated University Sanford School of Public sector collaboration to maintain care in the future for all children. Policy); Jennifer Lansford, PhD (Duke continuity of necessary supports and University Sanford School of Public services (eg, in schools, child welfare, Policy); Robert Saunders, PhD (Duke- and child care settings). Many ACKNOWLEDGMENTS Margolis Center for Health Policy); community-based and smaller We acknowledge Sallie Permar, MD, Rachel Roiland (Duke-Margolis agencies (eg, child welfare, home PhD (Duke Children’s Health and Center for Health Policy); Kelly health agencies, therapy practices) Discovery Initiative and Duke Kimple, MD, MPH (North Carolina

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Downloaded from www.aappublications.org/news by guest on September 25, 2021 Mitigating the Impacts of the COVID-19 Pandemic Response on At-Risk Children Charlene A. Wong, David Ming, Gary Maslow and Elizabeth J. Gifford Pediatrics 2020;146; DOI: 10.1542/peds.2020-0973 originally published online April 21, 2020;

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