'Unlike any challenge': Helping families cope amid pandemic

Strategies are needed to manage the unintended consequences for at-risk children of COVID-19–related school closings, social distancing, overwhelming numbers of distressing public health messages, and cancelation of non-urgent healthcare visits, according to a commentary in Pediatrics.

Similarly, a second commentary in the same journal outlines recommendations for pediatricians to guide assessment and mitigation of the family violence likely to endanger many children during a prolonged quarantine.

COVID-19 may mean more high-risk kids

In the first commentary, the authors, from Duke University, focus on three at-risk subgroups: (1) children with mental health needs, (2) children in foster care or at risk for abuse or neglect, and (3) those with complex medical conditions (CMCs) but point out that the mitigation strategies they suggest would likely benefit any child and family.

"Importantly, children not already in these groups are at risk of facing new medical, behavioral, or social challenges that develop during the pandemic," they wrote. "In particular, children in low socioeconomic status (SES) households are likely at highest risk for new or worsening measures, underscoring the critical leadership of Medicaid programs in these risk mitigation strategies."

For the roughly one in six children with mental illness requiring frequent visits with a therapist, the authors recommend promotion and reimbursement of telehealth visits for group and individual therapy, promotion of mental health equity, use of evidence-based mental health services to support behavioral health in primary care, and provision of developmentally appropriate educational materials to offset media pandemic coverage that might frighten children.

For the more than 400,000 children in foster care and other children at risk, paid leave, economic relief programs, and remote emotional support for caregivers could reduce abuse and neglect by easing household stress. Likewise, the Chafee Foster Care Independence Program can help older current and former foster youth with room and board expenses due to college closings or other economic difficulties.

The authors encourage virtual options to check child welfare and give parents options for complying with court-ordered actions such as drug testing and maintaining birth family rights. The Families First Prevention Services Act allows states to use Title IV-E funds for services such as counseling and parenting programs, which could be virtual.

For children with CMCs, guidance for home health and medical equipment companies could help them conserve personal protective equipment and ensure an adequate home health workforce, they said. Reimbursable telehealth visits can help ensure access to tertiary care and school-based physical and occupational therapy and educate parents on caring for their children.

"For these families, mutual aid resource groups, family resource centers, respite childcare, and caregiver support groups with expertise in CMC care and supply needs can help mitigate increased psychosocial and financial stress," they wrote.

The authors called for help for community-based and small agencies that may need technical help to institute virtual visits and flexibility of roles in different sectors, such as teachers contacting students every day for education and to ensure health and well-being.

"The social and health systems for children will be fundamentally transformed because of this pandemic," they wrote. "The innovations in the systems that support at-risk children and families are long overdue and needed now more than ever—and will position us to deliver higher value and better integrated care in the future for all children."

Flexible work policies, telehealth can help

The authors of the family violence commentary, from Vanderbilt and Tulane universities, say that reports of increased domestic violence from China during quarantine highlight the need to address isolation-related increased anger, confusion, posttraumatic stress, and substance abuse that can fuel family violence during and long after the pandemic.

One in eight US children have confirmed abuse or neglect to child protective services (CPS), a rate that could increase amid the pressures of the pandemic. The highest abuse-related death rates are in children younger than 1 year.

"If parents must leave their home to work, children face an increased risk for supervisory neglect (ie, not having adequate supervision to keep children from harm)," the authors wrote. "If working from home, parents with young children are forced to try to meet work demands while simultaneously caring for young children."

Upsetting changes in routine may lead children to act out, for which they may receive harsh reprimands from frazzled parents. "Unfortunately, school closures mean that the largest source of reports to CPS will disappear, resulting in reduced detection of maltreatment," they said.

Flexible work policies and lower expectations for productivity are needed for workers with young children, and more funding and support should be funneled to child welfare agencies and law enforcement for whom social distancing is not possible during investigations, placements, and supervision of at-risk children.

Telehealth visits in which providers advise families on coping strategies would enable clinicians to monitor for family violence by paying attention to nonverbal cues indicating fearfulness or irritability or other signs of abuse and report their suspicions to CPS, the authors add.

Because identification and management of the trauma, anxiety, and grief that will likely affect families is crucial, the authors call for the availability of practical resources such as those from the American Academy of Pediatrics and the National Child Traumatic Stress Network.

"This is important as our collective response to COVID-19 through social distancing and isolation may require these efforts for a prolonged period and will be unlike any challenge we have yet encountered," they said.

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