The National Association of Pediatric Nurse Practitioners strongly urges state policymakers, key education stakeholders and other pediatric advocates and decision-makers to prioritize policy planning to allow children to safely return to school in-person for the upcoming school year.
Impacts of School Closures
Beginning in March of 2020, children across the United States were abruptly and traumatically uprooted from their school environments as a critical component in combatting disease spread at the outset of the COVID-19 outbreak. Many of these children rely on their schools for access to critical support and services. Nearly 30 million children depend on school programs to provide food security and meet nutritional needs. School programs and services provide a safe and reliable source of childcare for tens of millions of parents who work outside the home. In addition, many children rely on primary care services provided in school settings. This includes access to high-quality care provided by school nurses, primary and acute episodic care provided by nurse practitioners, dental care and school sealant programs to promote oral health and thereby general good health, mental health care services provided by licensed professionals, and programs with school-based multidisciplinary therapists who support nearly seven million students with disabilities.
Lack of Access to Critical Services
In addition to the lack of connection to critical services, reports of adverse social, mental, emotional and spiritual health impacts of school disruption and social distancing measures taken to protect children from potential physical health threats presented with COVID-19 morbidity and mortality are alarming. School systems are essential to the identification of physical, emotional, and sexual maltreatment. Imposing continuation of distance learning removes this safeguard and isolates children at home with their perpetrator. In addition, the impacts of lost instructional time, lack of social skill acquisition, limited opportunity for physical activity, limited access to services for children with disabilities, and lack of adherence to immunization requirements will all necessitate significant interprofessional mitigation. The National Association of Pediatric Nurse Practitioners strongly urges prioritization of the safe return to in-person child education with as much normalcy and stability as possible.
Impact of COVID-19 on the Pediatric Population
Education and policy leaders along with public health officials are in the unenviable position of making high-stakes decisions in compressed time frames with rapidly changing data. Opening schools requires careful weighting of physical health priorities while balancing social, emotional, mental and spiritual health while adhering to federal, state and local guidelines. Although COVID-19 is a serious and potentially life-threatening illness, a growing body of scientific evidence supports children have been largely spared from significant burden of severe COVID-19-related illness. Analysis demonstrates most children infected with COVID-19 have mild or no symptoms, although children younger than three years of age and those with severe and/or chronic health conditions are disproportionately impacted and at higher risk of moderate-to-severe illness. Emerging evidence also suggests children are not significant super-spreaders of COVID-19, as previously anticipated.
Disparities Present in Online School Forums
Looking to the fall, schools are struggling to adapt to uncertainties ahead. Inequities are rapidly emerging and being identified with the implementation of universal online learning environments. Online school forums highlight significant disparities, including lack of broadband internet availability (particularly in rural and underserved areas), lack of access to electronic devices or reliance on adult devices with limited data plans, lack of social support at home, and working parent(s) unable to provide sufficient academic support while working to provide basic needs for their family. Essential workers are less likely to be able to work remotely or have paid sick leave or adequate health insurance, resulting in the inability to effectively manage online education for their children. In addition, there is a concerning disparity in state requirements to adhere to Individual Education Plans (IEPs), leaving some children with inadequate structural and resource support for learning.
Increased Risk of Exploitation, Abuse, and Neglect
When children are out of school, many lose their social safety net. There are fewer opportunities to identify children with substance use, suicidal ideation, self- harm and other crisis points in need of intervention. More children experience food insecurity, physical and/or emotional neglect, abuse, and exploitation. With children at home and spending more time on electronic devices, online predators have more opportunity in seeking child victims online for exploitation, abuse, and child trafficking. In the first month of the pandemic, the National Center for Missing and Exploited Children reported a nearly three-fold increase in the number of cyber tips received, totaling approximately 1.1 million. In addition, the number of crisis trafficking situations reported to the Human Trafficking Hotline increased by 40%, also in the first month of the pandemic. The Office of Trafficking in Persons provides free Stop, Observe, Act, Respond (SOAR) training for school-based professionals to help implement a trauma-informed response and assessment of risk factors for trafficking.
Discrimination, Prejudice and Racism
Also coinciding with the COVID-19 pandemic, children are experiencing rising levels of anxiety and depression while witnessing violence occurring following anger over systemic racial injustice acts and acts of discrimination and prejudice. The National Association of Pediatric Nurse Practitioners stands resolutely united and dedicated to advocating for all children to develop in a world that celebrates their diversity and advocates for their safety. The National Association of Pediatric Nurse Practitioners recognizes acts of racism and discrimination adversely impact child health and further contribute to health disparities identified in the COVID-19 pandemic.
Child Health Equity
Equity is central to any response efforts. The National Association of Pediatric Nurse Practitioners strongly encourages prioritization of research and guideline development for planning educational continuity, as education plays an important role in providing holistic support systems that promote holistic wellness during times of crisis. Priorities for ensuring safe return to schools should be coordinated by consulting with local and state health officials as well as educational experts to ensure optimal decisions are based on available data for their geographical area. This may result in variability in return to school plans based on geographic area. Should schools need to remain closed or close again after reopening, priority planning should be given to at-risk children including providing meals to children who rely on school programs, providing connection to services for children experiencing or vulnerable to homelessness, ensuring adequate transportation for children in need, and providing alternate delivery of medical and/or behavioral therapies outside the school environment for children in current treatment plans. A plan for understanding and accommodation should be prioritized for children with limited support inside their home.
Policy Recommendations
We urge state lawmakers to ask federal leaders to request waivers in meal plans to allow flexibility for schools which may be closed. Priority should be given to initiatives which accelerate efforts to address gaps in broadband service. Technology companies should provide additional and/or discounted data in cellular phone and device plans to allow for adequate access to streaming educational materials provided by the school. Funding and programs should be prioritized to educate healthcare providers, parents, caregivers and public educators about resiliency, coping and strategies known to protect against risk factors for mental illness and violence. Lawmakers should also consider funding for personal protective equipment, sanitization, and other materials needed to ensure a safe return to school, as risk for inequity exists should funding be inadequate. Schools should partner with pediatric health care providers to ensure access to timely, developmentally appropriate interventions for children affected by trauma associated with recent events; and to foster the development of healthy coping skills and resiliency.
A Holistic Approach to Child Health
The National Association of Pediatric Nurse Practitioners stands by our recent statements and urges them to be considered in prioritizing safe school return planning:
- Discrimination and Child Health
- Fostering Child Health and Wellness During COVID-19 Pandemic
- Immunizations During COVID-19 Outbreak
- Pediatric Mental Health and Violence
In addition, the National Association of Pediatric Nurse Practitioners supports COVID-19 Planning Considerations: Guidance for School Re-entry issued by the American Academy of Pediatrics, which contains many practical details of implementation for school officials.
The National Association of Pediatric Nurse Practitioners also encourages policymakers to integrate nursing voices in health policy decision-making forums surrounding school planning. Pediatric advanced practice registered nurses are experts in pediatrics and advocates for children who will continue to be active learners, adaptive and flexible while serving in the most trusted profession. Pediatric nursing professionals are reliable sources of information and provide an invaluable perspective as holistic practitioners of child health.
