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The Impact of the COVID-19 Pandemic on Children/Youth With Special Health Care Needs: A School Nurse's Perspective

Published:December 07, 2022DOI:https://doi.org/10.1016/j.pedhc.2022.12.001

      Abstract

      School nurses repeatedly have been stretched to the limits over the past few years with the COVID-19 pandemic—managing not only routine daily care of students but also juggling those unique needs of children and youth with special health care needs, especially for those who also lost a parent/caregiver from COVID-19. This article provides background demographic information on how the COVID-19 pandemic affected these children, along with a specific case report of a middle school student with attention deficit hyperactivity disorder who also experienced the loss of a parent from COVID-19. Specific practical suggestions are discussed on how school nurses proactively and collaboratively can assist these students whose lives were permanently changed by the life-changing event of losing a parent/caregiver from COVID-19.

      Key words

      INTRODUCTION

      As the COVID-19 pandemic enters its third year, significant life stressors continue to evolve, especially for those children who lost a parent/primary caregiver from COVID-19. According to the Centers for Disease Control and Prevention (CDC; Centers for Disease Control and Prevention [

      Centers for Disease Control and Prevention. (2021). The hidden U.S. COVID-19 pandemic: Orphaned children – More than 140,000 U.S. children lost a primary or secondary caregiver due to the COVID-19 pandemic.http://www.cdc.gov/media/releases/2021/p1007-covid-19-orphaned-children.html.

      ), a rising “hidden and ongoing orphanhood tragedy” exists, citing that one U.S. child lost a parent/caregiver for every four COVID-19 deaths, with an estimated more than 200,000 children aged under 18 years lost a parent/caregiver as of June 2022 (
      • Hillis S.
      • Blenkinsop A.
      • Villaveses A.
      Covid-19-associated orphanhood and caregiver death in the United States.
      ), with children of color affected far more frequently. School nurses play an integral role in facilitating the student's well-being by providing a supportive environment for those impacted by the death of a parent/caregiver, especially for those children and youth with special health care needs (CYSHCN). There is an urgent call for school nurses to understand, assess, and identify the social-emotional and psychological factors affecting these children and their families and to prioritize care, which allows school nurses to develop practical strategies to reduce and mitigate the effects of racial, ethnic, and geographic health disparities.
      CYSHCN are defined as “those who have or are at risk for chronic, physical, developmental, behavioral, or emotional conditions and require additional health and related services beyond that which is required by children generally” (
      • McPherson M.
      • Arango P.
      • Fox H.
      • Lauver C.
      • McManus M.
      • Newacheck P.W.
      • Perrin J.
      • Shonkoff J.
      • Strickland B.
      A new definition of children with special health care needs.
      ). The National Survey of Children's Health Data Brief reported that nearly one in five children in the United States experience a special health care need, representing 14.1 million children and more than one in four households with children with at least one CYSHCN (). School nurses provide a critical framework for delivering care to CYSHCN and those impacted by the death of a parent/caregiver during the pandemic.
      This paper reviews a case report involving a middle school student diagnosed with attention deficit hyperactivity disorder (ADHD) in a school setting and focuses on specific interventions used to assist the student and the student's caregivers in navigating the maze of challenges involved in raising a child with a chronic health condition while grieving the loss of a close family member. Two case report questions will address the child's and family's functional and mental health consequences.

      Background Statistics on COVID-19

      Losing a primary caregiver can be one of the most stressful experiences in a child's life, putting them at risk of a trajectory of depression, post-traumatic stress, and any physical manifestations of grief (
      • Jones C.
      Helping children grieve the loss of a caregiver due to COVID-19.
      ). The CDC reported in 2021 that significant racial, ethnic, and geographic disparities exist in COVID-19-associated death to caregivers, and the highest burden of death was observed in the southern U.S. states, along the U.S.–Mexican border for Hispanic children, in southeastern states for Black children, and states with tribal areas for American Indian/Alaska Native populations. For example, in the United States, one out of 50 children lost a caregiver. For American Indian/Alaska Native children, this figure was one out of 168; Black children, one out of 310; Hispanic children, one out of 412; Asian children, one out of 612; and White children, one out of 753.
      • Nelson R.
      Caregiver deaths from COVID: 5 million children affected worldwide.
      stated, “Native Americans are 4 times more likely than Whites to be orphaned, and Black and Hispanic children 2.5 times more likely to die.” Overall, two-thirds (65%) of the children who lost a primary caregiver belonged to a racial or ethnic minority. Unfortunately, the rate remains disproportionate to minorities. These data reflect the inequities observed since the beginning of the pandemic, as COVID-19 affected many racial and ethnic minority groups, which “puts them at a higher risk of severe illness and death” (
      • Nelson R.
      Caregiver deaths from COVID: 5 million children affected worldwide.
      ).

      Psychological and Social Impacts on Children

      • Rethy J.A.
      • Chawla E.M.
      How pediatricians can help mitigate the mental health crisis.
      identified the following reasons why the COVID-19 pandemic has exacerbated mental health conditions for many children for a myriad of reasons: missed or delayed opportunities for celebrations and marking milestones; direct stress related to the COVID-19 illness, avoiding COVID-19, and protecting loved ones; and ongoing economic distress, to name a few.
      • Adegboye D.
      • Williams F.
      • Collishaw S.
      • Shelton K.
      • Langley K.
      • Hobson C.
      • Burley D.
      • van Goozen S.
      Understanding why the COVID-19 pandemic-related lockdown increases mental health difficulties in vulnerable young children.
      stated:Understanding the immediate psychological and social consequences for children, especially those already at risk for significant emotional and behavioral problems, and their families is essential for rapid development of policies and interventions to mitigate the mental health problems and provide tailored support for vulnerable groups of children during and after the pandemic. (p. 2)
      Beginning in April 2020, the proportion of mental health–related visits in pediatric emergency departments increased significantly for children and adolescents (

      Leeb, R. T., Bitsko, R. H., Radhakrishnan, L., Martinez, P., Njai, R., Holland, K. M. (2020). Mental health–related emergency department visits among children aged <18 years during the COVID-19 pandemic – United States, January 1 – October 17, 2020. Retreived from https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3.htm

      ).

      Todd, B. (2021). The Psychological toll of COVID-19 on children. The American Journal of Nursing. Retrieved from https://pubmed.ncbi.nlm.nih.gov/34438413

      reported that “Pediatric hospitals in several states have reported sharp increases in ED visits for anxiety, depression, substance abuse, suicide attempts, self-harm, aggressive behavior, and eating disorders. One medical director desxribed the current situation as one of 'colliding pandemics' - one being the long-standing inadequacy of mental health resources for children coupled with the psychological toll of COVID-19 pandemic.”
      Multiple research studies examined the mounting evidence of the profound psychological impact of the COVID-19 pandemic on mental health functioning, specifically with elevated rates of anxiety and depression symptoms.
      • Breaux R.
      • Dvorsky M.R.
      • Marsh N.P.
      • Green C.D.
      • Cash A.R.
      • Shroff D.M.
      • Buchen N.
      • Langberg J.M.
      • Becker S.P.
      Prospective impact of COVID-19 on mental health functioning in adolescents with and without ADHD: Protective role of emotion regulation abilities.
      examined the changes in and predictors of adolescents with ADHD from pre-COVID-19 to the early spring of 2020. These researchers found that adolescents (aged 15–17 years) with ADHD experienced increases in sluggishness, cognitive tempo, inattention, hyperactivity and impulsivity, and oppositional/defiant symptoms above and beyond the effects of medication status.
      • Moss E.
      Roadmap to recovery: Year 2 of the COVID-19 pandemic.
      described the effects of the pandemic as parallel to those of natural disasters, which may potentially have short and long-term effects on the psychological, emotional, developmental, and physical health of children, as has been attributed to hurricanes, floods, tornadoes, and earthquakes.
      • Moss E.
      Roadmap to recovery: Year 2 of the COVID-19 pandemic.
      further stated that in the current COVID-19 pandemic, “families have experienced the loss of loved ones, job loss or displacement, and the breakdown in social networks” (p. 293).
      • Moss E.
      Roadmap to recovery: Year 2 of the COVID-19 pandemic.
      continued by asserting that school nurses use evidence-based strategies to plan for and practice a safe return of faculty, staff, and students with in-person learning.
      • Peck J.L.
      COVID-19: Impacts and implications for pediatric practice.
      contrasted the initial response of schools during the initial stages of the COVID-19 pandemic that “schools are struggling to adapt rapidly, making high-stakes decisions with little information available” (p. 626).
      The American Academy of Pediatrics issued guidance throughout the pandemic regarding return to school to shape conversations around holistic health and equity. Specific guidance provided principles of flexibility to respond to quickly changing information in individual communities, advocacy for vulnerable and disadvantaged children, equity in school inclusion, and policies to support the overall health of children, their families, and communities. At the beginning of the 2021 school year, the American Academy of Pediatrics published updated interim guidance on supporting the emotional and behavioral health needs of children, adolescents, and families during the pandemic (

      Wyckoff, A. S. (2021, August 2). Supporting emotional, behavioral needs of children in the pandemic: Updated guidance. American Academy of Pediatrics (AAP) News. Retrieved fromhttps://publications.aap.org/aapnews/news/16376?autologincheck=redirected

      ).
      • Beal J.A.
      Impact of the Covid-19 pandemic on mental health of children, adolescents, and young adults.
      stated:The wide range of emotional and behavioral health and economic challenges stressing the well-being of families is exacerbated in populations with higher baseline risk such as vulnerable and marginalized individuals and communities. The impact of structural racism has resulted in disproportionate challenges on communities of color. Concerns about long-term sequelae of the effects of COVID-19 on children and families must not be ignored. (p. 177)
      • Moss E.
      Roadmap to recovery: Year 2 of the COVID-19 pandemic.
      emphasized that parents, grandparents, caregivers, students, and teachers experienced stress while trying to adapt to the lack of the brick-and-mortar school routine. Parents of children who received virtual or hybrid instruction reported emotional stress, difficulty sleeping, loss of work, concern with job stability, childcare challenges, and conflict between working and providing childcare. In the fall of 2021, some students needed reintroduction to be in a classroom for the first time in more than 18 months.
      • Moss E.
      Roadmap to recovery: Year 2 of the COVID-19 pandemic.
      recommended that:A successful return to school this fall will be dependent on a strong school crisis response. Schools will need to plan for the social-emotional support of staff and students to build resilience before we can even address education recoupment. A collaborative school team is vital to the mental health of students. The school nurse's interdisciplinary relationship with school social workers, counselors, psychologists, and administrators needs to be stronger than ever before. (p. 294)
      • O'Connor D.B.
      • Aggleton J.P.
      • Chakrabarti B.
      • Cooper C.L.
      • Creswell C.
      • Dunsmuir S.
      • Fiske S.T.
      • Gathercole S.
      • Gough B.
      • Ireland J.L.
      • Jones M.V.
      • Jowett A.
      • Kagan C.
      • Karanika-Murray M.
      • Kaye L.K.
      • Kumari V.
      • Lewandowsky S.
      • Lightman S.
      • Malpass D.
      • Armitage C.J.
      Research priorities for the COVID-19 pandemic and beyond: A call to action for psychological science.
      highlighted seven research priority domains specifically related to the impact of COVID-19 on children and families. Two research domains (e.g., children and families and mental health) will be used as a template for the case report questions.

      CASE REPORT

      An 11-year-old Black male transferred to a private middle school from a local public school when local public schools were closed to in-person learning during the COVID-19 pandemic. His social history was significant for the death of his mother from COVID-19, which led him to move in with his maternal grandparents, who became his legal guardians. It is important to note that he was one of four students (out of a total class size of 20) who had lost a caregiver because of COVID-19. In fourth grade, he was diagnosed with ADHD, and his former public school had a formal education plan (i.e., 504-Plan) to help support his struggles to focus more on academics. Some of the specific accommodations included: allowing for extra time to complete assignments, offering preferential seating near the front of the class, and checking for understanding material with modifications of essential assignments with each of his classroom teachers. He had a primary care provider (PCP) that monitored his ADHD since 2019 and was followed every 3 months. He took Focalin XR each morning before school. His medical history was significant for mild intermittent asthma, and he was prescribed an albuterol inhaler for school use as needed.
      This child was closely followed by the school nurse as a new student with accommodations from his previous school. After the first month of school, his grandmother expressed to the school nurse some specific concerns about her grandson's health and well-being and asked for recommendations for a pediatric psychologist and therapist. She believed her grandson needed to talk with someone about the death of his mom.
      His grandmother wanted to “make sure that he was on the right medication to help him stay focused at school.” By the first quarter interim progress report, he had a failing math grade. This student, who did well in math at his previous school, believed he was “not good at math at this school” and did not see other students ask for special help. Through consistent oversight, a math tutoring program was initiated for him called Reach for the Stars. This allowed the student to meet with his teacher two-three times a week.
      His grandmother brought concerns about behavior changes that she described as her grandson as becoming “nervous” about going to school in the morning and that he did not have any friends. He had difficulty adjusting to this new middle school; most other children had well-established friendships for many years. The grandmother found a local counseling center that offered free services for local children and families. A telehealth appointment was scheduled with a pediatric psychologist and therapist. Weekly sessions were set up for both the student and his grandmother.

      CASE REPORT QUESTIONS

      Child/Family Functioning

      How will the COVID-19 pandemic affect family functioning and CYSHCN?

      Mental Health Consequences

      What are the immediate and longer-term consequences of COVID-19 for mental health outcomes with CYSHCN?

      CASE REPORT DISCUSSION

      Child/Family Functioning

      Multiple factors affecting the child's and family's adequate functioning are directly related to the COVID-19 pandemic, including the recent death of the student's mother. It is difficult to ascertain how much these factors impact an individual or family's overall mental and physical health. From the initial entry into the school, the school nurse established trust and rapport with the grandmother and the student to build communication and provide a solid support system in the new school. The nurturing relationship allowed the student to speak openly with the school nurse about his mental health and academic issues. This well-established relationship between the student, family, and the school nurse fostered continued communication, allowing the child and family to seek out and access appropriate health care services within the community (e.g., pediatric well-care visits, follow-up appointments, telehealth therapy appointments). Working with the student's PCP would be an important step to ensure his medication needs are met not only at the school (e.g., the need for an albuterol inhaler) but also to review with the grandmother and student ways to improve compliance with taking daily ADHD medications is critical.
      However, the child's troubling academic deficiencies (i.e., failing math) needed to be immediately addressed with the schoolteachers and administration. The grandmother wanted to afford him every opportunity to succeed at school—academically, socially, emotionally, and developmentally. Right from the start, the school nurse worked collaboratively with the student, his grandmother, and his teachers to create an “Academic Service Plan” (i.e., modified 504-Plan), which became the number one priority for him to improve his academic ability. Discussing ways to boost his self-confidence and help him adjust to the new school environment remained an essential part of his plan.
      Children with special education needs are at unique risk during the COVID-19 pandemic (
      • Fry-Bowers E.K.
      Children are at risk from COVID-19.
      ). The unprecedented previous disruption in this child's education and subsequent move to remote learning and then transfer to his new school amplified some of his learning difficulties stemming from system inequities and disparities. These risk factors need to be continually revisited and discussed for this student with the entire collaborative school team, as well as his PCP and his mental health therapist. Another significant factor that affected the student was the changes in his family's living situation. Over the past year, he has gone from living with his mother (pre-COVID) and attending a public school to now (during/after COVID) living in a different home with his grandmother as his guardian and grandfather (who is the main provider for the family) and attending a new private school with little or no existing friends in his class. Working out ways to involve the school counselor and other teachers who may encourage him to become involved in any extracurricular activities at his new school would be one way for him to socially engage with others his age. When asked what hobbies or interests he had, the student mentioned he liked to draw and had his comic book characters. Finding ways to encourage positive therapeutic strategies like art would benefit him socially, emotionally, and developmentally.

      Mental Health Consequences

      Working as an experienced school nurse and pediatric nurse practitioner opened my eyes to the acute and chronic health conditions and needs of this particular student and helped me identify any worsening preexisting mental health status, such as ADHD and any learning disabilities. Loss of a parent has been identified as childhood trauma or an adverse childhood experience that unbuffered can be linked to mental health problems, shorter schooling, lower self-esteem, sexual risk behaviors, and increased risk of substance abuse, suicide, violence, sexual abuse, and exploitation (CDC, 2021;
      • Jones C.
      Helping children grieve the loss of a caregiver due to COVID-19.
      ). Adopting a holistic approach, encompassing nonpharmacological supportive therapies, is essential for holistic care. Some children may benefit from evidence-based psychosocial interventions, such as counseling and cognitive behavioral approaches, whereas others may need specialized psychiatric services, including pharmacotherapy (
      • Riddle M.A.
      Pediatric psychopharmacology for primary care.
      ). After talking with the student's grandmother, her comments on how this student was having difficulty processing this student's mother's death prompted me to refer them to a local mental health therapist. His feelings of sadness and loss from his mother's death need to be discussed further with his therapist and within the family unit. The grandmother's response that she acknowledged and identified the need for therapy was encouraging and that he was willing to do the counseling was a positive step in improving the family's mental health status. Her concerns about him feeling “nervous” about coming to school and being self-conscious about his appearance appear to be typical preadolescent behaviors. However, it would be important to be aware of these behaviors and monitor his interactions with other classmates to be sure that these behaviors digress to worsening anxiety or possible depression.
      Long-term issues would be assessed by all those involved in his medical plan of care. Communication is the key to success in assessing this family's overall status. Being in close communication with the grandmother would be beneficial and should be done weekly by phone, email, or in person to ask how things are going for the student and family and to see if they need anything. The National Association of Pediatric Nurse Practitioners (

      National Association of Pediatric Nurse Practitioners (NAP-NAP) & Developmental Behavioral Mental Health Special Interest Group. (2020). NAPNAP revises position statement on integration of mental health care in primary care settings. Retrieved from https://www.napnap.org/napnap-revises-position-statement-on-integration-of-mental-health-care-in-primary-care-settings/.

      ) recently revised guidance for clinicians on integrating mental health in primary care settings.
      • Bartek N.
      • Peck J.L.
      • Garzon D.
      • VanCleve S.
      Addressing the clinical impact of COVID-19 on pediatric mental health.
      recommends “a holistic, family-centered, life span approach is advocated in conjunction with a collaborative model including telehealth, community partnerships between primary and mental health care, and colocation of services” (p. 379).
      The school nurse must be aware of any impacts on what has previously happened to this particular student and look for ways to help encourage communication within the school and collaborative medical team as well as within his family. Using strategies suggested by the , , the school nurse could clarify any questions about the pandemic and would provide proactive ways to manage any previous or present student wories about the COVID-19 pandemic. From my personal experience, middle school students usually have more in-depth questions and concerns than younger schoolaged students. It would be critical for the school nurse to be honest with these students—to provide accurate, factual information about the current status of COVID-19 and the preventive steps to control it and keep people safe. Referring him to appropriate and accurate websites for COVID-19 facts and information, such as the CDC website, would be an excellent teaching tool to use with such students (

      Mingoletti, A. M. (2021, February 21). Emotional Health Challenges of Students during COVID-19 and Beyond. Northeastern University College of Health Sciences Online Program. Retrieved from https://neusha.org/index.php/online-course-overview/?exam_id=1636

      ).

      CONCLUSIONS

      Addressing school health issues is a pivotal role of school nurses caring for children and adolescents in our current ever-evolving COVID-19 world. The pandemic has increased the risk and clinical presentation of mental health issues among CYSHCN, alerting pediatric providers to new social challenges and stress impacts that are felt universally (
      • Bartek N.
      • Peck J.L.
      • Garzon D.
      • VanCleve S.
      Addressing the clinical impact of COVID-19 on pediatric mental health.
      ). Research shows that when students’ mental health needs are properly addressed, the likelihood of school success increases, demonstrating how students overcome these stressful life events. School nurses play a critical role in students’ daily interactions, especially for children who recently lost a caregiver to COVID-19. These positive interactions will have not only an immediate impact but also a long-term impact for years to come. Every day, school nurses promote mental health wellness by recognizing and collaborating with pediatric primary care providers and making timely referrals to behavioral support networks in the community, which can lead to beneficial improvements in the health continuum for children whose lives were permanently changed by the loss of a caregiver from COVID-19.

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