What paediatricians can do to support children and youth during the COVID-19 pandemic

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The COVID-19 pandemic is an unprecedented global crisis affecting millions in Canada and around the world, with impacts reaching far beyond the infection itself. While efforts to limit the spread of infection and “flatten the curve” may spare children and youth from acute illness, these public health measures often accentuate, and may worsen, existing inequities for young people living in difficult circumstances. Paediatricians work with the best interests of patients, their families, and communities always in mind, while shouldering increasingly large burdens themselves. This practice point offers guidance to paediatricians and other health care providers (HCPs) for supporting child and youth health and well-being during the current pandemic, focusing on children and youth at risk and recognizing the challenges faced by child and youth HCPs at this time.

Take a social history for all patients

Taking a comprehensive social history at all patient encounters helps identify cases and conditions where the core social determinants of health are being further impacted by COVID-19. Worsening economic conditions created by the pandemic are increasing risk for, and rates of, child poverty ^[1], food ^[2] and housing insecurity ^[3], parental mental health difficulties, and family violence. Racialized children and youth may experience more discrimination in their day-to-day lives, leading to worsening stress and decreased resilience ^[4]. For all clinical encounters during the pandemic, whether virtual or face-to-face, care providers should inquire about family stressors and coping strategies.

COVID-19 poses a particularly serious health threat in remote Indigenous communities, where insufficient access to clean water and health services are everyday realities, along with housing shortages, food insecurity, and higher rates of chronic illness and communicable disease. Some Indigenous families may avoid accessing health care services, due to lasting impacts of colonization: racism, stigmatization, and discriminatory practices. Children and youth in Northern communities are also disproportionately impacted by limited travel options and self-isolation guidelines when they need to travel for specialty care.

A comprehensive social history should include inquiring specifically about key social determinants, adversity, and resilience factors ^[5], including:

• Barriers to accessing essential health and developmental services, medications, and equipment
• Economic, food, and housing security
• Family functioning (e.g., parental stressors, substance use and misuse, family violence, and other adverse childhood experiences (ACEs) and mental health challenges) ^[5]
• Safety at home and within the community
• Access to social and community services, including disability supports and cultural continuity.

IT HELLPS is a useful mnemonic for taking a complete a social history: Income, Transportation, Housing, Education, Legal status, Literacy, Personal safety, Support ^[6][7]. HCPs may want to ask the following questions, which have been adapted from the Child Poverty toolkit from Health Providers against Poverty ^[8]:

• Income insecurity ^[1]: “Have you had difficulty making ends meet?”
• Access to food ^[2]: “Are you having trouble feeding your family?”
• Access to safe housing ^[3]: “Do you have a safe place to live?”
• Social support ^[9]: “Do you have enough help caring for your child?” ^[5][8]

Essential care also includes being alert for signs of child maltreatment ^[10] or exposure to domestic or family violence. When concerns arise, they must be reported to designated child protection authorities. HCPs should take a focused HEEADSSS history (Home, Education and employment, Eating, Activities, Drugs, Suicidality and Safety) for every adolescent encounter, while ensuring patient confidentiality, particularly during virtual care visits ^[11]. Being familiar with resources to support children and youth who are having trouble coping, including Kids Help Phone, builds patient trust and family-centred relationships. Additional resources for families can be found here.

When needs are identified, quality care involves connecting families with local resources. Because resources vary so much by jurisdiction, HCPs should be aware of and able to provide information for available supports in their communities. Summaries of existing and new federal and provincial benefit programs are available online.

HCPs may need to help some families complete applications for existing programs (e.g., the Disability Tax Credit, Canada Child Benefit) and new pandemic-related provincial and federal programs (e.g., the Canadian Emergency Response Benefit, Ontario Support for Families) in current or subsequent visits, even in acute care settings.

Support access to health care services

The current pandemic has made accessing alternative care and caregivers, as well as essential services (e.g., public transportation), much more difficult, particularly for children with complex care needs. By examining the social context of families, HCPs can improve and facilitate the delivery of family-centred essential and supportive services.

Telephone or virtual visits (e.g., using Zoom or FaceTime) ^[12] can be a lifeline for families who are isolated or transitioning and trying to navigate the changing service landscape, including home visitation programs. For the many families with limited Internet access, telephone visits may be a preferred option. Medical interpreters should be engaged by telephone or video for conversations with families whose proficiency in English or French is limited ^[13].

HCPs should inquire specifically about health insurance coverage and be sure to inform patients about their right to access care. Some jurisdictions (e.g., Ontario and British Columbia) have temporarily rescinded the 3-month wait period for provincial health insurance. Eligible families with limited literacy may need help with their applications ^[14][15]. Children who are covered under the Interim Federal Health Program (IFHP) should receive ongoing care, including virtual assessments.
For Indigenous families, health and wellness practices based in tradition and culture can build resilience. HCPs can apply to Jordan’s Principle and The Inuit Child First Initiative to support the health care needs of First Nations and Inuit children and youth.

Connecting with local community and social services

Through the pandemic and beyond, HCPs can support well-being by advocating for supportive, resource-rich social environments for all children and youth in Canada. The Canadian Paediatric Society is calling on policy-makers to ensure equality of access to housing, food, and health care for Indigenous communities during this difficult period ^[16].

Paediatric care providers can support the families they serve by:

• Supporting community-led initiatives, such as grocery and food drives.
• Advocating local governments to consider rent and mortgage reductions or deferrals.

• Supporting universal access to technologies and the Internet for educational, health-related, and mental health services, including school-based lending programs for laptops and online connection ^[17].

• Ensuring that school-based and other programs bringing nutritious meals to children remain ongoing and fully funded ^[18].
• Collaborating with community services and allied care providers, including teachers and school administrators, social workers, and public health authorities, to support children and youth at risk.
• Facilitating connections with local community and social supports as they adapt to new restrictions on service.

The pandemic is a challenging time for all children and youth, but especially so for those who are socially or economically marginalized. Understanding their social environment and supporting the needs of families in a time of change will foster trust, build relationships, and deepen engagement with the health care system now and for the future.

Acknowledgements

This practice point has been reviewed by the Adolescent Health and Community Paediatrics Committees and the Child and Youth Maltreatment Section Executive of the Canadian Paediatric Society.

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Shazeen Suleman, Yasmine Ratnani, Christine Loock, Katrina Stockley, Susan Bennett, Radha Jetty, Katharine Smart, Sarah Gander; Canadian Paediatric Society, Social Paediatrics Section

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.