Fayaz Ahmad Paul
Vulnerable pediatric populations including youth who are lesbian, gay, bisexual, transgender, homeless, maltreated; and struggling with substance use disorders warrant particular consideration during the coronavirus. It is likely that stay-at-home orders, combined with increased economic instability and family pressures, will increase their risks for harm and, in some cases, may make it untenable for them to shelter in place. Simultaneously, safety nets that protect youth (child protective services, medical and mental health providers, and educators) have fewer staff available or are inaccessible because of the COVID-19 crisis. These conditions highlight how morbidity and mortality in vulnerable pediatric populations will likely extend beyond the pandemic itself.
For some children and youth, home can be isolating and, in some cases, dangerous. Adverse childhood experiences, including physical abuse, sexual abuse, and neglect, are common, with an estimated 7 lakh children and adolescents experiencing maltreatment in 2018, and young children are at highest risk for serious harm. These risks increase for specific populations. Indeed, LGBTQ and gender non-conforming youth (up to 16 per cent of all youth) are at far higher risk of experiencing physical and sexual abuse, with the level of gender nonconformity predictive of increased risk for polyvictimisation. Stay-at-home mandates limit exposure to mandated reporters; as a result, the maltreatment that some youth experience may go unrecognised. Risks for harm of vulnerable youth extend beyond physical safety. LGBTQ, maltreated, runaway, and homeless youth are at a disproportionately high risk for depression, suicidal ideation and suicide, and self-harming behaviors, with rates of attempted suicide 2 to 10 times those of peers. This is an astounding proportion of youth who are at risk for serious harm, absent the stresses and instability posed by COVID-19.
Homeless and runaway youth are more likely to experience poor physical health, substance use disorders, and sexually transmitted infections. They are also more likely to be engaged in sex trafficking or survival sex. Adolescents with substance use disorders may face barriers to access mental health support networks. They may be more likely to go through withdrawal or engage in risky behaviors to obtain substances. The morbidities associated with both homelessness and substance use disorders may put youth at increased risk for infection with COVID-19, which is compounded by the fact that they may also be less likely to access coronavirus testing and treatment.
With the challenges that COVID-19 poses to the health and safety of vulnerable youth, there is an immediate need to mitigate these impacts. Pediatric medical providers, in particular, have an important role to play in both bringing attention to the needs of special populations likely disproportionately impacted by COVID-19 and setting up alternate care. Specifically, there are several things medical providers, in partnership with child welfare agencies and advocacy agencies, can do right now.
During regular telemedicine appointments with LGBTQ youth, youth with substance use disorders, youth in foster care, and those at risk for maltreatment, providers should routinely ask about how things are going at home. Asking youth about exposure to abuse, household violence, resource instability, and mental health during medical evaluations of any format is of paramount importance. Providers should be attuned to increased risk for maltreatment in the context of economic and material stressors. For patients who have known risk-factors, it may be important to proactively assess their safety via direct communication or preexisting supports via psychiatric social workers, clinical psychologists, caseworkers or counselors. In addition, providers should be aware that it is sometimes difficult to ensure privacy with telemedicine practices. Youth with substance use disorders should be ensured continued access to medication-assisted treatment as well as telecounseling resources to manage issues related to relapse and withdrawal.
Online support systems have consistently been important for mental health of LGBTQ youth, even before the pandemic. Indeed, although their access to community resources has been limited, there are many Internet resources available for LGBTQ youth and their families to use.
For homeless youth and youth facing barriers to enter into foster care, policy makers and child protective services agencies should focus on creating special shelters and housing units, potentially using hotels or empty dorm rooms in partnership with universities or corporations, so that youth can be isolated and/or quarantined for appropriate time periods before entering other forms of care.
Universal testing for COVID-19 should be made available for these placements to ensure safety. Finally, collaboration with state child welfare agencies, departments of health, and advocacy organizations could increase marketing of these supports on social media.