Vulnerable pediatric populations (including youth who are lesbian, gay, bisexual, transgender, queer, and/or questioning [LGBTQ]; homeless; maltreated; in foster care; and struggling with substance use disorders) warrant particular consideration during the coronavirus disease of 2019 (COVID-19) pandemic. 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 (and potentially dangerous) 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 678 000 children and adolescents experiencing maltreatment in 2018, and young children are at highest risk for serious harm.1 These risks increase for specific populations. Indeed, LGBTQ and gender nonconforming youth (up to 16% 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 polyvictimization.2,3 Stay-at-home mandates limit exposure to mandated reporters; as a result, the maltreatment that some youth experience may go unrecognized. 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.4–6 This is an astounding proportion of youth who are at risk for serious harm, absent the stresses and instability posed by COVID-19.
Many supports to mitigate resource insecurities and increased health risks for the up to 6% of youth who runaway or experience homelessness per year have been removed because of mandates from the COVID-19 crisis.4 This population is at risk for negative health sequelae. Homeless and runaway youth are more likely to experience poor physical health, substance use disorders, and sexually transmitted infections.4 They are also more likely to be engaged in sex trafficking or survival sex.7 Adolescents with substance use disorders may face barriers to accessing mental health support networks as well as buprenorphine or methadone. 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 the increased risk for maltreatment in the context of economic and material stressors.8 For patients who have known risk factors, it may be important to proactively assess their safety via direct communication or preexisting supports (caseworkers or counselors). In addition, providers should be aware that it is sometimes difficult to ensure privacy with telemedicine practices. For instance, using correct pronouns or names or making reference to patients’ LGBTQ identities may put them at risk for additional harm. It should be ensured that patients have gender-affirming medications because access to appropriate medical care is already limited for transgender individuals. In addition, youth in foster and congregate care (∼440 000 youth in 2018) have complex and specific health care needs that continue to require proactive outreach and regular attention.9 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 social support systems have consistently been important for the mental health of LGBTQ youth, even before the pandemic.10 Indeed, although their access to community resources has been limited, there are many Internet resources available for LGBTQ youth and their families to use. Pediatricians should familiarize themselves with available resources so they can promote them and develop referral processes for specific online resources, including counseling. This should be balanced with the risks of youth victimization associated with unfettered access to Internet media; providers should consider specifically asking all youth about uncomfortable Internet encounters, new relationships, and exposure to pornography.
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. Pediatricians have a role in supporting these policy initiatives. In particular, medical care for these youth could be attended to by several types of providers, depending on existing systems. Pediatricians already providing care to residents of congregate care facilities, existing foster care clinics, or pediatric medical providers engaged in statewide supplemental medical response groups could potentially provide the medical assessments and short-term care for this population. Finally, collaboration with state child welfare agencies, departments of health, and advocacy organizations could increase marketing of these supports on social media. These initiatives would require intensive coordination between multiple parties and should have staff who are trained to proactively support LGBTQ youth, youth with substance use disorders, and other high-risk populations.
COVID-19 has likely increased the already elevated risks for LGBTQ, maltreated, and homeless youth, as well as youth with substance use disorders and youth in foster care, because of a complex combination of potentially negative family interactions, economic uncertainty, the stress and anxiety of living through a pandemic, and more limited access to resources. Increasing education and awareness about this will be an important step in strengthening support systems already in place. Vulnerable youth cannot wait for the COVID-19 pandemic to subside to have their increased risks addressed and their needs for emotional and physical safety met. We should all be ready to assist them.
Dr Silliman Cohen conceptualized the perspective piece, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Bosk drafted the initial manuscript and reviewed and revised the manuscript; and both authors approved the final manuscript as submitted.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.