One of the most critical lessons of the last two years is the importance of in-person school for children and adolescents. Remote learning exacerbated existing educational inequities and was detrimental to the educational attainment of students of all ages and worsened the growing mental health crisis among children and adolescents. The AAP has called for safe in-person learning since its original COVID-19 school guidance released on June 24, 2020. Schools do not significantly increase community transmission, especially when guidance outlined by the World Health Organization (WHO), United Nations Children's Fund (UNICEF), and Centers for Disease Control and Prevention (CDC) is followed.i,ii Transmission of SARS-CoV-2 in schools can still occur. The risk may be greater for individuals and families who have chosen not to be vaccinated or are not eligible to be vaccinated. However, schools and school-supported programs are fundamental to child and adolescent development and well-being. Schools provide our children and adolescents with academic instruction; social and emotional skills, safety, reliable nutrition, physical/occupational/speech therapy, mental health services, health services, oral health care and opportunities for physical activity, among other benefits.iii Families rely on schools to provide a safe, stimulating and enriching space for children to learn; appropriate supervision of children; opportunities for socialization; and universal support to cope with crisis and loss associated with the pandemic.
In Order to Keep Children and Adolescents in School the Following Must Happen:
All federal, state and local policies must prioritize children and schools
- Schools need adequate federal, state and local funding and resources so they can continue to implement all the COVID-19 mitigation and safety measures required to protect students and staff.
- Temporary school closures may occur due to a school outbreak or community surge in COVID-19. (Children cannot learn effectively if there are not enough healthy adults in the building to adequately supervise and teach them.) Such closures should be as brief as possible, and funding to support virtual learning and provide needed resources should continue to be available for communities, schools and children facing limitations implementing these learning modalities in their home (ie, socioeconomic disadvantages). School district should stay in communication with local health agencies and testing sites to coordinate and streamline responses if possible.
- School staff, teachers and administrators should be supported as they continue to navigate in person learning during the pandemic. They have had to work through new guidelines from various sources, funding issues, COVID-testing availability, school board changes and public backlash in order to provide our children and adolescents with the educational and socio-emotional support they need to learn and thrive.
- School leaders should recognize that staff, in addition to students and families, will benefit from sufficient time to understand and adjust to changes in routine and practices. This can be difficult when rapid changes are happening during the pandemic and the public health response continues to evolve. However, during a crisis, people benefit from clear and regular communication from a trusted source of information and the opportunity to dialogue about concerns and needs and feel they are able to contribute in some way to the decision-making process. Change is more difficult in the context of crisis and when predictability is already severely compromised.
School policies should follow mitigation measure strategies in order to not spread the virus
- The AAP recommends COVID-19 vaccination for all children and adolescents 5 years of age and older who do not have contraindications using a COVID-19 vaccine authorized for use for their age. Teachers and staff should also be vaccinated against COVID-19 as per CDC guidelines. Vaccination of all eligible individuals in schools is the single best strategy to protect students and staff from severe disease, hospitalization and death and to maintain in-person learning.
- Stay home when sick, with new symptoms, and isolate.
- Get tested if possible, following CDC guidelines. This will require providing adequate testing of students, teachers and staff.
- Wear well-fitting masks, especially during times of high community prevalence.
- In-school transmission has been observed more often in school districts that did not enact mask requirements. iv,v,
- All students older than 2 years and all school staff should wear well-fitting face masks at school (unless medical or developmental conditions prohibit use), regardless of vaccination status. The AAP currently recommends universal masking in school, with an emphasis on indoor masking.
- An added benefit of universal masking is protection of students and staff against other respiratory illnesses that would take time away from school.
- Improve ventilation in school buildings.vi
- Ventilation helps reduce exposure to SARS-CoV-2 as it helps dilute the viral load by reducing virus-containing aerosols in the air. vii The allocation of funds by the Department of Education to facilitate resources to improve ventilation in US schools acknowledges the importance of proper ventilation in preventing the spread of COVID-19.
- Besides increasing the flow of clean outdoor air when conditions permit, other simple measures to improve ventilation, such as properly placed fans, use of portable HEPA units (properly sized for the room) or creation of directional airflow, can help improve the indoor air quality. viii ix
- Certain previous sought-after strategies are not recommended. (ie, the use of ozone-generating devices, the use of plastic or plexiglass dividers or desk shields). These are not helpful in reducing spread and may serve as fomites.
- Use outside spaces and/or spread students out, especially during times where masks may be down such as lunch (if climate and space permit).
- Provide adequate and consistent opportunities for hand washing and appropriate school cleaning techniques.
School policies should protect the students, school staff and teachers using science as a guide
- COVID-19 vaccination and boosters as recommended by the CDC. Vaccination has proven to lessen transmission as well as severity of disease including death. Adequate and timely COVID-19 vaccination resources for the whole school community must be available and accessible.
- Ensure that school administration and medical staff (ie, school RNs and nurse aides) are given ample training and funding to better understand the latest recommendations around mitigation, testing and therapeutics.
- School nurses and school health personnel should not be the default to provide school-based COVID-19 testing (particularly routine asymptomatic testing) or contact tracing. School nurses and other school health services staff are responsible for the direct care of acutely ill and injured students, safety planning for students with chronic and life-threatening conditions, medication administration and skilled nursing services, screening, implementation of school wellness plans and many more critical functions that must continue. These functions cannot be conducted safely if testing and contact tracing are added to their scope of work, especially with limited staffing and underfunding of school health prior to the pandemic. If nurses are required to conduct testing in their schools, resources must be made available to provide additional support.
- School districts must be in close communication and coordinate with state and/or local public health authorities, school nurses, local pediatric practitioners and other medical experts including widely sharing district COVID-19 related policies.
- The AAP strongly recommends that school districts promote racial/ethnic and social justice by promoting the well-being of all children in any school COVID-19 plan, with a specific focus on ensuring equitable access to educational support for children living in under-resourced communities.
- Schools can play a critical role in addressing racial and social inequity.
- Schools should monitor the attendance of all students daily inclusive of in-person and virtual settings. Schools should use multi-tiered strategies to proactively support attendance for all students, as well as differentiated strategies to identify and support those at higher risk for absenteeism.
- Special considerations and accommodations to account for the diversity of youth should be made, especially for populations facing inequities, including those who are medically fragile or complex, have developmental challenges or have disabilities. Children and adolescents who need customized considerations should not be automatically excluded from school unless required in order to adhere to local public health requirements or because their unique medical needs would put them at increased risk for contracting COVID-19 during current conditions in their community.
- School policies should be guided by supporting the overall health and well-being of all children, adolescents, their families and their communities and in addition to creating safe working environments for educators and school staff. This focus on overall health and well-being includes addressing the behavioral/mental health needs of students and staff.
- These policies should be consistently communicated in languages other than English, when needed, based on the languages spoken in the community, to avoid marginalization of parents/guardians of limited English proficiency or who do not speak English.
January 14, 2022 Current State Update
The AAP agrees with the CDC’s current revision of isolation standards. But, with the current variant and high community transmission rates, the AAP recommends the following as practical strategies to keep children in school during this current stage recognizing the need to ease burden to school staff and families.
- The AAP recommends COVID-19 vaccination for all children and adolescents 5 years of age and older who do not have contraindications using a COVID-19 vaccine authorized for use for their age.
- Universal masking
- Continue to modify mealtime school spaces to reduce the risk of spreading COVID-19, especially during periods of high transmission. Face masks should be worn during mealtimes except when eating.
- Reinforce quick identification of COVID-like symptoms and isolation for 5 days (per CDC). In these circumstances testing can be offered through schools or the medical home. In the absence of tests, isolate for 5 days and then return (on day 6) with proper and consistent use of face masks for an additional 5 days.
- With the federal provision of tests to schools, see CDC guidance for practical use of these tests.
Visit the CDC COVID-19 Prevention Strategies for additional information on mitigation measures including physical distancing, symptomatic and asymptomatic testing, contact tracing, quarantining, isolation (calculating quarantine & isolation), ventilation and cleaning and disinfecting.
General Principles for School Recovery
In the following sections, some general principles regarding school recovery are reviewed that policy makers and school administrators should consider as they plan for in-person school as well as for before- and after-school programs. Several other documents produced by the CDC, the US Department of Education, the National Association of School Nurses, the National Academy of Sciences, Engineering, and Medicine can be referenced as well. For all of these, engagement of the entire school community, including families, teachers and staff, regarding these measures should be a priority.
Special considerations for school health during the COVID-19 pandemic
School Attendance and Absenteeism
The best way to reduce absenteeism is by closely monitoring attendance and acting quickly once a pattern is noticed. During the 2021-22 school year, daily school attendance should be monitored for all students, including students participating in in-person and distance learning. Schools should use multi-tiered strategies to proactively support student attendance for all students. Additionally, schools should implement strategies to identify and differentiate interventions to support those at higher risk for absenteeism. Local data should be used to define priority groups whose attendance has been most deeply impacted during the pandemic. Schools are encouraged to create an attendance action plan with a central emphasis on family engagement throughout the school year.
In an evaluation of Connecticut's attendance data from school year 2020-21, rates of chronic absenteeism were highest among predominantly remote students compared with students who were primarily in person; that gap was most pronounced among elementary and middle school students. Chronic absence was more prevalent among Connecticut students who received free or reduced-price lunch, were Black or Hispanic, were male or identified as English learners or having disabilities. x 29 National pre-pandemic chronic absenteeism data mirror several of these demographic trends. xi
Students with Disabilities
The impact of loss of instructional time and related services, including health services, as well as occupational, physical and speech/language therapy during the period of school closures and remote learning is significant for students with disabilities. All students, but especially those with disabilities, may have more difficulty with the social and emotional aspects of transitioning out of and back into the school setting because of the pandemic. As schools continue in-person learning with bouts of remote learning (as needed because of staffing shortages, etc), school personnel should plan to ensure a review of each child and adolescent with an IEP to determine the current needs of each student, as well as the needs for compensatory education and services to adjust for lost instructional time and disruption in other related services. There is a continued need to advocate for adequate funding to support these services. Many school districts require adequate instructional effort before determining eligibility for special education services. However, virtual instruction or lack of instruction should not be reasons to avoid starting services such as response-to-intervention (RTI) services, even if a final eligibility determination is delayed.
Each student’s IEP should be reviewed with the parent/guardian/adolescent yearly (or more frequently if indicated). All recommendations in the IEP should be provided for the individual child no matter which school option is chosen (in person, blended or remote). See the AAP Caring for Children and Youth with Special Health Care Needs During the COVID-19 Pandemic for more details.
Additional COVID-19 safety measures for teachers and staff working with some students with disabilities may need to be in place to ensure optimal safety for all. For certain populations, the use of face masks by teachers may impede the education process. These include students who are deaf or hard of hearing, students receiving speech/language services, young students in early education programs and English language learners. There are products (ie, face coverings with clear panels in the front) that may be helpful to use in this setting. Adjustments to the nursing care plans for students may also be required to optimize safety of the students as well as staff caring for the students. These adjustments may include clear plans for suctioning, tube feedings and toileting.
Adult Staff and Educators
Universal use of well-fitting face masks should be required of all staff, including staff and educators who are up to date on their COVID-19 vaccination. School staff working with students who are unable to wear a face mask or who are unable to manage secretions, who require high-touch (hand over hand) instruction and who must be in close proximity to these students should consider wearing an N95 or KN95 mask and eye protection. All staff and educators should have access to appropriate testing in order to ensure adequate staffing for in-person learning.
School health staff should be provided with appropriate medical PPE to use in health suites. This PPE should include N95 masks, surgical masks, gloves, disposable gowns and face shields or other eye protection. School health staff should be aware of CDC guidance on infection control measures.
On-site School-Based Health Services
On-site school health services, including school-based health centers, should be supported if available, to complement the pediatric medical home and to provide pediatric acute, chronic, preventive and behavioral health care. Collaboration with school nurses is essential, and school districts should involve school health services staff and consider collaborative strategies that address and prioritize immunizations and other needed health services for students, including behavioral health, vision screening, hearing, dental and reproductive health services. Plans should include required outreach to connect students to on-site services regardless of remote or in-person learning mode. School-based health centers (SBHCs) may want to serve as COVID-19 immunization sites for students and staff at their schools and in the surrounding communities. Public health agencies can provide support and technical assistance for SBHCs to assist them in establishing immunization clinics for all vaccines including COVID-19.
Pediatricians should work with schools and local public health authorities to promote childhood vaccination messaging throughout the school year. It is vital that all children receive recommended vaccinations on time and get caught up if they are behind as a result of the pandemic. The capacity of the health care system to support increased demand for vaccinations should be addressed through a multifaceted, collaborative and coordinated approach among all child-serving agencies including schools.
Existing school immunization requirements should be discussed with the student and parent community and maintained. In addition, although influenza vaccination is generally not required for school attendance, it should be highly encouraged for all students and staff. The symptoms of influenza and SARS-CoV-2 infection are similar and taking steps to prevent influenza will decrease the incidence of disease in schools and the related lost educational time and resources needed to handle such situations by school personnel and families. School districts may consider requiring influenza vaccination for all staff members.
Schools should collaborate with state and local public health agencies to ensure that teachers and staff have access to the COVID-19 vaccine, and that any hesitancy is addressed as recommended by the Advisory Committee on Immunization Practices (ACIP) of the CDC. Pediatricians should work with families, schools and public health authorities to promote receipt of the COVID-19 vaccine and address hesitancy as the vaccine becomes available to children and adolescents.
In order to vaccinate as many school staff, students and community members as possible, school-located vaccination clinics (partnered or through SBHCs) should be a priority for school districts. Schools are important parts of neighborhoods and communities and serve as locations for community members after school hours and on weekends. These clinics should be conducted in collaboration with students’ medical homes.
Vision screening practices should continue in school whenever possible. Vision screening serves to identify children who may otherwise have no outward symptoms of blurred vision or subtle ocular abnormalities that, if untreated, may lead to permanent vision loss or impaired academic performance in school. Furthermore, there is some evidence that myopia has increased among children during the pandemic . xii,xiii Personal prevention practices and environmental cleaning and disinfection are important principles to follow during vision screening, along with any additional guidelines from local health authorities.
Safe hearing screening practices should continue in schools whenever possible. School screening programs for hearing are critical in identifying children who have hearing loss as soon as possible so that reversible causes can be treated and hearing restored. Children with permanent or progressive hearing loss will be habilitated with hearing aids to prevent impaired academic performance in the future. Personal prevention practices and environmental cleaning and disinfection are important principles to follow during hearing screening, along with any additional guidelines from local health authorities.
Oral health programs should continue in schools whenever possible. During the COVID-19 pandemic, risk factors for dental decay increased as access to dental services declined dramatically. School-based oral health programs are designed to address barriers to access for children at high risk to prevent dental decay and improve overall health and academic success. Using a preventive frame, these programs can provide oral health education, promotion of healthy school nutrition, oral health screening and dental sealants in school buildings through drop-in services, including mobile vans operating on school grounds, through SBHCs and/or in the community but school linked.,xiv, School districts and school-based oral health providers should collaborate with state and local public health agencies to promote the safe continuation or restart of school-based oral health programs. School-based programs should ensure adherence to CDC guidance for the operation of dental facilities and school sealant programs during the COVID-19 pandemic.
Children with Chronic Illness
Certain children with chronic illness may be at risk for hospitalization and complications with SARS-CoV-2. These youth and their families should work closely with their pediatrician and school staff using a shared decision-making approach regarding options for return to school, whether in person, blended, home schooling or remote. See the AAP Caring for Children and Youth with Special Health Care Needs During the COVID-19 Pandemic for more details.
Behavioral Health/Emotional Support for Children and Adolescents
The COVID-19 pandemic has created profound challenges for communities, families and individuals, leading to a range of emotional and behavioral responses. There are many factors unique to this pandemic (ie, grief/loss, uncertainty, rapidly changing and conflicting messages, duration of the crisis and need for quarantine) that increase its effects on emotional and behavioral health (EBH). Populations with a higher baseline risk, such as historically under-resourced communities, children and youth with developmental disabilities and other special health care needs and children with pre-existing depression, anxiety and other mental health conditions, may be especially vulnerable to these effects., The impact of the pandemic is also compounded by isolation and an interruption in the support systems families utilize.
Schools are a vital resource to continue to address and provide resources for a wide range of mental health needs of children and staff. The emotional impact of the pandemic, grief because of loss, financial/employment concerns, social isolation and growing concerns about systemic racial inequity—coupled with prolonged limited access to critical school-based mental health services and the universal support and assistance of school professionals—demand careful attention and supports in place during all modes of learning, whether remote or in person. Schools should be prepared to adopt an approach for mental health support, and just like other areas, supporting mental health will require additional funding to ensure adequate staffing and training to address the needs of the students and staff in the schools.
Schools should consider providing training to classroom teachers and other educators on how to talk to and support children during and after the COVID-19 pandemic including how to support grief and loss among students. The United States has already accumulated more than 850,000 deaths from COVID-19; on average, it is estimated that each of these deaths impacts 9 people – many of these 7.5 million grieving individuals are children. Bereavement has a significant impact on the short- and long-term adjustment of children, their developmental trajectory, academic learning, psychosocial functioning and emotional adjustment and behavior. Students experiencing significant personal losses can be referred to school and community-based bereavement support programs, centers and camps, as well as to their pediatrician or other pediatric health care provider. Students with additional mental health concerns should be referred to school mental health professionals.
Suicide is the second leading cause of death among adolescents or youth 10 to 24 years of age in the United States. Schools should develop mechanisms to evaluate all students, whether or not they are attending in-person class, whenever concerns about a risk of suicide are voiced by educators or family members. Schools should also establish policies, including referral mechanisms for students believed to be in need of in-person evaluation, even before they resume in-person instruction.
School mental health professionals should be involved in shaping messages to students and families about the response to the pandemic and the changing school learning plans based on a variety of community SARS-CoV-2 factors. Communicating effectively is especially critical, given potential adaptations in plans for in-person or distance learning that need to occur during the school year because of changes in community transmission of SARS-CoV-2.
Schools need to incorporate academic accommodations and support for all students who may still be having difficulty concentrating or learning new information because of stress or family situations that are compounded by the pandemic. It is important that school personnel do not anticipate or attempt to catch up for lost academic time through accelerating curriculum delivery at a time when students and educators may find it difficult to even return to baseline rates. These expectations should be communicated to educators, students, and family members so that school does not become a source of further distress.
Mental Health of Staff
The personal impact on educators and other school staff should be recognized. In the same way that students need ongoing support to process the information they are being taught, educators cannot be expected to be successful at teaching and supporting children without having their mental health needs supported. The strain on educators, as they have been asked to teach differently while they support their own needs and those of their families, has been significant. Additional challenges with staff shortages, illness and safety fears for themselves and their families, changing learning modalities and prolonged duration of the crisis are continuing to present additional challenges and further impact teachers and school staff. Resources such as Employee Assistance Programs and other means to provide support and mental health services should be prioritized. The individual needs and concerns of school professionals should be addressed with accommodations made as needed.
According to the United States Department of Agriculture, in 2020, 38.3 million people, including 12 million children, lived in a household with food insecurity. We also know that disparities with food insecurity exist, with Black and Latinx adults being twice as likely as white adults to report their households did not get enough to eat.34 School planning must consider the many children and adolescents who experience food insecurity already (especially at-risk populations and those living in poverty) and those who will have limited access to routine meals through the school district in the event of school closure or if a child is ill. The short- and long-term effects of food insecurity in children and adolescents are profound. Schools can partner with community resources including federal and state food programs to mitigate the effects of food insecurity on children and families. More information about how families can access federal nutrition programs can be found in the AAP/FRAC Food Insecurity Toolkit.
Like food insecurity, housing insecurity is a significant and sometimes overlooked issue that affects many families and will impact children's ability to return and re-engage with school. With pandemic-associated job losses, there have been significant numbers of families with children who have been evicted or will soon be evicted from their homes. According to the US Census Bureau data, as of September 2021, 11.9 million adults living in rental housing are not caught up on rent; the percentage is higher for Black, Latinx and Asian renters compared with white renters. For renters with children, 1 in 5 is not caught up with last month’s rent. Housing insecurity impacts a child's education directly through missed school days and through transferring to a new school, which is associated with a 4 times higher risk of chronic absenteeism, lower grades and test scores and increased risk of dropping out of school. Housing insecurity also impacts education indirectly by impacting a child's overall physical and mental health, which can have negative consequences for educational achievement. Children who experience homelessness are at increased risk for malnutrition, asthma, obesity, and dental, vision, emotional, behavioral and developmental problems. In addition, the increased toxic stress children experience when they live in unstable housing situations can contribute to anxiety and other mental health conditions that interfere with a child's education. The interconnectedness of employment, housing, health and education and the disproportionate impact this has had on communities of color because of structural racism must be considered as children return to school. Schools are encouraged to partner with community agencies to address the effects of housing insecurity and mitigate the impact this will have on the education of children.
The digital divide has been a known disparity for decades, contributing to the “homework gap”—the gap between school-aged children who have access to high-speed internet and adequate devices at home and those who do not. According to a Pew research study in 2015, 35% of lower-income households with school-aged children did not have a broadband internet connection at home. According to the Pew Research Center, 1 in 5 teenagers are not able to complete schoolwork at home because of a lack of a computer or internet connection. This technological homework gap disproportionately affects Black families living in poverty.9 With the transition to virtual learning during the pandemic, this divide was highlighted as families struggled to adapt to school from home. In April 2020, 59% of parents with lower incomes who had children in schools that were remote because of the pandemic said their children would likely face at least 1 of 3 digital obstacles to their schooling, such as a lack of reliable internet at home, no computer at home or needing to use a smartphone to complete schoolwork. Gains have been made over this past year with creative local and state solutions working toward providing improved access to both technology devices and internet connections for students, but a significant gap still exists, particularly for students living in poverty or in temporary housing. This digital divide is a critical component to be addressed in schools even as children return to in-person learning as they navigate the increasing digital learning environment, academic recovery and extended home learning materials. Access to both reliable high-speed internet and adequate devices beyond a smart phone are critical to promote equity and support academic success. Long-term sustainable funding is needed to support school districts in providing universal internet access and technology for all students; this should remain a priority after the pandemic.
The AAP Interim Guidance on Return to Sports helps pediatricians inform families on how best to ensure safety during sports and physical activity participation. Preparticipation evaluations should be conducted in alignment with the AAP Preparticipation Physical Evaluation Monograph, 5th ed, and state and local guidance, with particular attention to considerations for students who have a history of COVID-19. In addition, the CDC provides recommendations on screening and testing of students and adults participating in school sports and other extracurricular activities based on the activity’s risk for COVID transmission and the level of community transmission.
- AAP HealthyChildren.org: Staying Safe in School During COVID-19
- Guidance for COVID-19 Prevention in K-12 Schools (CDC)
- COVID-19 Resources for Schools, Students, and Families (US Dept of Education)
- COVID-19 Testing in Schools (National Education Association)
- Using Social Stories to Support People with I/DD During the COVID-19 Emergency
- Social Stories for Young and Old on COVID-19
Interim Guidance Disclaimer: The COVID-19 clinical interim guidance provided here has been updated based on current evidence and information available at the time of publishing. Guidance will be regularly reviewed with regards to the evolving nature of the pandemic and emerging evidence. All interim guidance will be presumed to expire on June 30, 2022 unless otherwise specified.
American Academy of Pediatrics