The three guiding values of child welfare services are safety, permanency, and well-being. Maintaining child safety is essential, and even the circumstances of a pandemic should not undermine the vital work of supporting permanency and well-being for children and their families. The initial guidance from the American Academy of Pediatrics (AAP) addressed urgent questions around visitation, which was subsequently updated to acknowledge that the child welfare system is an essential service to our society, requiring treatment and permanency planning to continue existing standards and timelines, to ensure the ongoing promotion of development, attachment, and well-being for children and adolescents. Later updates provided new guidance on COVID-19 vaccination. Updated vaccination information and guidance on return to in-person school for children and youth involved in the child welfare system are now being provided.

Child welfare systems have the capacity to innovate during crises, and the challenges of the ongoing COVID-19 pandemic offer an opportunity to develop new ways to support families. The expansion of telehealth has helped facilitate visits that were often hindered by travel and difficulties with coordination of visits. Child welfare professionals have worked across disciplines in new and effective ways. Implementation of the Family First Prevention Services Act and expanded prevention efforts can help keep families safely together.

An example of innovations spurred by the current pandemic included the Supporting Foster Youth and Families through the Pandemic Act (H.R. 7947), which was part of the 2020 Coronavirus Response and Relief Supplemental Appropriations Act. The legislation included critical supports for older youth transitioning out of foster care, placed a moratorium on young people aging out of foster care, and allowed foster youth to re-enter care during the public health emergency. This legislation expanded access to Family First services by waiving the requirement for IV-E state matching funds for services until the end of the pandemic while providing emergency funds to support family preservation, reunification, adoption, and home visitation programs. It also strengthened Kinship Navigator Programs to help reach more kinship caregivers raising children, especially those who are older and more susceptible to the virus by waiving evidence-based requirements tied to Title IV-E reimbursement. Finally, this new law provided additional funding for the Court Improvement Program to allow family courts to operate safely and remotely during the pandemic, however, the policies in the Supporting Foster Youth and Families through the Pandemic Act ended on October 1, 2021.

Additionally, the Coronavirus Response and Relief Supplemental Appropriations Act included the Fostering Stable Housing Opportunities Act, which will prioritize housing assistance for youth aging out of foster care between 18 and 24 years of age who are at risk of experiencing housing insecurity by allowing them to apply for housing assistance prior to aging out of care and giving them top priority for receiving housing assistance through the Family Unification Program. These innovations testify to the need for child welfare services to be considered essential services that must continue despite the challenges of the pandemic and offer an ongoing opportunity to further support critical policies to help children and families.

Children in foster care and their families have experienced being “distanced” from each other even before the COVID-19 pandemic began. Feelings of isolation and loneliness during the current crisis can compound the uncertainty and change that may have occurred both before and during foster care placement. Perhaps most importantly, the pandemic has increased awareness of underlying racial and socioeconomic disparities that continue to affect children in foster care. Racial and ethnic inequities that result in Black, Indigenous, and Hispanic/Latino families’ disproportionate involvement in the child welfare system can be addressed by providing families access to needed services that prevent unnecessary foster care and child welfare involvement, in addition to all sectors of the child welfare system identifying and eradicating systemic and institutional practices and policies that further racial inequities and disparities.

The educational system has experienced and continues to experience ongoing disruptions because of the pandemic. Children and youth involved with the child welfare system already experience more disruptions in their education than other students, and the pandemic exacerbates these disruptions. The AAP Interim Guidance for Safe Schools provides strategies for schools and communities to meet both the educational and safety needs of children and youth. Child welfare, educational, and pediatric professionals should work together to ensure that the unique needs of children involved with the child welfare system are addressed as a part of the larger efforts around education.

We know from past crises such as Hurricane Katrina that the effects of disasters may not manifest until well after the event and can persist for years. In addition to all of the other challenges of the pandemic, many children have experienced the death of a parent or primary caregiver from COVID-19. Pediatricians must be ready to help children work through their grief in the months and years ahead while remembering that children are resilient and strong and that we can help support those strengths. Pediatricians stand ready to work alongside child welfare professionals to support their critical work devising optimal ways to serve children and families during the pandemic and beyond.

During crises such as the current pandemic, the protection of family integrity for children and families involved in the child welfare system remains extremely important. The AAP affirms that a stable home and caregiver are important to nurturing a child’s development and preventing trauma that can affect a child across the lifespan. This guidance is designed to support the continuation and improvement of that critical work so that all children and families may flourish.

Statement of Purpose

  • The child welfare system is an essential service that should be prioritized in the same way as services such as health care during the pandemic. The early years of brain development have profound impacts on child development, mental health, and lifelong well-being. This requires all members of the child welfare and family court systems to continue to provide timely care and services to children and adolescents with the goal of permanency.
  • For children in the child welfare system, continued family support and visitation with parents and siblings is critical to promote well-being, secure attachments, and successful timely reunification and permanency. Courts and child welfare systems must continue to find ways to provide services for children even—and especially—during the pandemic.
  • Child welfare and health professionals need to work together to ensure that children’s connections to their families remain strong while at the same time working to reduce the risks presented by COVID-19.
  • Given that Black, Indigenous, and Hispanic/Latino children are overrepresented in the child welfare system, clear formal guidance should serve to reduce inequities and promote decisions that support family connections and permanency for all children regardless of race or ethnicity.
  • Kinship care retains children’s critical familial and cultural ties. Although older relative caregivers may face unique risks from COVID-19, child welfare practices should continue to prioritize kinship care whenever possible.
  • Disparities among populations that are overrepresented in the child welfare system have become more apparent during the pandemic, with growing concerns around lack of access to technology and school supports. Although most schools have returned to in-person learning, there are likely to still be times when learning may occur in a virtual format. Child welfare professionals can help ensure that all children have the supports needed to be successful, including supporting kinship caregivers who may be challenged with helping children access and continue in virtual school classes.
  • The AAP continues to reiterate that children belong in families. Placements in nonfamily settings, such as residential treatment, congregate care, or detention facilities, should be a last and temporary resort when a family setting is not able to meet treatment needs.
  • Adolescents and young adults transitioning out of foster care require additional support to cope with the social isolation and loss of school and employment routines caused by the pandemic. See the AAP Interim Guidance on Supporting the Emotional and Behavioral Health Needs of Children, Adolescents, and Families During the COVID-19 Pandemic.

Visitation Principles

  • Whenever possible, in-person visitation is preferable—both for family visitations and for visits between child welfare professionals and children.
  • Agencies should prioritize obtaining regular feedback from birth families and caregivers regarding visitations so that adjustments can be made to best promote connection and secure attachment between the child and family members.
  • A combination of in-person and virtual visits can be considered to increase the frequency of parent-child and sibling interactions. It may be especially useful to use virtual visits to prepare a child for an in-person visit (for example, a parent’s appearance may have changed, helping children become familiar with wearing masks, and discussion of what to do for fun at the visit), to follow-up on an in-person visit (address sadness or acting-out behaviors), or as a substitute for a planned in-person visit if it must be postponed because of COVID-19 risks.
  • Everyone involved in the visits should adhere to the same guidelines to reduce the risk of COVID-19 infection.

Visitation Guidance

  • Now that there are safe and highly effective COVID-19 vaccines available for children and adolescents 5 years and older, visitation can be much safer and less stressful for everybody. The AAP strongly encourages everyone who is eligible to receive a COVID-19 vaccine as soon as possible. Child welfare agencies can assist by ensuring that all eligible children in their custody have access to the vaccine. Child welfare agencies should provide accurate and timely information and care to parents and foster families.
  • The CDC continues to update guidance about activities when all parties have been vaccinated. Because children younger than 5 years cannot yet be vaccinated, and since most visits will involve people from multiple households, caution should still be taken to avoid crowded closed spaces and sharing of food or drinks.
  • Everyone (child, caregiver and household members, birth family, and child welfare professionals) should be screened for COVID-19 exposure or symptoms the day before the planned in-person visit. A nonurgent in-person visit should not take place if anyone involved answers “yes” to these screening questions:
    • Are you COVID-19 positive or have you been exposed to someone with COVID-19 in the past 14 days?
    • Do you have any of the following symptoms of COVID-19: fever (100.4°F or higher) or chills, fatigue, nasal congestion, cough, shortness of breath, sore throat, muscle aches, headache, loss of taste or smell, vomiting, or diarrhea?
    • Are you, or is someone you have been with in the last 3 days, awaiting the results of a COVID-19 test?
  • Although not an absolute contraindication, consideration should be given to avoiding in-person visits with unvaccinated individuals considered by the Centers for Disease Control and Prevention (CDC) to be high-risk, including those 65 years of age or older or people who are immune-suppressed or have certain chronic illnesses. Children with medically complex conditions, (eg, children who have neurologic, developmental, genetic, or metabolic conditions and children who have congenital heart disease) are at higher risk for severe illness than other children (visit the CDC website for a full list). Extra precautions such as meeting outdoors or in large, well-ventilated indoor spaces, and even more stringent attention to physical distancing, use of cloth face masks, and sanitizing should be taken when such individuals are involved. More frequent virtual visits in these circumstances may also be a good option.
  • All vehicles used to transport children should be cleaned before and after a visit (see AAP guidance for more information). Children should sit in the back seat with ideally no more than 2 children in a vehicle. Keep windows open as appropriate.
  • Given the small possibility of the COVID-19 delta variant being transmitted by vaccinated children and adults, the best location for a visit continues to be outside whenever possible.
  • When a visit is held indoors, all surfaces (handles, doorknobs, toys, electronics, etc) should be thoroughly cleaned before and after the visit.
  • Unless all participants in the visit are fully vaccinated, everyone should still wear cloth or disposable face masks, except for children <2 years old. Masks should be worn by all individuals, including those who are vaccinated, when in an area of substantial or high transmission. Regional transmission rates can be determined in real-time using the CDC’s county-level COVID data tracker. The AAP recommends universal masking in schools.
    • In very rare cases, a child may not be able to wear a cloth or disposable face mask. Visits should not be canceled because of the inability to wear a cloth face mask (for more information on cloth or disposable face masks, visit healthychildren.org).
  • Hand hygiene should be implemented for every participant frequently before, during, and after the visit, using soap and water or hand sanitizer.
    • Gloves are not required except for when changing diapers. Gloves should be discarded and hands washed in soap and water or hand sanitizer once the diaper change is completed.
    • Gowns and goggles are not necessary in this setting.
  • Although physical distancing is strongly recommended, it may be difficult to enforce throughout the visit, recognizing the desire of parents and children to comfort and show affection for each other.
    • In the interest of risk reduction, try to use safer ways to physically connect. Strategies for physical contact that may be less risky include hugging with faces in the opposite direction and leg/waist hugs with children (as suggested in a NYTimes article). Try to avoid kissing on the face or hands and cheek-to-cheek or face-to-face contact.
    • Check the CDC website for the most current guidance on safety during gatherings.
  • Maintain a log of everyone present at the visit, with contact information. If anyone who was present develops symptoms of COVID-19 within 2 weeks of the visit, he or she should contact the child welfare professional, who should, in turn, notify local public health authorities.
    • The individual with symptoms should also contact his or her primary care provider, who can direct their health care related to COVID-19.
  • When in-person visits cannot safely occur, attention is needed to ensure that virtual visits are accessible and developmentally appropriate for the child(ren) involved.
    • Child welfare professionals should ensure that all people involved have access to and understanding of the necessary technology.
    • Visits should be developmentally appropriate for the child(ren) involved.
      • Shorter, more frequent visits will likely work better than single longer virtual visits, particularly for younger children or those with developmental delays.
      • Having games or activities planned for the visit can make it more successful and fun.
      • Having a facilitator can be helpful, both to engage all participants and to provide technological support.

Child Welfare Concerns for Children and Adults Who Are COVID-19 Positive or Exposed

  • Communication with the child’s primary care physician should be initiated immediately. If there is no primary care physician, then an available local pediatric health care provider should be contacted. Follow the directions of the health care provider for the child’s immediate health needs.
  • Most children will simply require isolation (when COVID-19 positive) or quarantine (when exposed to someone who is COVID-19 positive) and close outpatient monitoring.
    • Children should be kept with their families whenever possible.
    • With the requirements of isolation or quarantine, families may need additional supports, such as grocery or pharmacy deliveries.
  • Foster and kinship families who care for COVID-19–positive or –exposed children should have access to education, training, and consultation about the situation, as well as masks and adequate personal protective equipment for the entire household.
  • Child welfare professionals should refer to current CDC guidance and AAP interim guidance when transporting or visiting with children who are COVID-19 positive or exposed.
  • Caregivers and child welfare professionals who have been fully vaccinated do not have to quarantine after a potential exposure, per current CDC Guidelines, but should wear a face mask when around others and should be tested 3 to 5 days after the exposure.

Considerations for COVID-19 Vaccination

Children and youth who are involved with the child welfare system (both in family-based and congregate care settings) and their caregivers often have medical conditions that place them at higher risk of developing more severe COVID-19 illness. People of racial, ethnic, and cultural groups who have been disproportionately affected by the pandemic are disproportionately represented in the child welfare system. Child welfare professionals often work in high-risk, first-responder roles. Keeping all of individuals safe and healthy is vital to the continued functioning of essential child welfare services.

Child welfare systems should collaborate with state and local public health to ensure that children in their guardianship are vaccinated with the COVID-19 vaccine as recommended by the CDC. Pediatricians should work with families, child welfare systems, and professionals to promote receipt of the COVID-19 vaccine now that it is available to children 5 years and older.

The AAP strongly recommends that all people, and especially those who are involved in the child welfare system, be vaccinated against COVID-19 as soon as they are eligible. See the AAP COVID-19 vaccine policy and CDC for up-to-date recommendations on COVID-19 vaccines. It is recommended that all children and youth be caught up on all their vaccinations, including the influenza vaccine.

Collaborating with the Pediatric Community

  • Child welfare professionals and caregivers should maintain close communication with a child’s health care provider when a child is COVID-19 positive or exposed or has symptoms of COVID-19.
  • Pediatricians should work with foster and kinship families at this time, helping to educate, quell anxiety, and link to appropriate local supports.
  • Pediatricians should work with local child welfare agencies to provide consultation around individual cases and to help agencies develop protocols and strategies to deal with the issues of COVID-19 related to social work staff, foster and kinship families, and congregate care facilities.
  • Although testing of asymptomatic children is not recommended, a negative COVID-19 polymerase chain reaction (PCR) test result is sometimes required as a condition for reunification or placement into foster, kinship, or congregate care. In this situation, pediatricians can work with their hospitals and urgent care centers to establish protocols to facilitate expeditious testing.

Additional Information


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 December 31, 2022 unless otherwise specified.

Last Updated

12/09/2021

Source

American Academy of Pediatrics