The American Academy of Pediatrics has just released new COVID-19 Guidance for Safe Schools. Keep reading for more info or click here to view the original report.
The AAP strongly advocates that all policy considerations for school plans should start with the goal of keeping students safe and physically present in school.
Purpose and Key Principles
The purpose of this guidance is to continue to support communities, local leadership in education and public health, and pediatricians collaborating with schools in creating policies for safe schools during the COVID-19 pandemic that foster the overall health of children, adolescents, educators, staff, and communities and are based on available evidence. As the next school year begins, there needs to be a continued focus on keeping students safe, since not all students will have the opportunity or be eligible to be vaccinated before the start of the next school year. Since the beginning of this pandemic, new information has emerged to guide safe in-person learning. Remote learning highlighted inequities in education, was detrimental to the educational attainment of students of all ages, and exacerbated the mental health crisis among children and adolescents. 1,2 Opening schools generally does not significantly increase community transmission, particularly when guidance outlined by the World Health Organization (WHO),3 United Nations Children’s Fund (UNICEF), and Centers for Disease Control and Prevention (CDC) is followed. 4,5 There are still possibilities for transmission of SARS-CoV-2, especially for individuals and families who have chosen not to be vaccinated or are not eligible to be vaccinated. In addition, SARS-CoV-2 variants have emerged that may increase the risk of transmission and result in worsening illness. However, the AAP believes that, at this point in the pandemic, given what we know about low rates of in-school transmission when proper prevention measures are used, together with the availability of effective vaccines for those age 12 years and up, that the benefits of in-person school outweigh the risks in almost all circumstances. Along with our colleagues in the field of education,6 the American Academy of Pediatrics (AAP) strongly advocates for additional federal assistance to all schools throughout the United States, irrespective of whether the current local context allows for in-person instruction.
Schools and school-supported programs are fundamental to child and adolescent development and well-being and provide our children and adolescents with academic instruction; social and emotional skills, safety, reliable nutrition, physical/occupational/speech therapy, mental health services, health services, and opportunities for physical activity, among other benefits.7 Beyond supporting the educational development of children and adolescents, schools can play a critical role in addressing racial and social inequity. As such, it is critical to reflect on the differential impact the COVID-19 pandemic and the associated school closures have had on different racial and ethnic groups and populations facing inequities. Disparities in school funding, quality of school facilities, educational staffing, and resources for enriching curricula among schools have been exacerbated by the pandemic. Families rely on schools to provide a safe, stimulating, and enriching space for children to learn; appropriate supervision of children; opportunities for socialization; and access to school-based mental, physical, and nutritional health services.
Everything possible must be done to keep students in schools in-person. Many families did not have adequate support to the aforementioned educational services, and disparities, especially in education, did worsen, especially for children who are English language learners, children with disabilities, children living in poverty, and children who are Black, Hispanic/Latino, and American Indian/Alaska Native. 8,9,10,11
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 supports for children living in under-resourced communities.
It is critical to use science and data to guide decisions about the pandemic and school COVID-19 plans. All school COVID-19 policies should consider the following key principles and remember that COVID-19 policies are intended to mitigate, not eliminate, risk. Because school transmission reflects (but does not drive) community transmission, it is vitally important that communities take all necessary measures to limit the community spread of SARS-CoV-2 to ensure schools can remain open and safe for all students.
The implementation of several coordinated interventions can greatly reduce risk:
All eligible individuals should receive the COVID-19 vaccine.
It may become necessary for schools to collect COVID-19 vaccine information of staff and students and for schools to require COVID-19 vaccination for in-person learning.
Adequate and timely COVID-19 vaccination resources for the whole school community must be available and accessible.
All students older than 2 years and all school staff should wear face masks at school (unless medical or developmental conditions prohibit use).
The AAP recommends universal masking in school at this time for the following reasons:
-a significant portion of the student population is not eligible for vaccination
-protection of unvaccinated students from COVID-19 and to reduce transmission lack of a system to monitor vaccine status among students, teachers and staff
-potential difficulty in monitoring or enforcing mask policies for those who are not vaccinated; in the absence of schools being able to conduct this monitoring, universal masking is the best and most effective strategy to create consistent messages, expectations, enforcement, and compliance without the added burden of needing to monitor vaccination status
-possibility of low vaccination uptake within the surrounding school community
-continued concerns for variants that are more easily spread among children, adolescents, and adults
An added benefit of universal masking is protection of students and staff against other respiratory illnesses that would take time away from school.
Adequate and timely COVID-19 testing resources must be available and accessible.
It is critically important to develop strategies that can be revised and adapted depending on the level of viral transmission and test positivity rate throughout the community and schools, recognizing the differences between school districts, including urban, suburban, and rural districts.
School policies should be adjusted to align with new information about the pandemic; administrators should refine approaches when specific policies are not working.12
Schools must continue to take a multi-pronged, layered approach to protect students, teachers, and staff (ie, vaccination, universal mask use, ventilation, testing, quarantining, and cleaning and disinfecting). Combining these layers of protection will make in-person learning safe and possible. Schools should monitor the implementation and effectiveness of these policies.
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.
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.
School COVID-19 policies should be practical, feasible, and appropriate for child and adolescent’s developmental stage and address teacher and staff safety.
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 mandates 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 should also look to create 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.
Ongoing federal, state, and local funding should be provided for all schools so they can continue to implement all the COVID-19 mitigation and safety measures required to protect students and staff. 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 (eg, socioeconomic disadvantages) or in the event of school re-closure because of a resurgence of SARS-CoV-2 in the community or a school outbreak.
With the above principles in mind, the AAP strongly advocates that all policy considerations for school COVID-19 plans should start with a goal of keeping students safe and physically present in school. The importance of in-person learning is well-documented, and there is already evidence of the negative impacts on children because of school closures in 2020.13
Policy makers and school administrators must also consider the scientific evidence regarding COVID-19 in children and adolescents, including the role they may play in the transmission of the infection. 14,15,16,17,18,19,20,21,22 Although many questions remain, the preponderance of evidence indicates that children and adolescents are less likely to have severe disease resulting from SARS-CoV-2 infection. 23,24 We continue to learn more about the role children play in the transmission of SARS-CoV-2. At present, it appears that children younger than 10 years are less likely to become infected and less likely to spread the infection to others, although further studies are needed. 25,26,27 Some data suggest children older than 10 years may spread SARS-CoV-2 as efficiently as adults. Additional in-depth studies are needed to truly understand the infectivity and transmissibility of this virus in anyone younger than 18 years, including children and adolescents with disabilities and medical complexities. Current SARS-CoV-2 variants may change both transmissibility and infection in children and adolescents even in those who have been vaccinated.
Visit the CDC COVID-19 Prevention Strategies for additional information on mitigation measures including physical distancing, testing, contact tracing, ventilation, and cleaning and disinfecting.
In the following sections, some general principles are reviewed that policy makers and school administrators should consider as they safely plan for in-person school. There are several other documents released by the CDC, the National Association of School Nurses, and the National Academy of Sciences, Engineering, and Medicine that 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
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 (eg, 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, may be especially vulnerable to these effects. 32,33 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 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 the training of those staff 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 600,000 deaths from COVID-19; on average, it is estimated that each of these deaths impacts 9 people – many of these 4.5 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.34 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.35 Schools should develop mechanisms to evaluate youth remotely and in-person if concerns about a risk of suicide are voiced by educators or family members and should be establishing policies, including referral mechanisms for students believed to be in need of in-person evaluation, even before schools 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. Fear-based messages widely used to encourage strict physical distancing may cause problems when schools resume in-person instruction, because the risk of exposure to COVID-19 may be mitigated but not eliminated. 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 supports 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(See: Interim Guidance on Supporting the Emotional and Behavioral Health Needs of Children, Adolescents, and Families During the COVID-19 Pandemic)
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, teachers cannot be expected to be successful at teaching children without having their mental health needs supported. The strain on teachers, 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, 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.Although schools should be prepared to be agile to meet evolving needs and respond to increasing knowledge related to the pandemic and may need to institute partial or complete closures when the public health need requires, 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.
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.Food Insecurity: According to the United States Department of Agriculture, the number of food-insecure households has increased during the pandemic with a currently estimated 30 million adults and 12 million children living in households where they may not get enough to eat.36 We also know that disparities with food insecurity exist, with Black and Latino adults being twice as likely as white adults to report their households did not get enough to eat.34School 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.37 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.Housing Insecurity: 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, as of February 2021, there are 5.2 million households with children who are behind on rent and 4.5 million homeowners with children behind on mortgage payments.38 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.39 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.40 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.41 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.Digital Divide: 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 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.42 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. 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.Organized Activities: It is likely that sporting events, practices, and conditioning sessions as well as other extracurricular activities will be limited in some locations while reopening fully in other locations. The AAP Interim Guidance on Return to Sports helps pediatricians inform families on how best to ensure safety when considering a return to 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.
Additional Information
- AAP Guidance Related to Childcare During COVID-19
- AAP Guidance on Providing Pediatric Well-Care During COVID-19
- AAP Guidance on Face Masks
- AAP Guidance on Testing
- AAP Guidance on Use of Personal Protective Equipment (PPE)
- AAP Guidance on Caring for Children and Youth with Special Health Care Needs During the COVID-19 Pandemic
- AAP Guidance on Supporting the Emotional and Behavioral Health Needs of Children, Adolescents and Families During the COVID-19 Pandemic
- AAP Guidance on Return to Sports
- List of latest AAP News articles on COVID-19
- Pediatrics COVID-19 Collection
- AAP COVID-19 Advocacy Resources (Login required)
- Centers for Disease Control and Prevention: Guidance for COVID-19 Prevention in K-12 Schools
- US Department of Education: COVID-19 Resources for Schools, Students, and Families
- Information for Parents on HealthyChildren.org: Returning to School During COVID-19
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