Special needs can range from developmental delays to complex medical conditions 1. Therefore, children with special needs (CSNs) can be the ones with impairments such as locomotor disabilities, visual impairment, mild to moderate hearing impairment, and the mentally handicapped educable group (IQ 50-70) 2. They are limited or unable to do what most children of the same age can do because of behavioral, developmental, emotional, or medical problems 3.

Other than family care, CSNs receive care from rehabilitation settings, special schools, respite care, therapy centers, clinics, and social support groups and organizations. However, the Covid mandate temporarily discontinued all professional services for CSNs, increasing the burden on family caregivers. The lack of formal training for various responsibilities, including care and coordination of care, affected family caregivers' emotional and physical well-being 4. Besides, the pandemic challenged the caregivers to meet the requirements of the new normal to contain the virus spread and increased stress and depression in family caregivers 5. The pandemic-induced challenges to caring for CSNs drew the attention of researchers globally, so they researched the area and published a set of scholarly articles. A considerable number of researches, including scoping reviews 678, explored the issues of family caregivers to CSNs.

When the World Health Organisation (WHO) announced the outbreak of Covid-19, a Public Health Emergency of International Concern (PHIEC) on January 30, 2020, (WHO, 2020a, it called for unprecedented measures such as lockdown and home quarantine to curb the virus spread which resulted in the closure of service centers, the disintegration of support networks, and disruption of carefully developed routines, for CSNs 910. Cessation of regular activities escalated their behavioral conflicts and temper tantrums 1112 which warranted new strategies such as telehealth interventions and telerehabilitation for formal care to CSNs. A sudden shift from the traditional service to a pandemic-specific mode equally changed the organizations and the personnel working with them. Researchers studied the strengths and challenges of the pandemic-specific strategies adopted by the formal care programs such as childcare institutions, special schools, pediatric rehabilitation, and formal care providers. Therefore, a scoping review of the research carried out so far is essential to identify the knowledge gap for further studies to generate relevant knowledge on the status of formal care to CSNs, and its implications on formal care providers during the pandemic.

This study adopted scoping review as a technique to map the relevant literature 1314151617 on the formal care (FC) to CSNs and the challenges faced by formal care providers (FCP) during Covid-19 pandemic. Before starting the process, we developed an a priori protocol to guide the scoping review, according to Joanna Briggs Institute (JBI, 2020) reviewer's manual, which pre-defined the objectives, search strategy, search approach, and selection process, draft charting, and report presentation. The Institutional Ethical Clearance Committee at CHRIST (Deemed to be University) approved the protocol. We prepared a checklist based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) 18.

The purpose of this review was to investigate the research conducted during the Covid 19 pandemic on FC to CSNs, the challenges faced by FCP, understand the key concepts, and identify the research gap. For achieving in-depth and broad results, we incorporated Levac and others' (2010) recommendations into the original framework of a scoping review proposed by 13. Figure 1 shows the scoping review framework.

The review began by identifying the research questions using the Participant-Concept-Context (PCC) framework so that the questions can guide the reviewing process. After detailed discussions, the researchers articulated three research questions: 1) What are the pandemic-specific strategies for formal care for CSNs? Their strengths, weaknesses, and implications. 2) What are the professional challenges faced by FCP to CSNs during the Covid-19 pandemic? 3) What are the personal challenges faced by FCP to CSNs during the Covid-19 pandemic?

In the second stage, we identified relevant studies by searching electronic databases such as Google Scholar, PubMed, Research Gate, and JSTOR. The search string used for the initial search was: ("Special needs children" OR "children with special needs") AND care AND (COVID-19 OR pandemic). The search was customized to the range from 2020 to 2021, and papers in the English language only. We repeated the search replacing the keyword "care" with "institutional care" and "formal care", "daycare", "special school", and "therapy center". We searched first in Google Scholar, and the search for relevant studies in the remaining databases was conducted after selecting studies from Google Scholar.

The study selection was conducted through three steps; a) Title screening, b) Abstract screening, and c) Full-text screening. The screening excluded articles on parents or primary caregivers and children. It included original research papers, reviews, theoretical papers, and short communications on FC and FCP to CSNs, such as caregivers, care managers, special educators, therapists, psychologists, and other care experts. Title screenings excluded duplicates and papers with clear titles about parents, primary caregivers, and children. Abstract screening further excluded articles not related to FC or FCP to CSNs. Two researchers independently reviewed the abstracts and full texts and consulted the research guide to resolve disagreements in the discussions on the inclusion of papers in the scoping study. The agreement between the researchers was 100% during the abstract screening, which was reduced to 90% while screening the full text. Consultations with external experts helped refine our decisions on the inclusion of Journal articles. We further checked similar papers suggested by the database and the bibliographies of selected studies, ensuring their inclusion in this scoping exercise.

The researchers independently carried out a critical appraisal of the studies selected, using the Mixed Methods Appraisal Tool (MMAT) 19 to assess their methodological, ethical, and theoretical quality 20. We checked each criterion for qualitative, quantitative, and mixed-method studies in detail and rated included studies 1-5. This scoping review included studies ranging from low to high methodological rigor.

We have chosen to include grey literature since it is likely to contribute additional information. Grey literature promotes a balanced picture of the available evidence, increasing the timeliness and comprehensiveness of the review and reducing publication bias 21. Therefore, we conducted a Google search using the exact keywords for database search and extracted government guidelines, conference papers, webinars, magazine articles, newspaper reports, TV news reports, thesis, and dissertations. However, grey literature is not peer-reviewed. Based on the pandemic-induced delay in peer-reviewed articles reaching publication, another type of information is justified.

The review process was iterative and we moved back and forth through the stages of identifying relevant studies, study selection, and charting data. For charting data, we developed two different templates for journal articles and grey literature in Microsoft excel. Article code was assigned to all the selected articles; for journal articles (JA1-JA10) and grey literature (GL1-GL8) to facilitate the data analysis. Chart for journal articles included author(s), year of publication, country, journal name, article type, research design, study setting, participants, and MMAT rating. Grey literature chart tabulated author(s), year and date, country of origin, type of literature, title, target service, target personnel, and website name. We conducted the descriptive numerical summary analysis using the data from these two charts.

We extracted sterling concepts from the journal articles and grey literature to analyze them against the research questions, adopting a qualitative thematic analysis method. Then, we created the third chart for snippets from the excerpts, which displayed the pandemic-specific strategies for FC of CSNs, their strengths, weaknesses, and implications on FCP, and recommendations explained in each selected article. In the next step of the analysis, we developed codes from the snippets, which both the researchers did independently. Then, we sorted the codes and grouped them into subthemes and themes after removing the repeated ones.

The researchers drew answers precisely to the research questions by synthesizing the results. The results of descriptive numerical summary analysis and qualitative thematic analysis were combined, compared, and interpreted the results considering the context of the study or report. The agreement between researchers at this stage was 80% at this stage. However, discussions with the research guide and subject matter experts resolved the disagreements in interpreting results.

The researchers were cognizant of avoiding discrepancies between the protocol and the process. Therefore, we meticulously included all the key items recommended by PRISMA-ScR 18 in reporting this scoping review. We ticked off all items included in the checklist developed based on PRISMA-ScR and submitted with the review protocol.

The initial search in Google Scholar gave out 2900, 62, 19, 220, 239, and 14 results, respectively, with each string we used. As shown in figure 2, title screening excluded 3,007 articles from a list of 3,254 articles identified. This first-level screening omitted duplicates and titles, explicitly mentioning that the study was on primary care, parents or children. The 209 articles were excluded through the second level screening, abstract screening, the study area was not FC, or the participants were not FCPs. Of the 38 articles that underwent full-text screening, 22 were excluded owing to the wrong population, four wrong contexts, and two because of the incongruence of ideas presented in the article. Search in other databases such as PubMed, Research Gate, and JSTOR did not add any new articles to the list of ten journal articles selected. Four were excluded from the 12 pieces of grey literature identified through Google search, considering replication of information. (USA), Spain, Singapore, India, and South Asian countries (Afghanistan, Bangladesh, India, Maldives, Nepal, Pakistan, and Sri Lanka).

Grey literature included a WHO document, government guidelines, master's dissertation, webinar, magazine article, newspaper report, and a TV news report. The first three documents were guidelines for service providers and institutions. Of the remaining five, three discussed special education, one reported teletherapy, and the other explained new protocols to childcare officials. While six of them portrayed the American scenario, one explained the Indian scenario. Table 3 shows the characteristics of the journals included in the study.

The formal care programs for CSNs identified in this scoping review are pediatric rehabilitation, special education, residential care, and early childhood learning and knowledge program. Institutional care/ residential care was the avenue of research from Asian countries, while reports from the West focused on special education and pediatric rehabilitation.

The given word cloud (Figure 3) shows the different strategies that pediatric rehabilitation programs and child development units adopted during the Covid-19 pandemic. The selection process included ten Journal articles (Table 1) and eight pieces of grey literature (Table 2) in the scoping review. Of the 10 Journal articles, 4 were research papers, 5 were theoretical papers, and one was a short communication. The study designs were quantitative survey, qualitative case study, qualitative focus group study, and concurrent equal status fully mixed method. These articles discussed the pandemic-specific FC services for CSNs globally, in the United States of America Three theoretical papers, one with an international perspective (Camden & Silva,2021), the second one from the USA 22, and the other from Singapore 23, discussed the alternative services adopted by pediatric rehabilitation out-patient settings for CSNs during the pandemic. In addition, a short communication 24) and a grey article from the USA (Starrantino, 25 proved telehealth is the strategy adopted by the physical and occupational therapists for CSNs globally during the Covid crisis. Experience of an institution located in Bronx, New York, which transitioned its services to telehealth, demonstrated that pediatric physiatry clinics could successfully use telemedicine in rehabilitation via tele-visits 22. Similarly, the experience of a tertiary level academic institution at the National University Hospital, Singapore, confirmed the effectiveness of telehealth-based occupational therapy to CSNs during the national 'Circuit-Breaker' period 23. Since telehealth transferred rehabilitation services to the home environment, these two institutions leveraged their tele-resources for family education or parent training 2223.

The most apparent benefit of the tele-visit modality was that it increased access to rehabilitation care, especially for those who live in remote or rural areas 222423. Additionally, it saved on transportation costs, absence from work 22, travel time, and waiting time in the clinic 24. Moreover, home-based services came with the advantages of intervention in the natural environment of the child 2423, increased parental engagement 2426, and better therapist-parent rapport 23. Thus, telehealth offered opportunities to broaden access, increase cost-effectiveness, and strengthen family-centered therapy for CSNs 25. Teletherapy was identified as a collaborative method where therapists and parents collaborate to help children progress 26. During the Covid-19 crisis, relaxation of regulatory requirements for health privacy and protection while accessing technology in service delivery and reimbursement accelerated telehealth in pediatric rehabilitation 2225.

On the contrary, telerehabilitation faced potential challenges with its dependence on the caregiver's ability to understand instructions and observe and describe the findings during a telephone encounter 22. Caregivers without a high health literacy 24 and technological literacy 2223 faced challenges following the instructions of a physiatrist or therapist, which affected the outcome of teleservices. In addition, telehealth services were inaccessible to households that did not have adequate devices and home internet connections (Nulle & Nelson, 2021;22. While the negative perception of therapists, families and the community about teletherapy played a role in its implementation 25, poor audio and video quality adversely affected the outcome of telehealth services 2223.

Students with special needs need various support services, including specialized academic guidance, specialized personal support, behavioral intervention, counseling, and various therapies. The WHO (2020b) recommended that schools and other educational facilities take appropriate action to ensure that students with disabilities receive further education at home. This scoping review analyzed two research papers 2728, two conceptual papers 2930, and three pieces of grey literature 313233 for generating knowledge on special education strategies during the Covid-19 pandemic. 29 developed the Distance Support Model for special education, providing certified behavior analyst supervision and parent support. In this model, the behavior analyst guides the communication between parents, teachers, case managers, behavior interventionists, and special service providers. Another Distance Learning Model from Commerce Independent School District continued special education services through learning packets, online instructions, virtual meetings, communication with parents, counseling, and teleservice 30.

A national-level mixed-method study in the USA revealed that the method for remote delivery of services to CSNs is coaching families by shifting school goals to home goals and creating distance learning plans 28. Realizing that instructing their students from afar is impossible, teachers were teaching parents to teach 31. A qualitative study from Spain also reported home-school collaboration by empowering families to support their children's learning and delivering study materials 27. Although special educators could build better relationships with families, children were not getting the same quality of services 28, and behavior interventions remained hard to implement in the home context 27. The absence of evidence-based strategies made the goals of online special education hard to accomplish, regardless of the partnership between stakeholders 33.

The brighter side is that students with difficulty looking directly at people's faces found it much easier to do so through the computer screen 31. However, CSNs use assistive technology; for example, a student with visual impairments uses a screen-reader software or a braille reader, making online training and home-based learning ineffective 31. A newspaper report from India resonated with this concern that the absence of sign language interpreters in webinars left them useless for CSNs 32. In the Indian scenario, lack of internet access, smart devices, and necessary support to pursue their online school education denied learning to CSNs during the pandemic 32. In general, special educators were concerned about the learning curve and predicted a major backslide in learning 3128.

Two studies from Asian countries 342) explored the functioning of child care institutions/ residential care homes during the Covid-19 contagion. After the outbreak of Covid-19, some parents chose to keep their CSNs at home, so care homes had to develop two different strategies for serving their enrollees at the care center and at home 2. Care homes in Bangalore, a South Indian city, developed a creative calendar for engaging CSNs indoors, and they provided telephonic care guidance to parents to manage their CSNs at home, which strengthened the caretaker-parent relationship (Karalm et al., 2021). Child care institutions (CCI) in South Asian countries offered counseling sessions to children, relieving the pandemic-induced anxiety and stress, although the sessions were handled by caregivers who were not professionally trained 34. CCIs in India conducted Covid awareness programs at a moderate level, but the other countries studied were not at par in awareness creation among the inmates of CCIs 34. Due to the pandemic-driven financial crisis in government and private funding agencies, these institutions faced inadequate funding 342.

Centers for Disease Control and Prevention (CDC) updated guidelines for operating childcare programs/ Early Care and Education programs in the USA. The guidance was intended for all types of childcare programs. Table 4 shows the types of Childcare programs and recommended Covid prevention strategies.

Childcare programs were instructed to work with families to understand the individual needs of CSNs better and facilitate access to direct service providers such as paraprofessionals, therapists, early intervention specialists, and health care and mental health consultants (CDC 2021a). Additionally, they had to maintain an adequate staff-to-child ratio, screening procedures at the arrival of children, and update care plans (Foster, 2020). Physical distancing and wearing masks were found difficult for CSNs. Therefore, to help them adjust to transitions in routine, childcare programs were instructed to use behavioral techniques such as modeling and reinforcing desired behaviors using timers, visual indicators, picture schedules, and positive reinforcement (CDC, 2021b;35. Implications of pandemic-specific strategies on formal care providers to CSNs This review recognized a set of FCPs to CSNs, such as personal care attendants, institutional caregivers/caretakers, special educators, paraprofessionals, therapists (behavioral, occupational, physical), speech and language pathologists, behavior analysts, early intervention specialists, and mental health and healthcare consultants. WHO (2020b) identified a potential workforce shortage and recommended governments undertake targeted measures for disability service providers. This study reviewed articles against the research questions and extracted the challenges faced by FCPs to CSNs during the Covid-19 pandemic.

Childcare program workers faced risks, including essential workers, parents, home school teachers, short-order cooks, and financial stress 35. Teachers worked extraordinarily hard for their students with special needs, gaining creativity, spending time, and finding ways to move forward 31. In addition, they faced financial concerns, pandemic-induced stress, investment in equipment, and caring for their children. Heavy workload and non-payment made their lives miserable 28. With the implementation of telehealth, the reduction in reimbursement rates and the elimination of co-pay have reduced the income of service providers 22. Meanwhile, residential caregivers burnt out with the workload and were stressed to keep children safe 234. Covid infection and fear of getting infected made them distressed. Their meeting with family was reduced due to Covid restrictions, and their financial commitment increased as their family members lost their jobs in the Covid crisis 34. Moreover, institutional caregivers in India and Bangladesh faced salary cuts 34.

Teachers lacked ICT skills and knowledge for teaching online, yet they had to provide lessons for children and training for families 322728. They had to develop learning programs based on the learning materials available at home and the strategies for learning in the home environment 3327. In addition, inadequate teaching-learning content 32) and lack of guidance and resources challenged special school teachers 28.

Due to the technological illiteracy of caregivers, practitioners faced difficulty in instructing them to download the necessary platforms for teleconsultation 22. Therapists had to provide caregivers with technical guidance and clarify their strategies 23. They had to guide the family verbally throughout sessions 24. In addition, telehealth providers had to create and implement new procedures and processes, from getting scheduled by support staff to educating parents on the process. Developing new proficiencies in obtaining informed consent for virtual visits, navigating the online platform, manipulating audio/video visits, and ensuring patient privacy became necessary for telehealth providers in pediatric rehabilitation 22. In Singapore, therapists had to manage teletherapy with limited internet and hardware access due to the government's internet separation policy to protect data 23.

Institutional caregivers in South Asian countries found their job at stake, and they were forced to provide counseling to children, although untrained 34. In addition, developing new programs to engage children indoors and train them in the changed routine challenged the residential caregivers 2.

The Covid-19 pandemic transformed formal care for CSNs into a virtual model, and telehealth strategies have been widely used in pediatric rehabilitation. Therefore, 22 recommended integrating telemedicine into the health care system that provides insurance coverage. Online services, like face-to-face services, must be reimbursed 25. 24 also argued for the continuation of relaxation on insurance coverage for telemedicine. In addition, it was recommended that an IT support staff be included in the rehabilitation team and that telehealth be included in the curriculum for therapy students 25. However, to ensure health equity, the digital divide must end before integrating telemedicine completely into pediatric rehabilitation 23. Policies and provisions that offer virtual resources to the broader community are required to incorporate therapy into the child's natural environment.

This scoping review substantiates an excerpt from Simó-Pinatella (2021: 9) "as special education schools, we have felt abandoned. All the protocols that have been sent were for the mainstream schools, and nothing was said about special schools". 29 also shared that special schools did not have manuals or guidelines to support students and parents in times of crisis. Studies suggested that special education should be considered an essential service and that unique guidance should be given to special schools and teachers to work during health emergencies 3227. Disability-specific e-learning programs 32 and online platforms compatible with assistive technology 31 are essential for effective learning online. For practical interventions for CSNs in the home environment, a multidisciplinary approach is also recommended (Simó-Pinatella, 2021). In addition, provisions for technical infrastructure 3328, training for teachers on basic technology 3228, and professional development training on relationship building, family coaching, and problem-solving also required in making remote learning effective for CSNs 28.

There is an undeniable need for restructuring institutional care for children 36, in general, and for establishing separate institutional care for CSNs 37, in particular. In the Covid context, childcare institutions require financial packages for procuring food items and safety products such as face masks, gloves, PPE kits, and sanitizer 234. Other than financial packages, there must be provisions for deploying more staff 2. In addition, there need policies to provide technology infrastructure with the required equipment and internet connection for accessing online classes for children 34. Professional counseling services and Covid awareness programs are vital in helping them handle stress and keeping safe.

Institutional caretakers need significant training in psychosocial support mechanisms, stress management, and communication with special-needs children 34. Organization-focused and individual-focused interventions are needed to support caregivers during a pandemic situation. Formulating policies is essential for the systematic training and capacity building of caregivers 36. However, home-centered care strategies and parental training are essential for caring for special-needs children 2.

In telehealth, 22 recommended studying data algorithms for validating tools, advancing treatment, and improving the efficacy of tele-education. In addition, the role of teletherapy in routine care needs further exploration 24. Telehealth requires collaborative work between researchers, therapists, and families to find out what strategy is best to use in which context 25.

In special education, the impact of online instruction during pandemic situations requires further inquiry 30. Evidence-based strategies are essential in special education 33, so research is needed on specific strategies that are appropriate for each category. Training support for special educators opens another area for inquiry. Moreover, the rarity of research in special education and negligence from governments call for studies to inform policy.

This scoping review demonstrated that institutional care is an under-researched and underdeveloped model for childcare. This scenario requires studies from the individual level to the policy level for the proper reorganization of the care system to ensure the well-being of children and caregivers. 34 recommended studies in real-world settings on caregivers' coping strategies. However, the need to develop better strategies to support the training and well-being of institutional caregivers for CSNs highlights further avenues for research.

Formal care and service providers for CSNs have received relatively little attention from researchers, which has limited the number of studies in this review. In addition, theoretical papers and grey literature were mainly from the USA, as literature on CSNs was scarce in other parts of the world, limiting the generalizability of findings.

The Covid-19 pandemic and the subsequent stay-athome orders marked a significant paradigm shift in delivering special needs child care globally. Disciplines caring CSNs developed home-centered programs and adopted online modalities for delivery. Parents became the key players in all services for CSNs. When pediatric rehabilitation in the developed countries completely transitioned to telehealth, institutional caregivers in Asian countries were exhausted with workload and distressed with multiple stressors. However, the digital divide was prevalent in developed countries too. Special schools and teachers worldwide have struggled with the lack of guidelines and platforms with assistive technology.

On the other hand, childcare programs in the USA received guideline updates. Lack of technological savviness equally troubled service providers and recipients. Although a backslide is predicted, formal care providers could engage CSNs, in collaboration with families. However, this scoping review illuminated many new avenues for research in the domain of formal care to special needs children in a pandemic context.