Elena Man, MD, FAAP

Lucia had begun to take school seriously in 8th grade but now, in 9th grade, she has become disheartened and says the teachers do not explain things well virtually. She does not like to show her face on camera and has begun to stay in her room, refusing to even eat dinner with the family. She keeps asking them to leave her alone. Her parents are worried. She just wants to play video games and play music in her room, and she has stopped seeing her best friend. The freshman guidance counselor called the parents to say she has missed more than half of the school days in the last week. The parents had no idea because they both work through the day online and assumed Lucia was participating in school virtually. They don’t know what to do.

The impact of the COVID-19 pandemic has hit home, school, work, and social life unlike any other acute change in our lifetime. Resulting isolation, loss of routine, limited social contact, grief, hardship, and stress have increased difficulties and further challenged youth. The deficiencies in our health care provision of mental health care for children have been further highlighted in the press and academic journals. What can those of us on the front lines caring for children do?

Devising an approach for health care workers to address mental health concerns in brief office visits may feel overwhelming. The sections below offer practical pandemic relief to help manage mental health concerns brought by families. During office visits, you can discuss the pillars of well-being by including these 10 priorities.

 Since the pandemic hit, there have been a range of reasons for misery for everyone. Remind families that it is understandable that stress levels are high, and worrying is rampant. Parents and children face new stressors to navigate. Acknowledging this reality has potential benefit. Family environment, parenting practices, coping, and support influence psychological consequences on children.

Parental mental health significantly impacts children, so remind parents that their own self care is important for their own and their children’s well-being. Help parents acknowledge how much their children are missing from their usual lives. School no longer includes the favorites of lunchtime chatting and playful recess interaction. Children are not likely having much opportunity online to solidify new friendships or flirt with a new crush. Their favorite activities are likely limited or on pause. Encourage parents to set aside time to devote their full focus on their children. Emotional support from parents can be protective.

Speak privately to your patients themselves to hear concerns, validate their struggles, and share guidance for those whose home life is affected by substance use or other dysfunction. For the teenagers, their peers become top priority, yet their current environment is blanketed by a large dose of family. Family members that do not support a patient’s LGBTQIA identity, or hold opposing cultural beliefs or sociopolitical values may create tension in the home. Find out if your patients are facing rejection at home and ensure they are coping with that difficulty. Consequential stress from these conflicts and/or the presence of domestic physical, verbal, and/or emotional abuse may have a lasting impact that could be mitigated if identified.

Teach families the myriad ways the pandemic is increasing stress for many by reviewing how stress occurs in the following conditions:

When an event is UNPREDICTABLE as to when or how it may occur.

When competence is being THREATENED (challenged/threatened).

When lack of control forces SURRENDER of your autonomy.

Despite current times meeting all of the above criteria, there is reason for optimism. A study among 381 undergraduate students (age range: 17–24, mean: 20.16, SD = 1.46 years) suggested that active coping strategies predicted life satisfaction during the 2003 Beijing SARS epidemic, whereas the number of stressors and use of avoidant coping strategies predicted psychological symptoms.

Present this pandemic crisis as an opportunity to learn and support well-being.

 Because unpredictability contributes to stress, a schedule does much to regulate our daily lives and contribute to a sense of stability.

Recommend families maintain consistent routines for wake up, bathing, meals, exercise, designated screen time, unwind time, and sleep. Suggest schedules be discussed collaboratively with children emphasizing what is healthy and within reason. Instead of hours, speak in minutes

 about their available time after school of 180-360 minutes depending on grade and homework prior to bedtime. The reason? To children, 120 minutes of screen time sounds like a lot compared to 20 minutes for sitting with family for meals.

 Emphasize what you already know about the importance of sleep’s effect on physical health, appetite, mood, and coping ability. This may be the simplest but most powerful intervention you can suggest, as so many parents do not realize how significantly inadequate sleep affects a child’s functioning. Advise families on good sleep hygiene.

 Watching or scrolling through the media makes us even more anxious. An excess of news and visual images about a traumatic event can create symptoms of posttraumatic stress disorder and negative health effects that remain years later, according to research by University of California at Irvine’s Roxy Silver, PhD, and others.

 Turn off the background news. Monitor Internet safety. Encourage families to view the Netflix documentary, “The Social Dilemma,” because it provides a convincing argument to limit internet use.

 Sedentary scores have shot up during the pandemic. Our brains are programmed to move and when we don’t it’s not good for our mind or body. Children in school are recommended to get 60 minutes of exercise daily. Encourage parents to keep their children active. Websites online offer creative indoor options such as “indoor and at home exercises for kids” at 

 Suggest families identify a new skill/hobby/or activity to learn or do together. Learn sign language, paint a room, create questions to share with family at meals, create homemade gift surprises, play board games, learn to cook, teach the pets new tricks, make posters of passionate beliefs for windows, listen to audiobooks together, or start sharing a daily high and low.

 Research supports the link between altruistic behavior and increased health and well-being.

 Do something that makes someone’s day better. A surprise sticky note, help with cleaning up dinner, call a relative who is alone during the pandemic, bake cookies for neighbors, write a letter to a favorite teacher, volunteer online.

 Anyone interested can learn this skill with simple, brief, regular practice. Help your patients understand that their goal is not to empty their minds of thought but to become aware of their sensations, emotions, and thoughts so they can use that self-awareness for their own benefit. There is evidence supporting benefits on mood, cognition, and symptoms including pain and associated with depression and anxiety.

 There are many options for learning, and countless easy and practical ways to incorporate mindfulness into a daily routine.

 Social isolation and loneliness can contribute to worsening of mental health.

 It’s a human need. Urge families to prioritize social meet ups while keeping safety in mind. Meeting outdoors wearing masks and socially distancing can still allow kids to see each other at a park, for a walk, in the yard, on a deck or porch. Even a prearranged consistent Zoom connection for your child and a friend has value. A limited group of contacts by designating a pod within which to socialize could be considered. Reiterate Centers for Disease Control and Prevention guidelines, handwashing, and testing options to maintain safe activities.

 Encourage parents to initiate the daily practice of noticing 3 positive moments of the day and share them with family. Create opportunities to enjoy time together. Noticing and appreciating daily pleasures can help improve mood.

In every mental health diagnosis that by definition is causing impairment and/or significant suffering, whether mild, moderate, or severe, evidence supports inclusion of psychotherapy in the treatment plan. Especially in pediatrics, this may include parental guidance and intervention. When conditions are severe, a combination of psychotherapy and medications provides the best outcome across conditions. For anxiety and depression-related conditions that cause moderate impairment, consider adding Selective Serotonin Reuptake Inhibitors medication if needed to help them engage in therapy, if they have persistent issues despite evidence-based therapy, or they are unable or refuse currently to access therapy.

Finally: As caregivers, our role is to both support well-being and address common reactions during these historic threats. Additionally, we must remain vigilant and prepared to initiate treatment when challenges have progressed into significant impairment and suffering.

Coping advice and helpful links for range of potential challenges: 

https://psychiatry.ucsf.edu/copingresources/covid19

American Academy of Child and Adolescent Psychiatry Link

Broad list and links of resources for both Families and Clinicians

Clinician resources for mental health management in primary care

 (courses on caring for the mental health needs of youth for Pediatricians, PAs, NPs, Therapists, & Schools) 

Guidelines for Adolescent Depression in Primary Care (GLAD-PC).

This comprehensive and practical resource includes practice guidance for administrative steps and billing as well as clinician tools such as diagnostic guidelines, rating scales, and pt/family handouts.

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/Primary-Care-Tools.aspx

A Guide to Psychopharmacology for Pediatricians

http://web.jhu.edu/pedmentalhealth/Psychopharmacolog%20use.html#Other_issue

Text crisis line: 741741 (only 6 digits); text STEVE for POC counselor

Trans Lifeline Peer Support US:1-877-565-8860

TrevorLifeline(LGBTQIA support) 1-866-488-7386

RAINN Sexual Assault Hotline: 1-800-656-4673

National Helpline for Substance Use 1-844-289-0879

Substance Abuse and Mental Health Services Administration National Helpline 1-800-662-HELP, or TTY 1-800-487-4889

American Academy of Child and Adolescent Psychiatry: 

1. Cobham V.E., McDermott B., Haslam D., Sanders M.R. The Role of Parents, Parenting and the Family Environment in Children's Post-Disaster Mental Health. In 

. 2016;18(6) doi: 10.1007/s11920-016-0691-4

2. Gudmundsdóttir D.G., Ásgeirsdóttir B.B., Huppert F.A., Sigfúsdóttir I.D., Valdimarsdóttir U.A., Hauksdóttir A. How Does the Economic Crisis Influence Adolescents’ Happiness? Population-Based Surveys in Iceland in 2000–2010. 

. 2016;17(3):1219–1234. doi: 10.1007/s10902-015-9639-3

https://www.mentalhealth.org.uk/a-to-z/s/stress

. Published February 20, 2020. Accessed October 1, 2020. 

https://humanstress.ca/stress/understand-your-stress/sources-of-stress

. Published August 22, 2017. Accessed October 1, 2020.

5. Guessoum SB, Lachal J, Radjack R, et al. Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323662/

. Published September 2020. Accessed October 1, 2020.

6. As suggested by Grizelda Anguiano, MD, FAAP on REACh PPP call. 

https://mindworkstx.com/staff/grizelda-anguiano-md-faap/

7. Healthy Sleep Habits: How Many Hours Does Your Child Need? HealthyChildren.org. 

https://www.healthychildren.org/English/healthy-living/sleep/Pages/Healthy-Sleep-Habits-How-Many-Hours-Does-Your-Child-Need.aspx

8. Roxane Cohen Silver EAH. Mental- and Physical-Health Effects of Acute Exposure to Media Images of the September 11, 2001, Attacks and the Iraq War - Roxane Cohen Silver, E. Alison Holman, Judith Pizarro Andersen, Michael Poulin, Daniel N. McIntosh, Virginia Gil-Rivas, 2013. 

https://journals.sagepub.com/doi/10.1177/0956797612460406

9. Irani A. Positive Altruism: Helping that Benefits Both the Recipient and Giver. ScholarlyCommons. 

https://repository.upenn.edu/mapp_capstone/152

. Published 2020. Accessed October 1, 2020. 

10. Simkin DR, Black NB. Meditation and mindfulness in clinical practice. 

. 2014;23(3):487-534. doi:10.1016/j.chc.2014.03.002 

https://www.sciencedirect.com/science/article/pii/S0022347616315487

11. N. Leigh-Hunt, D. Bagguley, K. Bash, V. Turner, S. Turnbull, N. Valtorta, W. Caan. An overview of systematic reviews on the public health consequences of social isolation and loneliness, 

12. The Neuroscience of Gratitude and How It Affects Anxiety & Grief. PositivePsychology.com. 

https://positivepsychology.com/neuroscience-of-gratitude/

. Published 2020. Accessed October 1, 2020.

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The COVID-19 pandemic has had a severe negative toll on the mental health of many children. Here are some tips to help children achieve better psychological well-being.

Elena Man, MD, FAAP

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