Understanding the perplexing adolescent years

The article by Michael Jellinek, MD, “Helping parents cope with adolescent behavior,” provides a comprehensive review of emotional and behavioral changes that occur throughout the adolescent years. The article focuses the role of pediatricians helping parents and adolescents understand the vast array of emotions including promising behaviors as well as at-risk behaviors, eg, substance use, that can lead to troubling consequences for the adolescent and the parents. Jellinek describes the flux of emotions in cycles that occur on a pendulum with behaviors that demonstrate the promise of entering young adulthood with mature cognitive and emotional responses to a more toddler-like behavioral swing that frustrates parents, teachers, coaches, their friends, and perhaps, themselves. I highly recommend reading Jellinek’s article.

Thinking about adolescent emotional/behavioral swings during the COVID-19 pandemic

The normal day-to-day lives of adolescents have changed significantly over the past 18 months during the COVID-19 pandemic. Their routine behaviors, eg, meeting and interacting with friends, participating in sports, the anticipated experience by adolescents of ‘newfound’ freedoms, the excitement of entering high school, preparing to enter schools of higher education, and/or a first job have all been either put on hold or significantly altered during the pandemic.

Most adolescents have experienced at least some form of virtual education throughout the COVID-19 pandemic. For many, their first return to a classroom, either high school or college, will be this Fall 2021 semester. However, for high school students, return to school may be impacted by the current community spread of the Delta variant in areas of the country that have a high number of unvaccinated populations. How has virtual education impacted the totality of adolescent growth and development experiences? We do not have the answer to this question, as yet. Many pediatric providers schedule extra time for the annual adolescent visit. Today, this extended time for the visit is more critical than ever, to allow time to talk with the adolescent, identify real or potential emotional and/or behavioral health problems and make sustainable plans to assure the adolescent is on the path to healthy behaviors.

What about adolescents who lost a parent, sibling, relative, or friend to COVID-19?

On July, 20, 2021, the National Institute of Health published a news release based on a published research studyrevealing that 1.5 million children around the world lost a primary or secondary caregiver due to the COVID-19 pandemic.^1,2 The United States was identified as 1 of 6 countries with the highest numbers of children who lost their parent or primary caregiver during the pandemic. As pediatricians and pediatric nurse practitioners, it is essential to consider the loss of a parent by an adolescent and the influences and possible consequences of this loss on the adolescent emotional and behavioral development. Has the adolescent even had time to grieve the loss of their parent or caregiver? Who is now supporting the adolescent? Has the adolescent received counseling for their loss? How is the adolescent coping with the loss? This is a critical time to administer and interpret validated screening tools, such as the Patient Health Questionnaires (PHQ-2³ and PHQ-9³) the CRAFFT tool,⁴ and the Generalized Anxiety Scale,⁵ or the Screen for Child Anxiety Related Disorders (SCARED) tool,⁶ during each of the office visits. These tools will help to identify the emotional and behavioral status of adolescents who have lost a parent, and to implement evidence-based treatment plans to help the adolescent cope and emerge mentally and physically healthy. In addition, as Dr. Jellinek discusses, it is also essential to screen for suicide ideation in adolescents and even more so, for adolescents who have lost a parent or primary caregiver during this pandemic. The mental health, emotional and behavioral health of our adolescents must addressed in each primary care encounter.

References

1. Hillis S, Unwin H, Chen Y et al. Global minimum estimates of children affected by COVID-19-associated orphanhood and deaths of caregivers: a modelling study. The Lancet. July 20, 2021. Epub ahead of print. doi:10.1016/s0140-6736(21)01253-8

2. National Institute of Health. New Release: More than 1.5 million children lost a primary or secondary caregiver due to the COVID-19 pandemic. Published July 20, 2021. Accessed July 20, 2021. https://www.nih.gov/news-events/news-releases/more-15-million-children-lost-primary-or-secondary-caregiver-due-covid-19-pandemic

3. American Psychological Association. Patient Health Questionnaire (PHQ-9 & PHQ-2). Accessed July 22, 2021. https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health

4. The CRAFFT Questionnaire (version 2.0). Accessed July 22, 2021. https://njaap.org/wp-content/uploads/2018/03/COMBINED-CRAFFT-2.1-Self-Admin_Clinician-Interview_Risk-Assess-Guide.pdf

5. Generalized anxiety disorder GAD-7. Accessed July 22, 2021. http://www.medi-mouse.com/graphics/GAD7.pdf

6 .Screen for child anxiety related disorders (SCARED). Accessed July 21, 2021. https://projectteachny.org/wp-content/uploads/2017/09/SCARED_child.pdf