How Pediatricians Can Help Children and Parents Deal with the Pandemic
Even though her young patients weren’t experiencing major physical manifestations of COVID-19, Columbia pediatrician Evelyn Berger-Jenkins, MD, anticipated at the beginning of pandemic that children would still feel the stress.
“Since the start of the pandemic, we’ve all been feeling the stressors and mental health ramifications of COVID-19,” says Jenkins, assistant professor of pediatrics at Columbia University Vagelos College of Physicians and Surgeons and pediatrician at NewYork-Presbyterian/Columbia University Irving Medical Center, whose research focuses on the psychosocial determinants of mental health and well-being in children.
To help pediatricians and families, Jenkins recently co-authored interim guidance with a national group of pediatricians convened by the American Academy of Pediatrics.
We spoke with Jenkins to find out how the recommendations may help pediatricians and families support the mental health needs of children and adolescents as the pandemic continues.
What have you been seeing in terms of the mental health impact of the pandemic on children and families?
Families have been reaching out and telling us they are feeling stressed about being able to care for themselves and their loved ones, whether it is related to COVID or in general. We are witnessing the kind of stress that comes with uncertainty and loss—physical loss or loss of life—but also economic and other kinds of loss of control and security.
We're seeing a lot of children, adolescents, and families present with anxiety and difficulty functioning in terms of daily life, usual tasks, academics, employment, etc. This has created emotional distress, as well as physical distress, since the brain drives much of our physical health. We’re seeing more children with complaints of headaches, stomach aches, and difficulty focusing.
How can pediatricians help?
The pediatrician may be a source of support during this time of uncertainty. Pediatricians have always played a role in providing education and advice on child emotional or behavioral concerns. Our guidance emphasizes the importance of maintaining that role during COVID times.
We also recommend that pediatricians start to screen for emotional and behavioral problems if they don’t already do so. This should be combined with screening for social determinants of health, such as food security and family functioning, given the inextricable links between social and emotional health. We ask families about social and emotional health every time they come to the doctor. We want them to understand that it's as important as physical health and destigmatize social, emotional, and behavioral difficulties so that families will come forward and let us know when issues are affecting them.
The pandemic has presented some challenges in terms of screening and addressing mental health concerns. Screening used to be performed in the waiting room, but now families are being processed a lot more quickly so they don’t have to spend a lot of physical time in the office. Telehealth has provided an opportunity for screening, as we have more time with families during video visits to talk about their needs. Telehealth has also increased access to mental health providers, and pediatricians should be aware of opportunities to connect patients to tele-psychology or psychiatry in their communities.
When referrals for mental health are not warranted or made, pediatricians can provide advice for families on how to communicate with their child (depending on the age of the child and nature of the concerns) and how to help manage some of the stress their children are feeling at home. For example, a school-aged child who is having trouble focusing in virtual school but is otherwise functioning OK can be supported by having open and honest conversations with their caregivers about what thoughts and concerns might be distracting them and providing a space in their home, where possible, that is free of distractions. Providing a sounding board for parents who have to be creative during these tough times is also valuable.
The pandemic may have changed the way we've been able to operationalize mental health screening and communication but it's remained at the forefront of all of our visits. The first thing we say when we start a visit is, how are you feeling and what's been going on with you, is your family OK? With that question, we are asking if they are OK physically, but also emotionally. We want to improve communication with our families, and also support them in communicating with their children during the pandemic. Open communication is key to dealing with the distress that comes with the uncertainty of additional waves of illness, school closures, etc.
How can pediatricians and parents distinguish between what’s normal for a child and what may indicate a mental and behavioral health issue?
One of the main goals of our guidance is to remind pediatricians and families that young children react to stressful events such as the pandemic in varying ways depending on their age, developmental stage, prior experiences, individual temperament, and social context.
For example, an infant who is developing a secure emotional attachment to her caregiver(s) may react to the stress felt by their attachment figure. A toddler who is establishing independence and autonomy still requires guidance and structure, which is challenging to provide in these stressful times. Older children and adolescents depend on social connections as they develop a sense of self-competency and their position in the world—all of which is being disrupted with the pandemic. Many of these reactions are normal and expected, and children are very resilient. However, if parents notice that their child is unable to maintain a level of function that resembles their prior state, such as eating and sleeping well, concentrating on tasks such as schoolwork, or are isolating to the point where they can’t carry on their daily activities, then they should discuss with their pediatrician.
How does this guidance address the effects of the pandemic on children in communities of color?
The guidance reminds pediatricians to maintain awareness of the impact of racism on health disparities from long before the pandemic.
There are mental health disparities and inequities in the manner in which children with mental health concerns are identified and treated. For example, a Black or Brown child who presents with a behavioral concern may be mislabeled, and access to care for these concerns is often limited and/or misdirected. These disparities may be heightened during the pandemic as all children are more stressed and potentially displaying more symptoms, increasing the possibility of misdiagnosis and inappropriate recommendations or care when access to care is already more limited because of COVID.
General health inequities have also been exacerbated during the pandemic as marginalized populations are suffering a disproportionate amount of disease burden and loss, as well as economic loss and challenges of providing resources for their children.
How is the economic stress of the pandemic affecting the emotional health of children?
Emotional health encompasses the health of an individual’s mind as well as healthy relationships with others and overall social well-being. We're seeing a huge increase in social needs, including food and housing insecurity and unemployment. Before the pandemic, about 10-15% of the families in our population screened positive for food insecurity, but that has risen to 30-40% and it may be even higher now. And while many families are now facing unemployment, some of our families have to work in situations that put them at risk for COVID and they can’t be there for their child to nurture them and help them with virtual school. Thus in either scenario, with parents working or not, children are experiencing uncertainties and risks that lead to emotional distress.
Economic stress is also affecting the extent to which children can successfully engage in school and learn. Children and families without access to sufficient computers, WiFi access, quiet and adequate space, etc., are at a disadvantage.
We have several programs in place to help families facing food insecurity and other social stressors. We work closely with community organizations and social service agencies whose role has always been in assisting families with economic and other social challenges. Health care systems should partner with such agencies now during the pandemic and always.
How can pediatricians help families cope with winter approaching?
We are about to enter another surge of change, uncertainty, and risk during the winter, and with every change comes a wave of distress. We should anticipate this and provide guidance early and consistently rather than reactively. Our guidance emphasizes the importance of building resilience in families. In our traditional medical model, we focus on identifying what’s wrong—such as physical signs of illness—and treating those problems. We should instead focus on “what’s strong” and consistently build those factors. Remaining at home during the pandemic provides an opportunity for families to spend more time together focusing on positive things, enjoying each other’s company, and doing small things such as simply laughing and playing, which help build psychologic and physiologic resilience and protect against mental health problems.
The recommendations also point out the importance of self-care for parents and caregivers. Parents must be patient and take care of themselves to mitigate some of their sense of being overwhelmed in order to be able to recognize and care for their child's mental health needs. We encourage pediatricians to support parents by being empathetic, screening for maternal depression, partner violence, and other sources of emotional stress, spending a few moments discussing the caregiver’s well-being, and referring to resources for adult mental and behavioral health.
Evelyn Berger-Jenkins, MD, is a pediatrician at the Charles B. Rangel Community Health Center, part of NewYork-Presbyterian’s Ambulatory Care Network.
The American Academy of Pediatrics published the recommendations, titled "Interim Guidance on Supporting the Emotional and Behavioral Needs of Children, Adolescents, and Families During the COVID-19 Pandemic," on Oct. 23.