COVID-19 and Pediatric Mental Health
Oliver Joseph, MD
To say COVID-19, the disease caused by coronavirus, has changed healthcare would be an understatement. In a matter of days to weeks, we saw entire healthcare organizations transform their in-person delivery to telehealth platforms, we saw emergency rooms empty through fear of being exposed to the novel virus, and we saw primary care and routine screening, such as cancer surveillance, fall by the wayside all in an unprecedented effort to mitigate contagion spread. And this was just in the first weeks. Schools and businesses shuttered at first for two weeks, then another week, and then another, and, you know the rest. We are entering our sixth month into the variable shutdowns across different parts of the US and for some of us, we have lived through surges in our own states only to see the numbers fall now to take on a new sense of unrest as we live in daily uncertainty as to if or when there will be another surge. This degree of unrest, tension, ever-questioning, has created a sense of fatigue among many. Jonathan Zecher discusses the ancient term of acedia, referring to it as “the lost name for the emotion we’re all feeling right now.” He tells of John Cassian, a monk and theologian who wrote in the 5th century about this ancient Greek emotion. If I were to attempt to paraphrase his words, I would be doing an injustice. Rather, I will let his words speak for themselves: “…such bodily listlessness and yawning hunger as though he were worn by a long journey or prolonged fast…Next he glances about and sighs that no one is coming to see him. Constantly in and out of his cell, he looks at the sun as if it were too slow in setting.” Sounds familiar, right?
The pandemic has changed us. All of us. In many, deeply-rooted ways and in some ways that are only just becoming apparent. It has changed business, it has changed school, it has changed eating out—or, take-out for that matter. Vacations and travel have been on indefinite hold, whereas family outings to essential businesses, like the supermarket, have become the only chance for social interaction. In a matter of months, critical shortages of PPE have morphed into us being inundated with advertisements for fashionable designer-trend cloth masks. Who would have thought this is where we would be?
I write this article as a psychiatrist tasked with shining a light on how the pandemic has changed pediatric mental health. And I suspect in many ways, we will be seeing the effects for years to come. There will be evident discrepancies in many areas, some more obvious than others, and some of which we are already seeing. Differences in mortality rates among African-Americans and Latinx populations compared to Caucasian populations, differences in economic fallout rates of men compared to women returning to work versus staying at home to help care for kids who are home-schooling or out of daycare, educational fallout between private and public schools or even urban compared to suburban schools. We have heard of many inner-city children who rely on school not only for daycare and structure, but as ways to avoid gang activity and substance use, but also for some, as the only source for a consistent daily meal. We have heard about the lost education years from teachers and how far backward educationally some kids have slipped. We have heard about the difficulties of remote learning, lack of access to technology, poor internet connection, difficulties sustaining attention on a screen, as well as the paradoxical balance of limiting screen time for developing brains. And it is on the children I said I would focus. Certainly, most children have not experienced severe symptoms related to coronavirus with what appears to be an exponentially low mortality rate. This understanding, however, is a moving goal post and certainly we learn more daily as new research is conducted, testing capacity increases, and our awareness of the systemic effects of COVID-19 become clearer.
Mental health disorders are the most common disorder of childhood. Per the CDC, 1-in-6—or, about 17%—of children have or have had a mental health condition. As with adults, we see the incidence rise at times of widespread distress and tragedy. Children can demonstrate an array of symptoms, including anxiety, fear of going to school, changes in eating or sleep patterns, panic, depression, hopelessness, food and housing insecurity, and suicidal thinking and self-injury among other difficulties.
Though the research is limited this early in the pandemic, we are learning. And much of what we are seeing is exactly what one would expect. Forced school closures and the ensuing social isolation can increase the severity of current mental health symptoms as well as increase the risk for development of mental health symptoms (Clemens et al). We have seen increased rates of domestic violence and substance use in the homes, which children experience more frequently and directly when forced to stay in the home due to mandatory distancing (Campbell). Children have lost access to many social supports and routines that schools provide, including school-based mental health services, extracurriculars, classroom-learning and group work, as well as social groups (Thakur). Increased social isolation likely increases the risk of depression and some types of anxiety (Loades et al), whereas we also see for some—those with social anxiety—they enter a negative reinforcement pattern for social isolative behavior patterns and as a consequence, one would expect their symptoms to worsen as restrictions are lifted and they phase back into school, work, and other social networks (Morrison). Many youths are flooded with information—some good, some bad—from various social media accounts which can leave them feeling further isolated and hopeless (Wiederhold).
Tragic moments in history shape our outlook moving forward. Many of these are all too familiar comparisons: The Great Depression, The Holocaust, the dropping of the atomic bomb at Hiroshima and Nagasaki, 9/11, the Great Recession and housing crisis. This, too, will be a defining moment: COVID-19.
So, where do we go from here? Perhaps at least one positive has come from the COVID-19 pandemic and that is the mass implementation of telehealth platforms across the country. While telehealth has been around for years, its adoption on a widescale had been stark to say the least, largely confined to more rural areas. Now, however, it has jumped into the limelight.
Many mental health providers are implementing telehealth and this has reduced barriers to treatment. There is an array of telehealth services, including individual medication management and counseling, group work and family or couples’ therapy, and even partial hospital and intensive outpatient programs. Speaking anecdotally, telehealth appears to reduce wait times, increase appointment compliance, and reduce barriers to accessing care. If you do not have a provider, I would recommend touching base with your primary care provider seeking a referral should you need it, reaching out to local mental health organizations, or phoning your insurance company for a list of providers in your area. If you have a psychiatrist or counselor and feel your symptoms are worsening, touch base with them to be seen.
References
1. Loades ME, Chatburn E, Higson-Sweeney N, McManus M, Borwick C, Crawley E. Rapid Systemic Review: The Impact of Social Isolation and loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19. Review Article in Press. Journal of the American Academy of Child & Adolescent Psychiatry.
2. Clemens V, Deschamps P, Fegert JM, et al. Potential Effects of “Social” Distancing Measures and School Lockdown on Child and Adolescent Mental Health. European Child & Adolescent Psychiatry. 2020; 29: 739-742.
3. Campbell A. An increasing risk of family violence during the COVID-19 pandemic: Strengthening community collaborations to save lives. Published Online. Forensic Science International: Reports. 2020 Dec; 2: 100089.
4. Thakur A. Mental Health in High School Students at the time of COVID-19: A Student’s Perspective. Journal of the American Academy of Child & Adolescent Psychiatry. Letter to the Editor. August 26, 2020.
5. Wiederhold BK. Social Media Use During Social Distancing. Cyberpsychology, behavior and social networking. 2020. 23; 275-276.
Oliver Joseph, MD, is a board-certified psychiatrist in central Massachusetts. He is the Executive Director of Integrated Psychiatric Consulting, PC, and specializes in treating individuals with intellectual and developmental disabilities across the age range.
