The parent of a normally healthy, happy kindergartener whom you've cared for since birth calls. Her child is refusing to go outside of the home because he is scared of "the virus." This is not your only patient with behaviors or somatic complaints that are out of character during normal times.
What do you do? We spoke with John D. Guerry, PhD, a clinical psychologist at Children's Hospital of Philadelphia, about his advice to help kids remain emotionally healthy during this unprecedented pandemic.
What are you hearing, both from your own patients and your colleagues? What are their concerns about kids in their own practices? How are kids faring in these early weeks of the COVID-19 pandemic?
It's too soon, of course, to have real data on the effect of the pandemic and the resultant responses—school closures, social distancing recommendations, etc.—on kids. Anecdotally, from speaking to patients, families, and colleagues, it is pretty clear that these are, to say the least, very disconcerting times for all of us. And one thing that I'd emphasize for all practitioners, both behavioral health and medical professionals, is to remind families that some level of anxiety and sadness during this time—and this is an unprecedented time—is completely normal and even adaptive. We're in uncharted territory.
Along with that comes the recognition that anxiety, at its core, is there to protect us from danger because it motivates us to move away from or mitigate whatever threat we're facing. In this context, worry about getting sick and infecting others is exactly what drives us to follow the strict mandates from government leaders to avoid potential exposure to ourselves and others as much as possible.
It's also, right now, completely normal to experience a certain amount of sadness in response to the very serious precautions that we all need to take and the things we're temporarily losing out on in the process.
But the dramatic changes in all of our lives right now can also lead to a disproportionate emotional and behavioral response, and even panic. The child afraid to step outside whom you described earlier is an example. You may see children and parents who are so worried that they excessively wash their hands or clean their environment, even though they've not had any likely exposure. Or they may be so frightened that they are unable to go to the grocery store or pharmacy to meet their needs, even while following guidelines for reasonable precautions. Again, some level of anxiety is understandable, but these kinds of disproportionate reactions and behaviors can actually serve to make someone more anxious.
It's important to note that even though we're all in this together, a person's response may be very individual. A large part of anyone's reaction to the COVID-19 pandemic will depend on their personal vulnerabilities before it happened.
As I mentioned before, some people are overly concerned and driven to excessive behaviors. But some people—and you can hear the exasperation in the pleas from some of our state governors in response to those who chose not to follow social distancing guidelines—might benefit from having more anxiety right now.
What is your basic advice to anyone—overly worried or too cavalier—to help kids stay mentally healthy?
There are a number of simple measures that should be used for kids of all ages. Limit news consumption and ensure that it's coming from a reliable source. Keep kids exercising, outside if possible. Maintain a schedule, and stay on track with sleep and nutrition. Keep in touch virtually with important people in the child's life, such as teachers, friends, and extended family members. Keep kids in the loop about what is going on, but keep it simple and developmentally appropriate.
As a behavioral health practitioner, I always emphasize that stress management is foundational. And I would especially note that self-compassion is important for not just kids, but also parents.
And now is a good time for children and families to either continue their work with a therapist through telehealth or, if determined to be necessary, to initiate psychotherapy.
Recognizing your point that some degree of fear, anxiety, and sadness is normal and appropriate, what are red flags, voiced by kids or parents, that would suggest to you that there is more going on than an appropriate situational reaction?
First, it would be helpful for all caregivers, at home and in the clinic, to recognize that stress and worry sometimes result in unusual behavior and acting out. Children often express their experience of stress and anxiety in different ways (eg, body aches, irritability), so it is important to notice these changes and talk to your kids about the feelings underlying their behavior. I also suspect that pediatric clinicians are seeing a rash of somatic complaints, such as stomachaches and headaches. All of us, of any age, are going to be experiencing a lot of functional difficulties and physical symptoms resulting from the way we take care of and use our bodies.
We're eating differently, experiencing changes in sleep schedules and activity levels, and have unfamiliar levels of stress, above all. Temporary somatic changes are, for the most part, okay.
That's not to suggest that families should not check in with their child's medical professional, by phone ideally, if they fear that they may be misattributing their child's physical complaints to stress.
The red flags that worried us before this global pandemic are the same now. Suicidal ideation, self-harm behaviors, violent acting out, delusions, or a big change in a child's normal functioning need to be treated the way they have always been: with an urgent assessment.
We have already seen an increased use of suicide hotlines. During previous pandemics, such as the Spanish flu of 1918-1919, reports of psychosis and hallucinations increased. New York State is calling on mental health professionals to volunteer to staff emotional support volunteer hotlines, which are already seeing a rising volume of calls.
All of us in behavioral and mental health specialties are trying to understand and take into account this new baseline. The restrictions preventing us from doing so much of our daily routine are also causing us all to be socially isolated. Kids who are having difficulty adjusting to this really challenging time beyond what would be expected for their age and developmental level are going to require our support. We have no idea how big that population of children will be.
Social media is full of parenting tips to support parents and kids during this time. What do you say to parents of your patients?
It is an overused metaphor but one I think we should all use especially now. Before takeoff, all airlines remind passengers to secure their own mask before securing the mask of their child. That message is especially important when the parent is a healthcare professional or first responder. The first and most important thing that parents can do to take care of their children is to take care of themselves. Children in particular will react to parental cues about how to respond, both emotionally and behaviorally.
Parents are vulnerable humans, too. They need to give themselves permission to feel anxious amid the uncertainty arising from this public health crisis and the economic fallout. I encourage parents to seek outside support from friends and adult family members and to discuss their concerns away from their children and teenagers so that they can speak freely. That is not to say that they should keep information from their kids. Parents need to be able to talk to children in a developmentally appropriate way, but not when they are experiencing acute emotions themselves, are uncertain about information, and are concerned about how their coping might affect their children. In those circumstances, all of us in the healthcare field should reinforce the idea that it is important and okay for parents to hit the pause button and get to a place where they can process before they respond to their children.
It is anecdotal, but a number of experts have voiced concerns about potential upticks in domestic violence, including child abuse. The FBI issued a notice about increased risk for child exploitation. Some experts have also raised concerns about a rise in cyberbullying. Have you seen any evidence of increases?
I think it's too early to tell. I am not aware of any data reporting a real uptick in these kinds of things. But I'm sorry to say that I wouldn't be surprised to learn that this could be true. For example, any time kids have more time to spend on social media, there will be increased risk for all the potentially negative things that come with it. I do think now is the time when it's generally important for parents to keep an eye out and monitor their kids and teenagers and, in particular, their online activities. Ideally, this monitoring should be done respectfully and unobtrusively. It is good and important, especially for teenagers, to maintain that connection to their friends, but to do so in a safe way.
Now is also a good opportunity to teach empathy and prosocial behaviors to our kids. Parents can really help both their children and the members of the community by reinforcing an essential truth: What teens do or don't do right now can have a significant impact on people, and particularly on medically vulnerable others. At the same time, we need to recognize that stringent rules and restrictions in general, and social distancing guidelines in particular, really fly in the face of normal adolescent development. It is usually healthy for teenagers to strive for autonomy, connect with their friends, and even take certain risks. Parents can validate their teen's feelings while also helping them understand what is at stake here.
This is a time for parents to set clear structure and expectations, and even to gracefully put a foot down. For example, whatever expectations and limitations regarding the nature and quality of social media contact that parents had before the pandemic should absolutely continue, even if the amount of time they permit their child to be online might understandably be increasing.
You suggest that online behavior be monitored unobtrusively. How does that look in real life?
Good question. And so much of the answer depends on the age of the child. Many parents insist—and I think this is generally good practice, especially when a younger child is just getting started in the world of social media—that the parent be added as a friend and able to see what kids are posting. The unobtrusive part becomes more important as children get older. By high school, it is important for parents to back off and give kids more free rein while also sending the message that they always want their teenager to come to them for guidance if something is going on that they're unsure of or that makes them uncomfortable.
There is never a one-size-fits-all answer to that question. Parents just need to make sure that they are checking in with their kids; asking about the types of things getting sent around; and taking a curious, interested attitude.
More broadly, during times of stress, parents sometimes relax typical expectations for their kids' behavior and skip following through on natural consequences or rewards. It is important for medical practitioners and families to give permission to parents to continue to set limits, because kids of all ages benefit from routine, predictability, structure, and clear expectations. This will help kids feel a sense of normalcy. Parents of younger children might find it helpful to implement a reward system to help kids stick with their new routine and praise them whenever possible when they are doing the right thing.
My own kids are preschoolers. Early on, when my wife and I suddenly found ourselves working from home and trying—and mostly failing—to juggle full-time childcare, we made the mistake of not establishing firm routines with our kids. And now we are paying the price as we redevelop that structure. But we have forgiven ourselves while trying to help others learn from our early mistakes.
John D. Guerry, PhD, is a clinical psychologist specializing in the evaluation and treatment of anxiety and related emotional difficulties. He has a particular clinical interest in working with adolescents and young adults.
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Cite this: Keeping Kids Mentally Healthy During a Pandemic - Medscape - Apr 08, 2020.