COMMENTARY

COVID-19 Quarantine: Managing Pediatric Behavioral Issues

Susan D. Swick, MD, and Michael S. Jellinek, MD

Disclosures

May 15, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

We are living through unprecedented challenges, faced with profound uncertainties about the public health, the economy, the safety of our workplaces, the risks of gathering with friends and family, and even about the rhythm of the school year. Parents always have sought guidance from their pediatric providers when they are uncertain about their children's health, behavior, and development. We want to share some guidance with you about several of the most common questions we have been hearing in the past few months, in the hope that it may prove useful in your conversations with patients and families.

What happens when we are so busy at home that our 2-year-old is ignored for much of the day?

If they are fortunate enough to be able to work from home, but have lost their child care, many parents are suddenly facing the sustained challenge of parenting while working. Even older children will have a tough time remembering that home is now a workplace, and they can't interrupt their parents during a Zoom meeting. But older children will understand. Younger children (preschoolers) simply will not be able to understand that their parents are in sight but not fully available to them. They are exquisitely sensitive to their parents' attention. If they are consistently ignored, behavioral problems can emerge. If both parents are at home, they should try to arrange a schedule taking turns so that one of them could turn their full attention to their kids if need be. If a working parent can be out of sight (i.e., in another room), it makes the situation easier for everyone.

If there is only one parent at home, that mom or dad should consider arranging a babysitter or sharing child care with a friend, with some reasonable safety provisions in place. The small risk of exposure to the virus is balanced by the risk of sustained invalidation in a developing child. Help parents set reasonable expectations for how productive they can be at home. If possible, they can manage their employer's expectations, so that they do not find themselves in the impossible bind of choosing between a crying child and a crucial deadline. If they can work near the child (and be prepared for interruptions) when reading emails or writing, that may be enough availability for the child. And parents should not be discouraged when they have to repeatedly remind their children that they adore them, but also have to work while they are at home right now. Using age-appropriate screen time as a babysitter for a few hours each day is a perfectly acceptable part of a plan. Simply planning regular breaks when their children can have their attention will make the day easier for everyone at home.

What can I do about my 13-year-old who is lying around the house all day?

This is a time to pick your battles. If children can keep their regular sleep schedule, get their schoolwork done, and do some physical exercise every day, they are doing great. And if parents are continuously complaining that they are being lazy, it will probably cease to mean much to them. Instead, focus on clear, simple expectations, and parents should live by them, too. If parents can exercise with them, or try a new activity, that is a wonderful way to model self-care and trying new things. It is important to remember that the developmental task for a 13-year-old is to establish new avenues of independence that they will drive down further with each passing year. Give them some leeway to experiment and figure out their own way of handling this challenge, although it is bound to create some tension. Parents should always acknowledge how hard it is to stick with schoolwork without school, exercise without a team, practice music without a band, or do your work without an office!

What do we do about our 16-year-old who is staying up all night and sleeping until the late afternoon?

Adolescents naturally have their sleep cycle shift, so they are sleepy later and sleep longer. But staying up all night is usually about texting with friends or playing video games. The problem is that their sleep schedule can flip. They will not be able to participate in online class or enjoy exercise in the sun, and they rarely get enough sleep during the daytime, making them more irritable, anxious, inattentive, and tired. This will only make managing their schoolwork harder and increase the chances of conflict at home. So it is important to preserve rules around sleep. You might extend bedtime by an hour or so, but preserve rules and bedtime routines. Sleep is essential to health, well-being, and resilience, and all are critical during times of uncertainty and change.

We think our 17-year-old is using marijuana, and it might be a problem.

When parents think their children may have a problem with drugs, the children almost certainly do, as parents are typically the last to know about the extent of their use. Sheltering in place together may make their drug use much more apparent, and offer an opportunity for parents to respond. Talk with them about it. Let them know what you have noticed. See if they can tell you honestly about their drug use. Kids who are only experimenting socially are unlikely to be using drugs at home under quarantine. If you are truly calm and curious, they are more likely to be honest, and it could be a relief for them to discuss it with you. Find out what they think it helps, and what – if anything – they are worried about. Then share your concerns about marijuana use and the developing brain, and the risk of addiction. If they think it is “medical” use, remind them that anxiety or mood symptoms get better with therapy, whereas drugs (including marijuana) and alcohol actually worsen those problems. It is also a time to establish home rules, explain them, and enforce them. They will have your support while stopping and may learn that they are actually sleeping and feeling better after a few weeks without marijuana.

Parents should not hesitate to reach out to pediatric providers for guidance on local resources for assessment and treatment for substance abuse and addiction. These are medical problems, and they can become serious if untreated.

My 12-year-old perfectionist is very stressed about getting her work done well now that she is home schooling. How do I help her relax?

Some children, especially our anxious perfectionists, may respond to the switch to home school with great effort and organization. These kids usually are not the ones parents worry about. But they are very prone to expanding anxiety without the regular support and feedback of teachers. The school environment naturally encourages their taking chances and normalizes the setbacks and failures that are an essential part of learning something new. At home, parents are inclined to let these kids work independently. But they benefit from regular check-ins that are not focused on work completion or scores. Instead, ask about what they are doing that is hardest, and let them teach you about it. Model how you approach a new challenge, and how you regroup and try again when you don't get it right. Finally, this is a good age to start discussing “reasonable expectations.” No one can “do their best” all the time; not parents, not professional athletes, not even machines can sustain long bursts of maximum speed without problems. Help them to start experimenting with different speeds and levels of effort, and see how it feels.

My 10-year-old is very anxious about catching coronavirus or one of us catching it. How do I help ease her anxiety when there is no certainty about how to prevent it?

Anxiety is a normal response to a situation with as much uncertainty as this one. But some are prone to more profound anxiety, and parents may find they are doing a lot of reassuring throughout the day. For especially anxious children (and adults), accommodating the anxiety by avoiding the stressful situation is a common response that provides temporary relief. But accommodation and avoidance actually fuel anxiety, and make it harder and harder to manage. It is important to talk about the “accommodations” we all are doing, how masks are recommended to protect others (not ourselves) and to slow down the spread of a new illness so our hospitals aren't overwhelmed. It can seem counterintuitive, but rather than jumping to reassurance or dismissing their sense of risk, ask your children to play the full movie of what they are most worried about. What happens if they get sick? If you get sick? If they are worried about dying, go ahead and ask what they think happens then. You are demonstrating that you have confidence they can handle these feelings, and you are modeling curiosity – not avoidance – yourself. Correct any misunderstandings, check on facts together, acknowledge uncertainty. It also is very important for parents to assess whether their own anxiety level makes this task especially hard or may even be contributing to their children's level of worry. Each of us is managing anxiety right now, and this moment presents an opportunity for all of us to learn about how we can face and bear it, learn to manage, and even master it.

We are all getting cabin fever at home and snapping at each other constantly. How do we keep the peace without just hiding in our rooms all day?

Cabin fever seems inevitable when a family is suddenly at home together all day every day with no end in sight. But if we establish some simple and realistic routines and preserve some structure without being rigid, it can go a long way to helping each member of a family to find their equilibrium in this new normal. Structure can be about preserving normal sleep and meal times. Ensuring everyone is getting adequate, restful sleep and is not hungry is probably the most powerful way to keep irritability and conflict low. It is also helpful to establish some new routines. These should be simple enough to be memorable and should be realistic. You might identify predictable blocks of time that are dedicated to school (or work), exercise, creative time, and family time. While much of the day may find each family member doing some independent activity, it helps when these “blocks” are the same for everybody. Try to consistently do one or two things together, like a walk after the family dinner or family game time. And also remember that everyone needs some alone time. Respect their need for this, and it will help you to explain when you need it. If someone wants to sit out the family Yahtzee tournament, don't shame or punish them. Just invite them again the next night!

We are all getting cabin fever at home and snapping at each other constantly. How do we keep the peace without just hiding in our rooms all day?

The great majority of kids (and parents) will not suffer any adverse consequences from the increased amount of time spent in front of screens when these activities are varied and serve a useful purpose – including distraction, senseless fun, and social time. Beyond letter or email writing, screen and phone time are the only ways to stay socially connected while physically distant. But parents are the experts on their kids. Youth who are depressed and have in the past wanted to escape into long hours of video games or YouTube videos should not be allowed to do that now. Youth with attentional issues who have a hard time stopping video games will still have that difficulty. If they are getting adequate sleep and regular exercise, and are doing most of their school work and staying socially connected, screens are not dangerous. They are proving to be a wonderful tool to help us visit libraries and museums, take dance classes, learn new languages, follow the news, order groceries, or enjoy a movie together. If we stay connected to those we care about and to the world, then this time – although marked by profound suffering and loss – may prove to be a time when we were able to slow down and remember what truly matters in our lives.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They have no relevant financial disclosures.

This story originally appeared on MDedge.com.

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