Mental Health During Covid-19: Child Mental Health Crisis

What about the children? How are they doing during COVID 19? What are the issues? What are the action items?

Some children are and will continue to suffer as a result of Covid-19. Let’s talk about three ways in which children might be suffering, and let’s talk about how we can develop a greater sensitivity to children who are living through this pandemic.

1. There is very likely to be an increase in child abuse, including verbal, physical and sexual abuse. The increase in child abuse is likely to be a result of greater family stress, more time together, and economic uncertainties. Parents have become de facto home school teachers, with little preparation or training to educate their children. In addition, some parents are trying to maintain full time jobs while home-schooling their children. Other parents are laid off from work, and are looking for a new job, and they are home-schooling their children. Babysitters, tutors, housekeepers are all not allowed in quarantine, so the family tension has increased significantly, which can lead to poor impulse control in both the parents and the children. Online education is limited by how much time a child can spend in front of a computer screen, and the younger the child, and the more immature the child’s nervous system, the more it is unlikely that the child can have sustained attention for online learning, thereby adding even more stress to unprepared parents.

In addition, in the absence of children physically attending school, there is less of an opportunity for teachers or school counselors to report abuse to social services. For children in loving families, this can be a special and precious time together, which will cause loving and long-lasting memories. For children in previously abusive families, this can cause unmitigated abuse, without the presence of previous safety nets. For most children, it will be a combination of loving times, alternating with unloving, and impatient times, alternating again with mean/abusive times. Although in ordinary times, all of the above is true, what is unique about COVID-19 is that a child’s life is deeply compressed because there is no physical school, there are no after-school activities outside the house, and there are no trips to friends houses or to grandparents houses.

The family unit is a closed unit, and so we, as healthcare professionals need to be prepared to advocate for these children who are in environments which are harmful to their emotional growth and development. We cannot assume that each parent is coping “as best as they can” because “as best as they can” may be causing long-lasting damage to the innocent child who literally has no where to escape to.

Suggested action item: Each clinician, including pediatrics, family medicine and obstetrician/gynecologists need to be mindful about how the children are coping during this pandemic. Pediatric clinicians should ask every parent, and every child (without the parent present) about how they are doing during this time. More specifically, the pediatrician needs to take private time with the child, ages 4 and up, and ask directly, if their parents are ever mean to them, or if their parents beat them up, or if there is any inappropriate touching. I know these are delicate questions, and they may not be needed for every child, but at the very least, each pediatric clinician needs to be ready to ask these questions, if the child suggests there may be abuse at home or if there is known prior abuse. A positive response may prompt a report to children’s services, but if the response is vague, it could prompt a referral to a child mental health professional for further investigation.

Pediatric clinicians need to embrace mental health assessments as part of their job, as there are fewer eyeballs on our children, and so clinicians need to step up during this time.

Family medicine clinicians must also check in with the children, but since the parents may also be their patients, they should also check in with each parent, specifically about how their parenting is going, and asking directly, if the parent feels they are maintaining or losing control with their children? Allow the parent to ask for help for their parenting, and have resources on the ready, for parents who are feeling at loose ends. An example of a good resource, is one put out by NYU https://nyulangone.org/news/schools-out-parents-guide-meeting-challenge-during-covid-19-pandemic.

Obstetricians/Gynecologists should inquire about new mothers, specifically inquiring about how the attachment is going, as stressed mothers may have trouble bonding with their newborns.

2. Children with special needs, particularly less verbal children, might propose a huge challenge during this period. Special needs children often have multiple specialists who help them, but during this time, not all specialists can help these children with online work. Special needs children may not have the motivation or the attention span to stay in front of a computer screen, and so vital learning may not be taking place. There is no easy answer to this problem, as parents are not usually special education teachers, and so these children might simply miss out on important parts of their education during this time. However, as time progresses, it is possible that some special education teachers can be considered essential services, and as such, learning can resume with the proper protective equipment.

3. Each child has an emotional growth curve which is dependent on their peers for social learning. The age of the child will determine the needs of that child, but as a general principle, the isolation of these children from in-person play is going to hamper their emotional development. The degree to which this will harm a child is individualized, and as children are resilient, most children will bounce back as social isolation recedes. Having said that, as clinicians, it is our job to watch out for those few children that have trouble bouncing back. Some children will develop anxiety disorders, and in particular, social anxiety disorder, in which being with people is a source of enormous stress. Although in the context of the virus, that makes sense now, if social anxiety persists long after the virus threat is gone, then clinicians must identify and treat this as we would any other form of social anxiety disorder.

In summary, we, society, we, primary care clinicians, must think about our children. The children we see, the children of our patients, our own children, and our friends’ children. It is easy to lapse into cliche that “children are resilient” but we must avoid this lapse, because it is our job as stewards of health care to make sure children grow and develop in the best possible way. The kids may not be all right.