Understanding and supporting our most vulnerable youth

The impact of COVID-19 on the Greater Houston community has been, and continues to be, unpredictable. However, there is one thing we know with certainty — the pandemic is affecting children’s mental health. Adults and children alike feel the psychological impact of the pandemic, which often includes anxiety about the possibility of becoming infected and/or infecting others, the significant economic toll on families who have lost jobs, and decisions regarding whether and how to send children back to school. Social distancing can also make us feel more socially isolated, depressed, and lonely. In fact, we know that social support is a major protective factor when facing adversity — one that is now missing for many children and families.1

It is also important to recognize that most of these reactions are completely normative in the context of the pandemic. And in fact, small amounts of anxiety can actually be adaptive and protective. To some degree, this is what helps us to feel compelled to wash our hands and practice social distancing. Too much anxiety, on the other hand, can cause significant distress and lead to further psychological issues. 

COVID-19’s psychological effects on children

Children may be at particularly high risk for longer term anxiety and depression as a result of the pandemic. They are often highly attuned to their parents’ own reactions; however, they may lack the cognitive ability, insight, or support to effectively express and process their feelings. In addition, the return to school, either virtually or in person, can have its own set of psychological consequences. For example, we have heard children who recently returned to in-person learning worry, “What if I get sick? What if I end up getting mom or dad sick, how will they take care of me?” We have also heard children participating in remote learning say, “Sometimes I feel invisible. I’m not sure if anyone remembers that I’m even there.” 

Increased anxiety and depression 

Although there have been few rigorous research studies examining the impact of the pandemic on children’s mental health, we know from a recent review of studies from other countries that children and adolescents appear to be experiencing high rates of anxiety and depression.2 

How children manifest these symptoms can vary widely depending on the child’s age and developmental stage. For example, preschool-aged children may appear to be “clingy” with caregivers and become distressed at even brief separations. They may also show developmental regressions (e.g., eating, speech/language delays, toileting), increased oppositional behavior, and increased tearfulness. School-aged children may develop new fears or worries, such as fear of the dark, being alone or loud noises. They may also have difficulties sleeping, nightmares, increased irritability, and somatic complaints (headaches, stomach aches). Adolescents may exhibit similar problems, and are also likely to demonstrate lethargy or apathy, social withdrawal (isolating themselves in their room), increased moodiness or hopelessness about the future.

Worsened outcomes for children with pre-existing risks 

The psychological impact of the pandemic on children is closely intertwined with other preexisting risks and protective factors. For example, children may be more at risk for psychological and behavioral problems, including school-related outcomes, if they had preexisting mental health issues and/or had experienced prior traumas or losses. One of our studies conducted prior to the pandemic showed that bereavement was the strongest predictor of poor school outcomes (e.g., poor school grades, increased school drop-out, lack of school connectedness) among adolescents above and beyond any other form of trauma, including physical abuse, sexual abuse and/or witnessing domestic violence.3 This is particularly relevant for children in our underserved Black and Latino communities where we are seeing higher rates of pandemic-related deaths.4 

For children with histories of trauma or loss, certain aspects of the pandemic can serve as trauma reminders (people, places or situations that remind the child of a prior traumatic event), leading to symptoms of post-traumatic stress. For example, seeing or hearing about individuals dying from COVID-19 can bring back disturbing thoughts or images of how other loved ones may have suffered or died. A twelve-year old girl who experienced the death of her mother to cancer began to complain of heart palpitations and nausea every time she saw a news story that involved COVID-19 patients in the hospital. “It makes me feel like her death is happening all over again. Just seeing the hospital gowns and doctors rushing into the room — I start to feel sick to my stomach.”

Children’s grief in the context of the pandemic

Over 215,000 Americans have died as a result of COVID-19 at the time of publication. A recent study estimated that nine family members are affected by one person who dies of the coronavirus.5 This means that nearly two million individuals (including children) are grieving. Unfortunately, these numbers are growing, even within our own Greater Houston community, and even more rapidly among our Black and Latino families. The context in which the deaths are occurring (e.g., social distancing that prevents in-person, ongoing support and collective mourning) makes the grief-related impact even more pronounced, particularly for children and adolescents.

After a death, concerned parents and caregivers often ask, what should I expect from my child? What is considered a “normal” grief reaction? This is a difficult question to answer given that grief is influenced by a host of factors including the child’s age/developmental stage, prior traumas/losses, culture, religious/spiritual beliefs, family environment, and circumstances of the death, just to name a few. Our work with bereaved youth has shown us that children tend to grapple with three primary bereavement-related challenges: separation distress, existential/identity distress, and circumstance-related distress.6,7

Separation distress can take the form of really missing the person who died and yearning and longing to have them back. Existential or identity distress includes feeling lost without the person or unsure of how life will go on without the person’s physical presence. Circumstance-related distress involves excessive worries or concerns about the way the person died, such as guilt or shame or anger about what caused the person to die. 

At the same time, it is helpful to recognize that there is such thing as “good grief”, in that children and adolescents can and do find healthy ways of coping with each of these bereavement-related challenges.6 For example, when facing separation distress, children often engage in behaviors or activities that help them to feel connected to the person who died either by doing the same things that they used to enjoy doing with the person, memorializing them or identifying personality traits or interests that they had in common. 

When facing existential/identity distress, youth can often find ways to carry on the legacy of the person who died or ensure that they’re living the kind of life that the person would have wanted for them. 

And when facing circumstance-related distress, children naturally gravitate toward finding ways to transform the circumstances of the death into something meaningful so that people can avoid suffering in the same way.8 For example, a ten year-old boy who lost his mother to breast cancer said, “I try to raise money every year for the breast cancer walk so that other kids don’t have to go through what I went through.” Or a fourteen year-old girl who lost her sibling in a car accident said, “I want to become an ER doctor so that I can save kids’ lives. I don’t want other kids to die like my brother did.”

What can we do to help children during COVID-19?

Although the pandemic may feel out of control, there are things that we, as adults and caregivers, can do to help children who may be struggling with strong emotions.

Addressing anxiety

Help children to recognize what they CAN and DO control.
While we may not be able to control what’s happening in our environment, we can control our own proactive efforts to stop the spread of the virus through physical distancing, wearing a mask and hand washing. Help children to feel empowered by “choosing” the ways in which they are helping themselves and their family to stay safe. We can also help to monitor and control children’s exposure to graphic news stories about the pandemic.

  • Encourage emotional awareness.
    Children have an easier time coping with their own emotions when they are encouraged to observe and identify them, as opposed to trying to push them away or hide them. This often requires the help and support of a caring adult to label feelings and normalize their reactions. For example, a parent might say, “It looks like you might be feeling nervous about going back to school. That’s totally normal and understandable, and sometimes it can help to talk about it. What can you tell me about how you’re feeling right now?”
  • Teach breathing exercises
    Breathing exercises can help to reduce the physiological aspects of anxiety by helping to reduce heart rate and blood pressure. Children and adolescents can easily implement these exercises when they’re feeling stressed. This is very effective for adults as well.
    • Breathe in through the nose for a count of 4 seconds.
    • Hold the breath for a count of 7 seconds.
    • Exhale through the mouth for the count of 8 seconds.
    • Repeat the cycle 4-8 times as needed.
  • Embrace enjoyable activities
    Sometimes a little distraction can go a long way to reduce anxiety or stress. Caregivers can help children by identifying activities that they might enjoy, whether it’s going for a walk, watching a favorite tv show, or calling a friend or family member.

Addressing sadness or depressive symptoms

  • Shift focus to a better future: Help children recognize that the pandemic is temporary (even though it may seem like it’s going to last forever) and it will eventually come to an end.
  • Emphasize gratitude: Introduce the idea of practicing gratitude by helping children write in a journal or on paper three things that they’re grateful for each day. This can also become an end-of-day activity that the whole family participates in together.
  • Find a support network: For adolescents who may be less comfortable confiding in their parents, help them to identify at least one person who they can check in with each day – someone who can be a listening ear and offer comfort or support.

Addressing Grief

Caregivers often shy away from discussing the death of a loved one with children, as they tend to worry that they’re somehow “planting a seed” or raising concerns where there aren’t any. On the contrary, what we’ve learned is that children feel understood and validated when caregivers openly discuss the person’s death.9 It is helpful to use simple, developmentally appropriate language and let the child guide the conversation whenever possible. For example, a parent might say “I know Grandma’s death can feel confusing or upsetting, especially since we couldn’t be there to say goodbye to her. What kinds of questions or worries do you have? I would really like to hear how you’re feeling.”

To address separation distress (yearning or longing for the person who died):

  • Help children find ways to feel connected to the person who died, which can include looking at photos or videos of the person together, memorializing the person by lighting a candle or planting flowers in their honor, or engaging in activities that the person really enjoyed.
  • If children were not able to say goodbye prior to the person’s death, it can help to write a letter to the person that includes everything they would have wanted to say to them.
  • If at all possible, give children an opportunity to hold onto something tangible that reminds them of the person, like a necklace or a photo.
  • Talk about the person who died – say their name often, talk about positive memories, encourage the child to share stories about the person.

To address existential or identity distress, (when we feel like our lives are permanently altered or we don’t know who we are anymore):

  • Help children identify all of the positive traits or characteristics they have in common with the person who died and discuss how they can carry on the legacy of the person by focusing on those traits and behaviors.
  • Help children think about what the person would have wanted for them. How can they live their life in a way that honors the person’s memory?

To address circumstance-related distress, (being very preoccupied with unhelpful thoughts about the circumstances of the death):

  • If the death is due to COVID-19, help children identify the ways in which we are coming together as a society to try to tackle this problem and things they are already doing to prevent the spread of the virus.
  • Often the circumstance-related distress stems from unanswered questions or concerns that children have about the way the person died (e.g., Did they suffer? Were they sad or scared?). . It can be helpful for children to ask the questions they have, or if it’s too difficult to express them out loud, they can write questions on a sheet of paper. Use simple and straightforward language to answer the questions without going into excessive detail. For more complicated questions, it can be helpful to have children speak to a physician who can provide information in developmentally appropriate terms that they will understand.

Know When to Seek Additional Help 

  • Although most children will be resilient and even grow and learn from this pandemic, we also know that a number of youth will require more than just parental support. Below are what we would consider “red flags” that may indicate that a child requires a more thorough evaluation and possibly therapy:
  • Functional impairment: For younger children this can look like behavioral regressions or significant changes in behavior like extreme aggression or extreme fear to the point where a child refuses to leave a caregiver’s side. For older children, this can involve trouble getting out of bed in the morning, constant tearfulness or extreme withdrawal.
  • Dangerous behaviors: Excessive risk-taking behaviors, alcohol use, or drug use in adolescents should also be considered concerning.
  • Obsessive behaviors: Hand washing is encouraged, but if children reach a point where they become visibly distressed when they are not washing their hands or if it feels excessive, this is something to explore further.
  • Self-harm or suicidal tendencies: Any expression of a wish to die or hurt themselves likely requires an evaluation with a therapist.

There are now plenty of telehealth options across the U.S. where children can be seen virtually by a therapist. You can either call your pediatrician or a mental health provider in your area to see what might be available, and there is good evidence to suggest that teletherapy is just as effective in reducing distress as in-person therapy.10

In addition, Texas Health and Human Services has launched a 24/7 statewide mental health support line operated by the Harris Center. Individuals who are experiencing distress due to COVID-19 can call 833-986-1919 at any hour of the day to speak with a mental health professional.

Although the pandemic has, in many ways, created more social isolation, it has also helped to raise awareness about the importance of mental health and well-being for our youth. Collectively, we have the ability to help children identify and address difficult emotions and come through the pandemic with even more skills to cope with whatever life throws their way.

Julie Kaplow, Ph.D., ABPP, is executive director of The Trauma and Grief Center (TAG) Center at The Hackett Center for Mental Health. The TAG Center raises the standard of care and increases access to best practice care among youth who have experienced trauma and bereavement.

References:

  1. Hostinar, C. E., Sullivan, R. M., & Gunnar, M. R. (2014). Psychobiological mechanisms underlying the social buffering of the HPA axis: A review of animal models and human studies across development. Psychological Bulletin, 140(1), 256-82. doi: 10.1037/a0032671.
  2. Wagner, K. D. (October, 2020). New findings about children’s mental health during COVID-19. Psychiatric Times.
  3.  Oosterhoff, B., Kaplow, J. B., & Layne, C. (2018). Links between bereavement due to sudden death and academic functioning: Results from a nationally representative sample of adolescents. School Psychology Quarterly, 33(3), 372–380.
  4. Centers for Disease Control and Prevention (2020). COVID-19 hospitalization and death by race/ethnicity. Report can be found here: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
  5. Verdery, A.M., Smith-Greenaway, E., Margolis, R., & Daw, J. (2020). Tracking the reach of COVID-19 loss with a bereavement multiplier applied to the United States. Proceedings of the National Academy of Sciences, 117 (30), 17695-17701.
  6. Kaplow, J.B., Layne, C.M., Saltzman, W.R., Cozza, S.J., & Pynoos, R.S. (2013). Using Multidimensional Grief Theory to explore effects of deployment, reintegration, and death on military youth and families. Clinical Child and Family Psychology Review, 16, 322-340.
  7. Layne, C.M., Kaplow, J.B., Oosterhoff, B., Hill, R., & Pynoos, R. (2017). The interplay of trauma and bereavement in adolescence: Integrating pioneering work and recent advancements. Adolescent Psychiatry, 7(4), 266-285.
  8. Kaplow, J.B., Layne, C.M., & Pynoos, R.S. (2019). Treatment of Persistent Complex Bereavement Disorder in children and adolescents. In M. Prinstein, E. Youngstrom, E. Mash, & R. Barkley (Eds), Treatment of disorders in childhood and adolescence (4th ed., pp. 560-590) New York, NY: Guilford Publications, Inc.
  9. Shapiro, D., Howell, K., & Kaplow, J. (2014). Associations among mother-child communication quality, childhood maladaptive grief, and depressive symptoms. Death Studies, 38(3), 172-178.
  10. Boydell, K.M., Hodgins, M., Pignatiello, A., Teshima, J., Edwards, H., & Willis, D. (2014). Using technology to deliver mental health services to children and youth: A scoping review. Journal of the American Academy of Child and Adolescent Psychiatry, 23(2), 87-99.

Additional Resources:

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