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Table of Contents
CASE SERIES
Year : 2020  |  Volume : 2  |  Issue : 2  |  Page : 159-162

COVID-19, Social Distancing: Mental Health Implications for Children, Adolescents, and Families – Pediatric and Psychiatric Perspectives


1 Department of Psychiatry, Jersey Shore University Medical Center, Neptune, New Jersey, USA
2 Department of Pediatrics, Cooper Medical School of Rowan University, Camden, New Jersey, USA
3 Department of Psychiatry, Cooper Medical School of Rowan University, Camden, New Jersey, USA
4 Department of Psychiatry and Behavioral Health, Cooper University Health Care, Camden, New Jersey, USA

Date of Submission02-Jun-2020
Date of Acceptance04-Jun-2020
Date of Web Publication14-Aug-2020

Correspondence Address:
Rama Rao Gogineni
Cooper Medical School of Rowan University, 410 Baird Road, Merion Station, PA 19066
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WSP.WSP_55_20

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  Abstract 


COVID-19 is creating a mental health crisis among children and youth around the globe. At the time of this writing, more than 1.5 billion, i.e., 91% of the world's students are out of school. The pandemic is raising fears, and causing clinginess, distraction, irritability, anxiety, depression, lethargy, impaired social interaction, and reduced appetite. Adolescents are at higher risk for depression, anxiety, distress, low self-esteem, substance use disorder, and suicide. Mental health consequences of the pandemic can be categorized as adjustment disorders, reactions to social isolation, reactions to family and family events, violence against women and children, and intensification of preexisting mental health conditions. Major challenges are being experienced by those struggling with attention-deficit hyperactivity disorder, autistic spectrum disorders, medical complications, posttraumatic stress disorder, and other conditions. After a short description of each category, we provide case examples, which, though fictitious, bear sufficient resemblance to real-life situations encountered in our daily practice to serve as useful vignettes. The mental health community, social psychiatrists and pediatricians, and other health-care providers should take an active role to address these serious issues.

Keywords: Children and adolescents, COVID-19, families, mental health, social distancing, treatment and advocacy


How to cite this article:
Chottera S, Douglass-Bright AM, Sedky K, Gogineni RR, Rostain AL. COVID-19, Social Distancing: Mental Health Implications for Children, Adolescents, and Families – Pediatric and Psychiatric Perspectives. World Soc Psychiatry 2020;2:159-62

How to cite this URL:
Chottera S, Douglass-Bright AM, Sedky K, Gogineni RR, Rostain AL. COVID-19, Social Distancing: Mental Health Implications for Children, Adolescents, and Families – Pediatric and Psychiatric Perspectives. World Soc Psychiatry [serial online] 2020 [cited 2020 Sep 21];2:159-62. Available from: http://www.worldsocpsychiatry.org/text.asp?2020/2/2/159/292143




  Introduction Top


The COVID-19 pandemic has the potential to impose far-reaching, long-term negative consequences on children around the world. As the global death toll from COVID-19 increases, a large number of children will become orphaned and vulnerable to exploitation and abuse, to trafficking and to other forms of exploitation. Global deaths from COVID-19 could reach 10–40 million, with additional lives lost to suicide, leaving many children parentless. Widespread economic insecurity, poverty, and homelessness are likely to increase the rates of child labor, sexual exploitation, teenage pregnancy, and child marriage. Interruption of the maternal–fetal bond due to the separation of the mother–infant dyad when mothers are COVID-19 positive is another concern. Health-care systems, already overwhelmed, will not be able to provide children with access to immunizations and basic routine preventive care. Family distress and disruption, particularly due to quarantines and shelter in place guidelines, will likely increase the rates of domestic violence. And more than 1.5 billion young people, which constitute 91% of the world's students, are currently out of school. Even with the easing of stay-at-home orders and reopening of schools, many children will drop out of school to support their families by caring for younger siblings.[1]

Global perspectives

Early investigations of Chinese children's behavioral and emotional reactions to COVID-19[2] showed children experiencing fears, uncertainties, and prolonged school absences due to physical and social isolation. The most common psychological and behavioral problems (depending on age) were clinginess, distraction, irritability, anxiety, depression, lethargy, impaired social interaction, and reduced appetite. In April 2020, Spain had the world's second highest number of COVID-19 deaths, exceeding 10,000. Its seven million youngsters, cooped up indoors for weeks, struggled with increased levels of stress and anxiety, insomnia, chest and stomach pains, and weight gain.[3] In the United States, a study by the Kaiser Family Foundation[4] predicted that adolescents at risk for depression or suicidal ideation were at higher risk for increased depression, anxiety, distress, and low self-esteem and higher rates of substance use disorder and suicide. The Iranian Association of Psychology and the Ministry of Health recommended the establishment of a task force for physicians, psychiatrists, psychologists, and social workers to conduct workshops and psychological training courses through social media. Similarly, the Korean Academy of Child and Adolescent Psychiatry's committee for disaster and trauma created guidelines on the COVID-19 outbreak, including “Coping with the stress of COVID-19 epidemic: Tips for families getting through school closing period” and “Tips for adolescents: Coping with the stress of COVID-19 epidemic,” which offer strategies and interventions to address the effects of anxiety, fears, and trauma. Similar interventions have been advanced in Italy, England, Germany, Scandinavia, and India.


  Mental Health Consequences of the Pandemic Top


Broadly speaking, mental health consequences can be divided into the following categories. After a short description of each category, we provide case examples, which, though fictitious, bear sufficient resemblance to real-life situations encountered in our daily practice to serve as useful vignettes.

Adjustment disorders

As many as one in five primary age children are afraid to leave their homes and are worried that there will not be enough food to eat during the course of the pandemic. A study from the University of Oxford[5] suggested that different age groups show variation in the expressions of anxiety and stress reactions. Younger children worry about catching the infection, fear infecting others, and are anxious about missing school work. Older children worry more about their families, friends, and relatives than about themselves. Interestingly, the authors found that anxiety levels are much greater among parents than their children, which suggests that interventions need to be targeted at adults as well as youth.

Case example

A 7-year-old girl with no significant past history started to experience increasing anxiety, mood lability, and temper outbursts. She started having 30 min meltdowns when she learned that school was going to be postponed for the remainder of the year, screaming: “I need people,” “nothing will be the same,” “my life is over.”

Reactions to social isolation

Social isolation could increase anxiety, depression, stress, and other negative feelings. For children who spend time in multiple households, and a stream of relatives, prolonged social distancing will mean profound separation from people who provide care. They miss help from aunts, uncles, grandmothers, and gym coaches and others.

Case examples

A 15-year-old female, otherwise healthy teenager, became fed up with the quarantine. She went to a friend's house and drank a significant amount of alcohol. She was found passed out on the street, and was later admitted to the pediatric intensive care unit and requiring intubation. A 13-year-old female with a history of depression overdosed on her escitalopram and stated that having to stay at home has exacerbated her tendency “to think about a lot of stuff, a lot of negative stuff” about her past.

Reactions to family and family events

Parents experience much turmoil due to fear and anxiety about COVID-19. They are likely to be burdened by the need to care for the children and perhaps their parents. Having to cope with their children's demands and needs may cause parents to experience intense distress, anxiety, and depression. Children tend to react to their parents' stress reactions which can exaggerate their own distress.

Case examples

A 16-year-old female with a history of behavioral issues and anxiety, now presents with increasing anxiety when she is apart from mother who works as a COVID-19 nurse. The child's intense separation anxiety, worsened by fears of the mother going to work and worries about her safety, became a major struggle for this patient. A 13-year-old female patient with diagnoses of attention-deficit hyperactivity disorder (ADHD) and generalized anxiety disorder, decompensated within weeks of the start of the pandemic. The major focus of her worrying is her diabetic mother who works in a nursing home. She is highly fearful of her mother's safety and well-being.

Violence against women and children

Times of economic uncertainty, civil unrest, and natural disaster are linked to a myriad of risk factors for increased violence against women and children. Pandemics are no exception.[6] In fact, the regional or global nature and associated fear and uncertainty associated with pandemics provide an enabling environment that may exacerbate or spark diverse forms of violence. Understanding mechanisms underlying these dynamics is important for crafting policy and program responses to mitigate adverse effects.

Intensification of preexisting conditions

The COVID-19 pandemic may worsen the existing mental health problems of ADHD, mood and anxiety disorders, autistic spectrum disorders (ASD), obsessive compulsive disorder, posttraumatic stress disorder (PTSD), substance abuse, and others. This is more often seen in children with neurodevelopment disorders.

ADHD children, particularly adolescents, are vulnerable to the distress caused by the pandemic and physical/social-distancing measures. They may display increased behavioral problems because of their executive functioning difficulties, impulsivity, and risk taking.

Case example

A mother of a 16-year-old male who is experiencing an increase in ADHD and aggressive symptoms states: “I am doing okay. I know this will be over. But I am worried about my son, about him going to jail, ending up living on streets or getting killed.” While this mother tries to comfort herself about the situation getting better, she describes significant worries about her son's behavior.

Autistic spectrum disorder

Thom and McDougle[7] observe that COVID-19 challenges are very likely to be magnified in children diagnosed with ASD. Most ASD children are not able to receive support services including special education, behavioral therapy, occupational therapy, speech services, and individual aides through school during the pandemic. Parents are finding themselves simultaneously expected to play the role of parent, special education teacher, and individual aide, all the while having to provide care for other children and juggling work-from-home responsibilities. Aggressive and self-injurious behaviors in ASD children may also increase during this time of fear and uncertainty.

Case example

A 16-year-old teenager male with a history of high-functioning ASD, oppositional/defiant disorder, and violent/aggressive outbursts was admitted to the hospital for exacerbation of the same with limited access to his usual psych supports because of COVID. He required crisis placement and changes in medications.

Medically complicated children

As COVID-19 continues to spread, children and youth with special health-care needs may be at increased risk for complications. This includes children with chronic conditions, physical disabilities, and medically complex conditions. Moreover, school and business closings may limit the availability of therapies and supports for these children.

Case example

A 17-year-old female with past medical history of hypothyroidism, obesity, seizure disorder, and mild persistent asthma presents after having difficulty coping with her father's diagnosis of COVID-19 and his subsequent intensive care unit hospitalization. She subsequently experienced difficulty sleeping, decreased appetite, and became significantly depressed. Fortunately, she denied any safety issues and was thus referred to the outpatient psychiatry services. Supportive therapy has significantly helped her cope better.

Posttraumatic stress disorder

The prevalence of significant PTSD symptoms in COVID survivors has been reported to be as high as 96.2% (95% confidence interval 94.8%–97.6%).[8] Half of the participants in this study (49.8%) reported that psychoeducational services were helpful for them. Similarly, family members of COVID patients are at risk for PTSD. Appropriate crisis psychological interventions and long-term follow-up assessments should be urgently initiated for all COVID-19 survivors and their families.

Case examples

A 16-year-old boy presented after his father was admitted to an intensive care unit after being diagnosed with COVID-19. In addition, his mother was also diagnosed with the disorder. He was referred for severe anxiety, panic symptoms, nightmares, excessive worry, and vague suicidality. During supportive psychotherapy treatment, elaboration and exploration helped him as did the addition of an antidepressant medication (selective serotonin reuptake inhibitor). It is important to note the complete recovery of his father. A 14-year-old male was referred for increasing anxiety, panic, and depression with suicidality. Talking to the teen and his parents, it was revealed that his father is an Iraqi War veteran who suffered from severe PTSD. While his father's situation was currently stable, the teen often worried that his father would relapse and become anxious and/or panicky. Exploration of family issues, strengths, and resiliency skills reassured the teen who improved without a need for medications.

Positive outcomes during the early stages of the pandemic

Many children and families report positive outcomes emerging out of the crisis. For example, Dr. Alicia Areal of Spain has reported “I have families telling me that they're rebuilding relationships now that day-to-day life has calmed,” citing adolescents who said they were speaking more to their parents and engaging in more family time with activities such as baking or painting.[9] Children with attachment issues and families with intimacy issues or with communication difficulties can work through these challenges if there is an absence of hostility. There are other silver linings that individuals and families are discovering, all of which suggest that resiliency skills can make a major difference in the way people are experiencing the pandemic.

Recommendations

  1. See and remain in close touch with your family members
  2. Get sufficient sleep to mitigate mental health difficulties under stressful circumstances
  3. Proactively manages stress threshold – Try to lay a solid foundation for your mental health and well-being by prioritizing sleep, eating well, and exercising regularly
  4. Practice mindfulness: Be compassionate with yourself and with others, maintain connections and manage uncertainty by focusing on the present moment
  5. Parents: Establish and maintain daily routines, encourage virtual social interaction, and develop strategies for nurturing resilience in children and adolescents. Make sure to address their fears and concerns, play collaborative games to alleviate loneliness, encourage activities that promote physical activity, play or listen to music, and practice relaxation methods. Model a positive psychological attitude to reduce stress and divert children's attention in productive and positive directions.[10],[11],[12]


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
COVID-19's Devastating Impact on Children. Governments Should Mitigate Harm, Protect Most Vulnerable. Available from https://www.hrw.org/news/2020/04/09/covid-19s-devastating-impact-childre. [Last accessed on 2020 Jun 01].  Back to cited text no. 1
    
2.
Jiao WY, Wang LN, Liu J, Fang SF, Jiao FY, Pettoello-Mantovani M, et al. Behavioral and emotional disorders in children during the COVID-19 epidemic. J Peds 2020;221:264-6.  Back to cited text no. 2
    
3.
Arango C. Lessons Learned From the Coronavirus Health Crisis in Madrid, Spain: How COVID-19 Has Changed Our Lives in the Last 2 Weeks [published online ahead of print, 2020 Apr 8]. Biol Psychiatry. 2020;S0006-3223(20)31493-1. doi:10.1016/j.biopsych.2020.04.003.  Back to cited text no. 3
    
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Panchal N, Kamal R, Orgera K, Cox C, Garfield R, Hamel L, et al. The Implications of COVID-19 for Mental Health and Substance Use. Available from: https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use [Last accessed on 2020 Jun 01].  Back to cited text no. 4
    
5.
The Guardian. Fifth of Primary Children Afraid to Leave House over Covid-19, Survey Finds. Available from: https://www.theguardian.com/world/2020/apr/10/fifth-of-primary-children-afraid-to-leave-house-because-of-covid-19-survey-finds [Last accessed on 2020 Jun 01].  Back to cited text no. 5
    
6.
Peterman A. Pandemics and Violence Against Women and Children. Available from: https://www.cgdev.org/publication/pandemics-and-violence-against-women-and-children [Last accessed on 2020 Jun 01].  Back to cited text no. 6
    
7.
Thom R, McDougle C. Strategies to Support Teens and young Adults with Autism Spectrum Disorder During COVID-19. Available from: https://www.health.harvard.edu/blog/strategies-to-support-teens-and-young-adults-with-autism-spectrum-disorder-during-covid-19-2020042419619 [Last accessed on 2020 Jun 01].  Back to cited text no. 7
    
8.
Aten JD. Are COVID-19 Patients at Risk for PTSD? Psychology Today; 4 April, 2020. Available from: http://www.psychologytoday.com' blog ' hope-resilience [Last accessed on 2020 Jun 01].  Back to cited text no. 8
    
9.
Lucas Pablo. How Spain's Corona virus Lockdown is Affecting Children; 14 April, 2020. Available from: https://english.elpais.com/society/2020-04-14/how-spains-coronavirus-lockdown-is-affecting-children.html [Last accessed on 2020 Jun 01].  Back to cited text no. 9
    
10.
Lori Gottlieb. Dear Therapist's Guide to Staying Sane During a Pandemic, The Atlantic; 17 March, 2020. Available from: https://www.theatlantic.com/family/archive/2020/03/a-therapists-guide-to-emotional-health-in-a-pandemic/608161/ [Last accessed on 2020 Jun 01].  Back to cited text no. 10
    
11.
Lombardi M. Tips on Talking to Children about the COVID-19 Pandemic; 10 May, 2020. Available from: https://www.westernconnecticuthealthnetwork.org/novel-coronavirus-covid19-update/tips-for-coping-with-covid19/tips-on-talking-to-children-about-the-covid19-pandemic www.westernconnecticuthealthnetwork.org [Last accessed on 2020 Jun 01].  Back to cited text no. 11
    
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Coronavirus Anxiety-Helpful Expert Tips and Resources 5-5-20. Available from: https://adaa.org/finding-help/coronavirus-anxiety-helpful-resources [Last accessed on 2020 Jun 01].  Back to cited text no. 12
    




 

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