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Daniel E.
When Things Aren't OK With a Child's Mental Health
The New York Times
By Perri Klass, M.D.
Aug 10, 2020

Everyone is stressed and anxious now. We have to find and help the children who are hurting most.

Last week, to write about the risks of summer -- the recurring safety issues of children being out in the sun, or near the water, I talked to safety-minded pediatric emergency room doctors about what was worrying them, as they thought about the children they might be seeing during their shifts over the coming weeks, and I specified that I wasn't asking about Covid-19 infection -- I was asking about other dangers to children, in this summer shadowed by that virus.

But among their concerns about drownings and fractures, the emergency room doctors kept bringing up mental health as a worry. At a time when we are all definitely not safe and not OK, we have to find and help the children who are hurting most.

Dr. Maneesha Agarwal, a pediatric emergency physician and assistant professor at Emory in Atlanta, said that although the lockdown and social distancing have been hard on children, "we initially saw a lull in children coming in with mental health problems." There was less bullying, because school and social interactions had stopped, and children were being supported by their families.

But she was concerned that returning to school could bring a new wave of bullying, particularly around pandemic-related issues, whether because of lockdown-related weight gain, or because of changes in family circumstances, with parents losing jobs and families more stressed.

Dr. Maya Haasz, an attending physician in the pediatric emergency room at Children's Hospital Colorado and an assistant professor at University of Colorado School of Medicine, brought up the vulnerability of children who already had mental health concerns, especially depression and anxiety, and emphasized the need for parents to ask children about their moods, mental health and low moments.

"Our whole society is stressed," said Dr. Sarah Vinson, an associate professor of psychiatry and pediatrics at Morehouse School of Medicine. She said that for some children, "school was their refuge," and being home was a deprivation, while, "for other kids, school was where all their stress was held, they're much happier to be at home." Now, those children may be headed back to school, facing old anxieties, as well as all the new stresses of school during the pandemic.

Dr. Adiaha Spinks-Franklin, a developmental behavioral pediatrician at Texas Children's Hospital and an associate professor at Baylor, said, "parents are reporting an increase in anxiety levels for children who were already kind of anxious in their temperament, and kids who previously had not had anxiety have developed anxious behaviors." Some parents are reporting their children have germ fears, she said, or fears of other people, or obsessions with following the pandemic news. She's seeing more issues with sleep, she said, and more symptoms of depression, usually connected to social isolation.

Nadine Kaslow, a professor of psychiatry at Emory School of Medicine, said, "I'm concerned we're going to have a generation of compulsive hand-washers, scared of people, anxious and depressed." There's a lot more tension in many homes, she said, with parents trying to juggle multiple responsibilities, and children may be witnessing conflict between their parents.

Parents need to help children talk about their feelings, Dr. Kaslow said. Some parents of younger children find it helpful to use feelings charts, available on the internet. If kids consistently can't point to things they enjoy, think about looking for additional help.

Dr. Spinks-Franklin suggested a free downloadable ebook about coronavirus for children, put out in collaboration with the American Psychological Association. "I actually read that with one of my patients through our online call," she said. "She was just so anxious about coronavirus and we read the book together." Afterward, she said, "she was able to articulate how much she learned from the book and what she can do and what her family can do to keep them safe."

If you're worried about your child, you may need some guidance in finding help in this changing landscape of remote therapy and tele-mental health. "Often I'll tell people to start with their pediatrician, they often have a sense of what's available, and recommendations around mental health providers," Dr. Vinson said. "Insurance companies have really lowered barriers around providing tele-mental health services," she said.

The summer may be a good time to look for a therapist if a child is struggling; as the school year picks up, schedules may fill. Talk to your child's primary care provider, talk to the school, consider reconnecting with a counselor or therapist who has seen your child before. If your child is already taking a medication - for anxiety, for attentional issues, for depression - talk to the doctor who prescribed it to see if an adjustment is indicated.

Remote mental health may be harder with young children, Dr. Kaslow said, though many therapists are finding ways to be really creative, asking children to show their favorite toys and how they play with them, and to talk about their home environments and how they're feeling.

Dr. Vinson said that for many children with mental health problems, symptoms have gotten more severe. "If they were anxious, they're more anxious, if they were depressed, it's harder, if it's schizophrenia, the voices went up." Her own work as a child and adolescent psychiatrist has increased, she said, with children needing more help during the pandemic.

"Parents need to take their children seriously," Dr. Spinks-Franklin said. "This is a very stressful time for adults and children, and we don't want to disregard it when a child tells us how stressed they are, how worried they are."

Cindy Liu, a clinical psychologist in the departments of pediatric newborn medicine and psychiatry at the Brigham and Women's Hospital and the director of the developmental risk and cultural resilience program, said that in a setting in which we are all now accustomed to thinking of the risks of viral infection, it's important to consider "stress contagion" and the risks to those who are most vulnerable, and to families at higher risk because of structural racism and socioeconomic disparities.

"Stress in families can be quite contagious as well," said Dr. Liu, an assistant professor at Harvard Medical School. Quarantined together, she said, children are exposed to parental stress, but also get to witness "how parents cope and regulate their stress." And racial minorities may have less access to mental health services, she said, and to other supports to help parents cope themselves, and help their children through.

Dr. Kaslow, past president of the American Psychological Association, said that amid all the stresses of the pandemic, there have been positive experiences for many children, with strong family bonds and unusual amounts of time together. "Be sure the balance of your interactions with your children are about love, positive nurturance and fun," she said. Even with the responsibilities of overseeing remote learning, she said, "loving warm interactions need to take precedence" over struggling with them about behavior, or about schoolwork. "When children feel connected, they're going to learn better, do better, stay on track," she said.

"Having a kid struggling right now in no way means you're not a good parent," Dr. Kaslow said. "It's not a reflection on your love for them - it's an unprecedented time."

Dr. Vinson said she is encouraging families "not to take for granted the things that sound simple - sleep, movement. I talk to all my families about movement, exercise, nutrition, and really protecting those things, because you need your brain at its best while you're dealing with all this stress right now."

Dr. Perri Klass is the author of the forthcoming book "A Good Time to Be Born: How Science and Public Health Gave Children a Future," on how our world has been transformed by the radical decline of infant and child mortality.
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