Editor's note: Updated guidance has been released since the time this article was published. Please visit https://bit.ly/3hFb7fj. AAP interim guidance is based on current evidence and best data at the time of publication. Updates are provided to reflect changes in knowledge about the impact of the disease on children and adolescents. For the latest news on COVID-19, visit https://www.aappublications.org/news/2020/01/28/coronavirus.
The AAP is providing new interim guidance on how to evaluate and support children, adolescents and families who are struggling with emotional and behavioral health during the COVID-19 pandemic.
“There are many factors unique to this pandemic (e.g., uncertainty, rapidly changing and often conflicting messages, duration of the crisis, need for quarantine, and use of face coverings) that increase its impact on emotional and behavioral health,” the AAP said in the new guidance.
Some children are especially vulnerable, including those with special health care needs, those with pre-existing mental health conditions and historically marginalized communities. Racism and inequities that result from structural racism can be especially harmful.
“Pediatricians should bear witness to these stressors, the effects they have on child and adolescent developing brains, and the disparate outcomes they will drive well beyond the COVID-19 pandemic,” the guidance says.
Emotional and behavioral responses
The emotional toll the pandemic takes on children may depend on their temperament, family stress level and the level to which the pandemic interrupts typical life.
For infants and young children, reactions to stress may manifest in disruption in sleep, toileting and feeding. Older children and adolescents may withdraw or express fearfulness, anxiety and externalizing behaviors. In many cases, caring adults and peers can help them cope with these feelings, but some may need more support.
“As a pediatrician, I know that children don’t always know how to express their true feelings and they may even try to protect their parents from added worries rather than share when something is wrong,” said AAP President Sara “Sally” H. Goza, M.D., FAAP. “This is one reason we want to see your children and teens during office visits, not just to stay up to date on immunizations, but to check on their social and emotional health, too.”
Evaluating the impact on children
Pediatricians should screen for social determinants of health such as food insecurity and housing stability, especially for families of color who may be impacted disproportionately. They also should ask parents and caregivers about their own well-being, which could impact their ability to support their child.
Pediatricians should help children and youths with special health care needs maintain access to needed services. For children with behavioral challenges, routines and reward systems are helpful. Mindfulness and reframing should be encouraged for those with anxiety or depression.
Other children who may need additional support include LGBTQ youths living in homes with unsupportive families; adolescents in the juvenile justice system who may experience increased isolation, stress, anxiety and depression; and children in the child welfare system who have unique needs with complex trauma and loss.
Advice, education, anticipatory guidance
Pediatricians should use their expertise in providing surveillance, screening, assessment and guidance around developmentally appropriate behaviors and remind parents their child’s behavior may be a way of expressing emotional distress. The guidance also stresses the importance of using community engaged solutions to address health inequities.
Parents can help their children by being present, empathic and nurturing. Children and adolescents should be encouraged to explore their creativity, passions and strengths to help others in the community. Giving them opportunities to socialize within local, state and national guidelines also can help their emotional health.
Caregivers also should be encouraged to have open, honest, age-appropriate conversations with their children and adolescents about what they see in the media. While many children may be using screens more than usual, the AAP recommends keeping their use to education and socialization more than passive viewing. Parents should have conversations about excessive TV viewing and game playing, and the impact social media can have with regard to bullying and ostracism.
Referral and follow up
Children and adolescents with more severe emotional or behavioral issues may need a referral to a mental health provider. For those who aren’t referred to specialist, common factors approaches and brief interventions can be provided in primary care. Telehealth can be used to access care.
Children should be screened for depression and suicide, according to the guidance. For those who have lost a friend or family member to COVID-19, grief counseling may be appropriate.
Poverty, stress and isolation may exacerbate the risk for child abuse when children aren’t seeing teachers and physicians who can detect it. Pediatricians should look for signs of abuse and ask about intimate partner violence, guns in the home, parental mental health and struggles with adolescent behavior and discipline. They should provide support and resources for families and refer concerns of maltreatment to child protective agencies.
