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Supporting emotional, behavioral needs of children in the pandemic: Updated guidance

August 2, 2021

Editor’s note: The guidance in this article has been updated since the time of publication. Please see the interim guidance on supporting emotional and behavioral health. For the latest news on COVID-19, visit

The AAP has updated its interim guidance on supporting the emotional and behavioral health needs of children, adolescents and families during the COVID-19 pandemic.

The guidance includes new information on managing uncertainty, screening for mental health concerns and helping children who have lost a parent. There also are updates on use of telehealth, fear and anxiety, peer relationships and parental well-being.

The duration of the pandemic, evolving recommendations and uncertainty about the future can take a toll on emotional and behavioral health, according to the guidance. Families living in poverty and in historically under-resourced communities, children who are refugees, children and youth with special health care needs and children involved with the child welfare and juvenile justice systems may be at particular risk. Challenges are compounded when families lack access to health care, affordable housing, safe environments and community supports and services.

Pediatricians can serve as both educators and advocates in addressing these stressors.

“The pandemic has underscored the need to continue to integrate emotional and behavioral health into standard pediatric care,” the guidance states.

Emotional, behavioral responses

The guidance outlines reactions to stress by age and context. Caring adults or supportive peers can help most children and adolescents manage stress. However, children require further assessment if their stress levels disrupt daily routines or prevent them from engaging with school and family. Expressions of hopelessness are another red flag for assessment and support by pediatricians.

Children and adolescents who experienced anxiety and depression before the pandemic are at greater risk of symptom exacerbation and may need additional treatment and resources.

An estimated 40,000 U.S. children have lost a parent to COVID-19. Such loss can lead to overwhelming grief, poor education, long-term mental health consequences and loss of economic stability.

Social isolation also can take a toll. Children and adolescents who have been unable to participate in milestone transitions may experience loss and grief. Therefore, emotional and behavioral health need to be considered in school planning, according to the guidance.

Surveillance, screening

Due to the pervasiveness of pandemic-related changes, the AAP recommends that behavioral and mental health surveillance and evidence-based screening be integrated into every office visit. It helps to implement a universal surveillance/screening strategy.

Assessing for the social determinants of health has taken on added urgency during the pandemic.

Surveillance can involve incorporating questions about the impact of the pandemic on the well-being of the child, focusing on any behavioral difficulties. Screening and assessment utilizing evidence-based tools are the next steps.

Pediatricians can check in on parents’ well-being as well, providing support through active listening, and recommending self-care or counseling.

Pediatricians should ask about challenges related to remote learning, such as whether the family has appropriate learning spaces at home with access to technology/internet service. They may need to reassure families who are reluctant to send their children back to school in person.

For children with special health care needs, pediatricians should inquire about access to specialized medical and/or mental health services. Interruption of these services is a source of stress. Structured routines and reward systems remain important for these children.

Other groups that may have increased stress and anxiety/depression include teens in the juvenile justice system, children and families involved with the child welfare system and LGBTQ youths who are not supported by their families

COVID restrictions also have interrupted developmental surveillance of some infants and toddlers. Therefore, the AAP says it is critical to refer children suspected of having significant delays and disorders to early intervention.

Anticipatory guidance, follow-up

For general anticipatory guidance, the AAP recommends that pediatricians continue to advise families about emotional and behavioral responses and needs in the context of typical development. The interim guidance addresses some of the needs of infants, toddlers, preschoolers, school-aged and older children.

Developmental regression is not uncommon during stress; individualized support and attentive caregiving can help. Parents can be reminded that behavior is a manifestation of emotional reactions.

Adolescents may need to talk to a trusted adult about their pandemic-related concerns. Extreme withdrawal is cause for concern.

Parents should maintain open and honest conversations with their children and teens. Guidance on the uncertainty of the long and evolving pandemic can be communicated to children, with a focus on what families do have control over, such as healthy habits and spending time on activities that bring them joy.

Guidance on ways to maintain physical distancing while still spending time outdoors in activities, along with selective use of screen time and media also are addressed in the guidance.

Pediatricians should follow up frequently with infants, children and adolescents having behavioral health challenges. Telehealth can be helpful.

The AAP recommends paying special attention to children and families at risk for abuse and violence, and those needing help to manage grief, suicidal ideation or anxiety.

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