We must not lose sight of children and adolescents during and after the covid-19 pandemic, says Elizabeth A Rider
The rapidly evolving covid-19 pandemic, now with confirmed cases in 213 countries, has caused worldwide fear, anxiety, and confusion in adults, and major disruptions in almost all aspects of daily life. The primary focus of healthcare leaders is necessarily containment of the epidemic. What about the pandemic’s effects on children?
Although covid-19 currently appears to be less frequent and less severe among children and adolescents, they remain significantly impacted by concomitant disruptions, including separation, social isolation, illness of caregivers and family members, uncertainty, and increasing stresses on families and living situations. Quarantines, school closings, home confinement, and other containment approaches mandated in a rapidly growing number of countries pose additional challenges.
Children are especially vulnerable to the emotional and psychological impact of covid-19 given their need for security and comfort in the world, and their difficulty conceptualizing the real impact of a health or other disaster. Sprang and Silman studied the reactions of children and their parents to pandemic disasters and found that 30% of isolated or quarantined children and 25% of their parents met criteria for post-traumatic stress disorder (PTSD). PTSD was found to be four times higher in quarantined children compared to those who were not quarantined. Quarantined individuals often experience post-traumatic stress, detachment, anger, and insomnia, even years later.
Healthcare systems and clinicians worldwide are stretched thin looking after people who require acute care due to covid-19 in numbers that are unprecedented for non-wartime events. Children and parents are sheltering at home, with the primary burden of childcare and teaching now resting on at-home parents and other caregivers. Many parents do not have training in understanding child development, nor knowledge of age appropriate responses and interventions when their children articulate or exhibit behavioral, and sometimes physical, reactions to the covid-19 pandemic.
Increasing the capacity of parents, families, teachers, and other frontline child caregivers to recognize and respond to children’s and adolescents’ emotional and behavioral reactions to the covid-19 pandemic may help to prevent some of the negative sequelae of childhood emotional trauma from the pandemic. Consequently, understanding the impact of the covid-19 pandemic on children and adolescents, and its relationship to their developmental stage, is vital.
Children and adolescents are acutely aware of their parents’ and caregivers’ stress and anxiety. Those also experiencing the life threatening illness or loss of family members or friends will be especially impacted. Practical interventions include giving parents and children permission to talk about their feelings and reactions. Avoidance makes the pandemic scarier in children’s minds––seemingly so dangerous that it cannot be discussed. Healthcare workers can help parents to understand how children may communicate through their reactions, behaviors, and symptoms, and guide parents to label and validate feelings and offer constructive ways to manage emotions. Common reactions and supportive interventions by developmental stage include:
Infants and Toddlers (0 – 3 years):
Reactions:
- Infants and toddlers are aware of parents’/caregivers’ worry.
- They are distressed by parents’ distress.
Interventions:
- Remain calm, reassuring, patient.
- Maintain normal routines.
- Shield them from media coverage.
Preschool Children (3 – 5 years):
Reactions:
- Preschool children often view illness as resulting from wrongdoing or as punishment.
- Child’s primary concerns are separation from family members and safety.
- Children often work through issues via play and may replay images they have seen.
- They may regress—i.e., whining, clinging, sleep problems, physical symptoms.
Interventions:
- Provide basic reassurance about child’s and family’s safety and what is being done—e.g., handwashing, staying home, etc.
- Answer questions simply.
- Label and validate child’s feelings.
- Let child know parents’ and family members’ whereabouts.
- Maintain normal routines.
- Limit television / media exposure. Young children do not understand the frightening images they may see.
School Aged Children (6 – 12 years):
Reactions:
- Understand the cause of illness as external to themselves.
- May ask many questions.
- Concerned about their safety.
- May be frightened and confused by television images of protective gear, masks, bodies.
- May be more irritable than usual.
Interventions:
- Answer children’s questions directly and honestly.
- Be open to questions: “Tell me more about that.”
- Label and validate child’s feelings: “Yes, it is scary, and this is what we are doing to stay healthy.”
- Ask their opinions.
- Keep usual routines where possible.
- Encourage participation in family or other efforts to help as appropriate.
- Minimize television/ media viewing.
Adolescents (13 – 17 years):
Reactions:
- Adolescents can integrate multiple factors in understanding illness and imagine alternative possibilities.
- Able to understand the implications of the events.
- May have legitimate fears about the future—e.g., economic repercussions, long term health issues.
- May express concerns about justice, power, and control, and want to discuss the policy issues involved.
- May have varied responses such as worry, fear, sadness, anger.
Interventions:
- Show respect for the adolescent’s feelings.
- Discuss their opinions, feelings, and different ways to cope.
- Discuss causes and effects of the covid-19 pandemic.
- Talk about what adolescents see on social media and hear from their friends.
- When possible, be present if they watch television; discuss and debrief what is seen.
- Share your own coping mechanisms.
- Encourage participation in family/community efforts to help.
Children and adolescents with particularly intense reactions, such as frequent, aggressive emotional outbursts, preoccupation with the traumatic event, serious problems at school, or emotional numbness or withdrawal, will need further evaluation and referral.
We must not lose sight of children and adolescents during and after the covid-19 pandemic. Psychological risks are high during health and other disasters and may ultimately negatively influence their adult lives. We can work together with existing frontline home support—parents, caregivers, teachers, and others—to recognize and protect children’s emotional health, as well as physical health, and to minimize potential negative sequelae including PTSD, anxiety, depression, and other issues that would require more substantial care and resources in the future.
Elizabeth A Rider is a pediatrician and former child and family therapist. She directs the Boston Children’s Hospital/Harvard Medical School Faculty Fellowships in Humanism & Professionalism, and in Interprofessional Leadership. She is in the Division of General Pediatrics at Boston Children’s Hospital, and a faculty member at Harvard Medical School. Twitter: @Teach_Caring
Funding source: None.
Competing Interests: None declared.