As we begin 2021, the term “unprecedented times” seems to be the buzzword on everyone’s mind. This moniker couldn’t be more fitting for the experiences of children and their families when it comes to schooling during the pandemic. Subsequently, when family systems have become overwhelmed, we often see them in our offices, through patient messaging, and phone contacts. Now, obviously there are varying degrees of struggle, but realistically children and their families have had to be incredibly plastic on a week-to-week basis since the beginning of the COVID-19 pandemic when it comes to education.

Some are faring relatively well, with only minor anxiety and tribulations that could be expected during this time. Most often this presents as worry, asking questions, feeling frustrated with an ever-changing schedule, some difficulty understanding/completing assignments without extra support, a few sleepless nights, and at worst a frustrated meltdown here and there. Typically, children experiencing these reactions are not struggling with comorbid behavioral health issues, which is largely one of the most prominent protective factors during this time. Other positive prognostic characteristics include families who adhere to realistic schedules (when remote or hybrid learning) while offering flexibility to modify depending on the level of stress. Families who promote open communication, strengths based approach to schoolwork, appropriate use of news and social media, and good sleep hygiene tend to be faring the best. However, even the most defended system may feel destabilized during this time.

As providers of pediatric health care, we must always remind ourselves to view things under a developmental lens; a Kindergartner struggles differently than a high school senior. For our younger patients, we may see anxiety or questioning about the virus or safety. They may feel more overwhelmed with instruction from home or with a hybrid model due to a less predictable routine. They may be struggling with difficulty sleeping, expressing frustration about mask wearing in school or not seeing their friends, and likely an occasional display of regressive behavior such as wanting to sleep in parent’s beds again or struggling to avoid temper tantrums. Juxtaposed at the other end of the spectrum, our younger adolescents/teens will likely feel frustrated by limitations on social interaction and in some instances frustration and falling behind with their schoolwork if structure and syllabi are not provided by teachers. As we continue through the pandemic, we have been seeing an increase in social media/phone/gaming use as a means to stay socially connected. If used properly and with realistic boundaries, this is a safe and effective way to mitigate feelings of isolation, however if used excessively or later in the evening, has a high likelihood of promoting academic struggles, poor sleep, and social stress. We have also seen an increase in anxiety in our adolescents as well as they are more likely to follow traumatizing news and consume ambiguous social media posts. Providing consistent information that is age-appropriate and limiting access to being overwhelmed by this information is a difficult balance to strike, but can help in addressing this reactive based anxiety.

Based on calls coming in to the Project TEACH phone line, we also know that the pandemic and associated school stressors has been an incredible challenge to the children you care for who have pre-existing behavioral health concerns. Commonly, we have seen exacerbations of depression and anxiety; however, more severe issues such as bipolar disorder, psychosis, or PTSD have seen elevated symptom impairment as well. Perhaps the best way to familiarize us with this is to explore them categorically.

Depression:
Many children and adolescents who had pre-existing depression or may have developed it during the pandemic have seen an increase in insomnia, feelings of isolation and hopelessness, struggles with low mood, and sometimes increased suicidal thoughts. In discussions with these youth, we are often finding that family/social stressors related to isolation/social distancing, academic difficulties, unfavorable views toward tele-health platform for mental health, and reduced access to support systems to be common exacerbating factors for worsening depressive symptoms. In my roles as a Project TEACH Child and Adolescent Psychiatrist and consultant child psychiatrist at Upstate Golisano Children’s Hospital, in the most severe cases, this has shown a somewhat noticeable increase in suicidal ideation, non-suicidal self-injury, and suicide attempts. Subsequently, we have seen an increase in referrals for inpatient psychiatry.

Anxiety:
Many of us recognize that anxiety and depression are often comorbid and during this time, children who have anxiety can struggle in multiple areas. Most apparent is pandemic related safety concerns which are usually more apparent. However, anxiety related to school success may add another layer, making things more complicated. We have been seeing more difficulty keeping with routines, maintaining good sleep patterns, and not falling behind with schoolwork as main targets in mitigating anxiety in children at this time. It would be beneficial to screen for anxiety for any child with new onset insomnia, academic issues, or regressive behavior. Paradoxically, children with social anxiety disorder and/or school avoidance may actually be doing relatively well given mandates for at home schooling and social distancing. We would need to keep them on our radar as the pandemic eventually begins to wane and return to school is expected.

ADHD:
As a reminder, our patients with ADHD or other learning issues likely need added support and creativity, as they may not have access to their education accommodations under Individualized Education Plans or 504 Plans. These may include extra time on tests, preferential seating, limited distraction, use of PT/OT interventions, and resource room. Parents and clinicians may have to get creative to cover some of these gaps or advocate for the child if they are in school on a modified schedule.

Aggression:
Clinically, we have also seen an increase in presentations for “aggression” in our emergency department and pediatric hospital here at Upstate Medical University. As we often mention in our intensive trainings, aggression is not a psychiatric diagnosis, but instead can be a symptom of many diagnoses. For the sake of this article, I will remind the reader that aggression can manifest in any of the above mentioned diagnoses, but here I will discuss it in relationship to some of the more rare, but concerning behavioral health issues.

Autism Spectrum Disorder:
Children and adolescents with Autism Spectrum Disorder may act out more aggressively due to worsened anxiety or also abrupt deviations in school and home schedules they once found predictable. Children with particularly severe sensory sensitivities may struggle with social distancing, mask wearing, and repeated hand washing/sanitizing. In more severe situations, in-home or school-based services they may have once relied on often are not available due to COVID concerns. This can leave some of the most vulnerable children and families in a precarious position of how to best manage their day-to-day functioning.

Bipolar Disorder, Psychosis, and PTSD/Trauma:
Children with Bipolar Disorder or psychosis may feel more disruption as external stressors often impact these diagnoses. Additionally, with less intensive services and access to mental health face-to-face meetings, some may have discontinued their medications and are now saddled with reemerging symptoms impairing them at school and home. In a similar vein, we have seen worsening symptom burden in children with PTSD/trauma related diagnoses as stress can often reignite symptomology. I would also like to emphasize that we must also recognize that some children are now stuck at home in unsafe situations, possibly with those who have traumatized them. We as providers must take extra care to screen for concerns of abuse, reemerging PTSD symptoms, and general safety in the home.

In closing, it must seem difficult to feel positive in our current situation. However, I do believe that better days are ahead and that we can get through this pandemic if we are thorough, empathic, and resourceful. Although it can be clichéd, I do believe that the mantra “it takes a village to raise a child” is very applicable in this current situation. It is our role in Project TEACH to partner with you as the pediatric primary care provider in order to keep a patent line of assessment and intervention for the children and adolescents you see in your practices. We welcome and encourage providers to reach out with any and all questions to help the child you are working with. Finally, your work as a collaborator with your patient, their family, their supports, and their school can help reduce burden on your patient and keep them pointed forward on their journey.