MAY 4: CLINICAL PRACTICE TEAM
Welcome to the 5 Things Digest from the NTTAC Clinical Team, bringing you 5 Things to know right now about helping children manage their mental health during a pandemic, even as vaccinations and other measures provide us some optimism that circumstances are improving and we’ll be resuming more face-to-face interactions, travel, and activities with others.

The pandemic will likely not immediately end, but instead will gradually change, so our transitions back to school, work, and activities may take time. In moments of feeling anxious, sad, and unable to focus, these ideas may be helpful for children as they transition toward something new.
#1: Adjusting the family routine may benefit everyone’s mental health during all stages of the pandemic. 
 
The home schedule may need continued refinements to better fit both children’s and caregivers’ ever-changing needs in the home. Several strategies may help these changes in routine work better:
  • Seek input from everyone in the home about their routines so that everyone is invested in any changes. Some changes will work and others may not, so be prepared to notice problem times and try different approaches or sequences of tasks. Not everyone may agree about priorities, so be prepared to listen and negotiate–children convey their messages in a variety of ways.
  • Draw or write out the schedule so that everyone can see it, as necessary. Everyone tends to do what’s familiar rather than what may be new and unfamiliar, so it may take days or weeks to regularly implement changes as circumstances continue to change.
  • Focus on telling children what you want them to do (and noticing when they do it) to keep them motivated to do what’s desirable.
  • For the daily schedule, adjust times for snacks and meals, breaks for physical activities, play times for caregivers with children, and reward times/activities after they complete chores or school tasks. Parents still need time for their chores and work tasks as well, and for their own breaks throughout the day. Take moments to celebrate what works well and identify what doesn’t.
  • Use what’s available, e.g., make up dances to preferred songs, and let everyone imitate these moves; use ordinary items like mops or brooms to become imaginary horses.
  • As parents resume working outside the home or traveling, they may need to ensure others at home keep an eye on children during virtual or hybrid schooling, or to regularly check-in to ensure children complete school tasks.
  • As the social groupings for children and parents move from “just the family” to include others, remember to reward siblings for working together, sharing, and being considerate throughout the day. Jumping jacks or other exercise contests can be family activities, where everyone can contribute to an identified point total and receive a reward when the goal is reached (e.g., special dessert). This can help keep the family connected while members return to school or work.

RESOURCES

A helpful link for scheduling practices to help the family manage children well during the pandemic.

Parenting tips across multiple categories (teens, disabilities, stress, financial concerns, etc.) for managing children during the pandemic.
 
The frequently updated CDC fact page about managing mental health at home during the pandemic.
#2: For children showing signs of anxiety, try to keep their world consistent, safe, and predictable.

Uncertainty often seems to equate to danger, so modeling how to address uncertainties, and indeed how to distinguish those things that are more likely represent real threats, will remain important throughout all stages of this pandemic. Several strategies may help:
  • Address children’s fears of still becoming infected, or by being exposed to others who have not been vaccinated, by thinking through the probabilities together. If the probabilities seem high, focus on how you’ll manage any negative outcomes that might occur. A problem-focused style, compared to an emotional style, was reported to decrease both anxiety and depressive symptoms in adolescents contending with various worries (Duan et al., 2020).
  • Help children distinguish how anxious various scary things are. Gauges (“On a 10-point scale, how anxious are you right now?”), thermometers (cold to hot), streetlights (“Is this red/severe, yellow/mild, or green/good?”) help children recognize that some fears are small; more importantly, it helps them recognize if things they’re trying in order to calm down are making it better or worse gradually.
  • Empathize more than sympathize with their concerns and distress. Empathy is reflecting how someone feels (“It does feel scary”) where sympathy is taking on the feeling of another (“Now I’m scared, too”). Just remember to share with your children about THEIR feelings most, and be thoughtful how you show and express your feelings; notice if your own sharing is more overwhelming than bonding.
  • Keep the world predictable even as you engage more with the world now by talking through how their lives will change as you enter different stages such as resuming school (“The plan is that you’ll be with about 20 other students, but sit about 3 or more feet apart, and you’ll be able to sit with your friends at lunch”) so that children are not frustrated or disappointed with the steps of the process. Also, alert children about changes to your schedule (“Since I’m back at work now on Tuesdays and Fridays, our neighbor will pick you up and you’ll play there from 3-5 PM”).
  • Maintain and expand other activities. Use the new opportunities available as community activities open to exercise, engage with other friends and family members, visit restaurants or parks (safely), and pursue appealing activities together that may not have been possible in earlier stages of the pandemic.
  • Particularly if parents resume work off-site and children are at home, clarify screen usage. Limit children’s observations of the news when you’re not present; instead, identify what is acceptable for them to watch that is positive, and favor appropriate, safe physical activities in place of recreational screen time.
  • Stay in good shape for whatever may come. Sleep, meals, exercise, and predictable routines are especially important as we navigate the stress of changes (with resuming work and school), as even positive changes are different than what is familiar and can negatively impact sleep or family meals.

RESOURCES

The CDC provides effective strategies for managing stress and worries in children during the pandemic.
 
Tips for parenting children so that they are less likely to feel anxiety.
 
ChildMind Institute provides strategies for addressing children’s anxiety around the pandemic.
 
Duan L, Shao X, Wang Y, et al. An investigation of mental health status of children and adolescents in china during the outbreak of COVID-19. J Affect Disord. 2020;275:112-118. doi:10.1016/j.jad.2020.06.029
#3: For children showing signs of depression, recognize and respond to their distress to partner against their depression.

The pandemic has had diverse impacts on children and youth. Some have felt decreased pressures and stresses from school and peers, while others miss their friends, do not feel engaged in virtual schooling, and feel trapped or limited in their current restricted activities. Resuming school may seem wonderful to some children, but not so to others, as their life is again changed from what is familiar. Some may struggle with new school practices or giving up the autonomy they preferred during earlier stages of the pandemic. It’s important to understand the developmental differences in how children express sadness, depression, and other reactions to life circumstances; for example, young children may report more bodily aches or pains, while adolescents may withdraw from activities or isolate. The following tactics may help caregivers respond to signs of depression in children:

  • The two symptoms most likely to suggest depression are an ongoing sad or irritable mood, most days, and withdrawal from previously enjoyable activities. It has been hard during this pandemic to know what is withdrawal vs. restriction from enjoyable activities, but those youth who seem to shut down, show little interest in anything, and have not replaced previously preferred activities with other activities, are more at risk for experiencing depression.
  • It can be awkward to talk about depression with children. Sometimes, it’s easier to text or write to them about it (and gives them time to think through their reactions instead of shutting the conversation down by denying or fighting back). It may also be helpful to just calmly recognize concerning behaviors (“I’ve noticed you haven’t been eating/sleeping/playing soccer as you’ve started back to school; how are you feeling?”) when bringing up these topics.
  • Accept their feelings rather than try to talk them out of those feelings. Let them speak more, and then ask if they’d like suggestions (as sometimes they may just want to express how they feel rather than go to problem-solving mode too quickly). Writing about it, listening to music (even sad music that reminds them that others have also experienced sadness), or doing other activities can sometimes be helpful in breaking a cycle of feeling “stuck” in sadness.
  • Doing a competing activity is often helpful for breaking out of a painful rut. Doing nice things for others (e.g., sending a kind message to a friend or relative) and engaging in productive activities that distract one from current distress can be helpful. If someone has been sleeping frequently and reports little energy, more passive tasks (walking a short distance with a parent or pet, watching something humorous, etc.) may be more realistic than trying to take a 30-minute bike ride or read a novel, for example.
  • Helping children recognize that sometimes their thoughts may be inaccurate or inconsistent with the evidence around them can be helpful. Sometimes these thoughts sustain depressive feelings and behaviors, and evaluating such thoughts is often what therapists do to improve depression.
  • Suicidality is always an important consideration, and particularly in youth who appear depressed and may feel hopeless or worthless. Reaching out to one’s current providers is appropriate, and also to suicide hotlines. 
  • A number of free apps (such as My3) are available for youth to identify coping strategies and people they could call if feeling suicidal or despondent.

RESOURCES

This site breaks down signs and symptoms by age to help parents recognize depression in children and adolescents.
 
The Kaiser Family Foundation website and early (July 2020) mental health findings from stress of COVID-19.
 
A review of global studies of the impacts of pandemics on mental health in youth.
 
Parent resource toolkits to ensure the social, emotional, and mental well-being of their children (by age level: early childhood, childhood, adolescence, young adulthood).
#4: For children having trouble following through with tasks or paying attention during virtual schooling, several strategies may help improve focus and management of impulsive behaviors.

The most common symptom reported in children during the COVID-19 pandemic emerged has been difficulty concentrating. Children have struggled to pay attention in a completely different structure as a result of virtual schooling, and teachers and schools similarly were not prepared to teach and engage students using this approach. Impulsivity has been associated with decreased adherence to public health measures such as social distancing and hygiene (McGowan et al., 2020).
 
  • Make the environment a good fit for each child. That starts with having your child help design their space. If it doesn’t work well, ask them what changes would help, and together make reasonable changes to their space. Some children need lots of stimulation to spark interest, while others become overwhelmed and distracted by even a few items in a room. Each child may need something a bit different to find a good setting in terms of sights, sounds, smells, etc. Eliminate computer and phone notifications popping up on screens used for learning.
  • Identify a dedicated workspace for students struggling with inattention or hyperactivity, and limit opportunities to view other screens so that the work environment is a place associated with learning (rather than working in bed, for example, which is associated with sleep).
  • Daily routines can be written down or tracked visually, such as through pictures of the child doing different activities. For example, knowing what the table looks like for math compared to language arts can help a child prepare for each class.
  • Identify productive activities a child can do when feeling fidgety or restless, such as jotting down notes, or rubbing felt or a fabric to keep hands busy.
  • Organizing the child’s room may need to be different during the pandemic, and items may need to find a “home” when not in current use (“When I finish math, I put my book and calculator on the middle shelf in my closet”). Color-coding by class and creating a list of tasks to cross off each day may be helpful.
  • Learning and practicing to think of “Situations-Alternatives-Consequences” can be helpful for children to use throughout the day, e.g., when they feel like getting up and moving about (“I can, but then I may miss out on how to do this assignment”) or when they want to turn off their screen or look at other materials (“It may be more fun, but then I won’t know how to do this and I may have to do more chores”)
  • Emphasize positive praise by being specific; using more or longer compliments than negative comments; and speaking in a positive, enthusiastic, and louder-than-normal voice (e.g., “Great job getting your paper ready with your name and date on it”).

RESOURCES

Tips and strategies for parents to manage children with attention, impulsivity, or hyperactivity symptoms.

The ChildMInd Institute provides a number of interventions to help students manage activities when they struggle to focus or manage behaviors.
 
McGowan G, Conrad R, Potts H. 51.2 Challenges with managing children and adolescents with aDHD during the Covid-19 pandemic: A review of the literature. J Am Acad Child Adolesc Psychiatry. 2020;59(10):S251. doi:10.1016/j.jaac.2020.08.412
#5: Recognize the unique impacts of the COVID-19 Pandemic on BIPOC (Black, Indigenous and People of Color) children and families, and think about interventions that are targeted, comprehensive and holistic as everyone transitions back to work and school.
 
It is important to use a contextual lens when applying the strategies provided above to BIPOC youth and families. The pandemic has disproportionately impacted different groups in the U.S., so more targeted efforts are required to diminish mental health risks and impairments. Social determinants have historically impacted the mental health of BIPOC children and families; however, the COVID-19 pandemic has magnified the impact. For example:
  • By July 2020, 64% of Latinx adults, 57% of Black adults, and 55% of Asian adults reported at least one household member losing employment since March 2020, compared to 44% of White adults. 
  • In addition, one in five Black and Latinx families reported not having sufficient food the previous week, compared to 8% of White and Asian families. These economic and food insecurity factors increase the risk of children dropping out of school and experiencing poverty themselves.
  • Approximately 31% of Black families and 27% of Latinx families reported being unable to pay their rent the prior month, compared to 15% of White renters.
  • Native Americans have also been disproportionately impacted, with COVID-19 infection rates more than 4 times that of the general population in New Mexico, with those experiencing poverty most at risk for COVID-19.
  • Approximately half of Black and Latinx children had classes (virtual or on-site) cancelled, compared to 40% of Whites. Black and Latinx families report less access to the Internet, such that virtual schooling has been less available to these children. Recognition of economic and school access variables remains important to address persisting factors that disproportionately impact BIPOC students. 
 
We must also acknowledge that BIPOC children, families, and communities have been burdened with the impact of racism and racial injustice, while simultaneously dealing with the impact of the COVID-19 pandemic. This exacerbates unique mental health needs for BIPOC children and families. Further, barriers to mental health care pose additional challenges, and highlight the urgency of not only recognizing these unique needs, but engaging in targeted, comprehensive, and holistic intervention development efforts.
 
Social determinants of mental health, which have been compounded by COVID-related stressors, can negatively impact overall health and wellbeing, and perpetuate mental health disparities for BIPOC children and families. Targeted social and structural interventions to address economic disparities, educational disparities (to include the provision of equitable educational access and services), and racism/racial injustice remain important efforts at the local, state, and federal levels to address current mental health needs and barriers for BIPOC children and families.

RESOURCES

This website provides an overview of social determinants of health, along with interventions and resources.

This research brief identifies the inequities in education experienced by American Indian and Alaska Native children and families.

This website describes current factors disproportionately impacting BIPOC children and families.

This website provides specific recommendations for children of color to manage distress with support from others in their school buildings.
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Disclaimer: The views, opinions, and content expressed in this email do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS).