PolicyLab

While children have largely been spared from severe COVID-19 symptoms, the effects of the pandemic on children’s development and behavioral health—which have been illuminated across research and media—have raised concerns among mental health professionals. Just last week as Mental Health Awareness Month began, a team here at Children’s Hospital of Philadelphia (CHOP) released a study finding the proportion of pediatric emergency department visits for mental health conditions increased since the start of the pandemic, and that the visits during this time were more likely to require hospital admission.

At the same time, related stressors such as parental job loss and financial challenges, food insecurity, civil unrest, and racial injustice have amplified the potentially traumatic impact of the pandemic on children’s sense of safety and security. Further adding to existing health disparities, Black, Native American, and Latinx communities have been disproportionately affected during these interrelated crises.

As more data comes to light, we are just beginning to understand not only the immediate repercussions of the pandemic for the mental health of children, but also the full extent of what the many challenges families encountered over the last year might mean for children’s well-being long-term.

We do know that experiences can be vastly different based on where a child or teen is at in their growth and development. Understanding these nuances will be an important component in helping children and families through pandemic recovery. Below, members of PolicyLab’s Behavioral Health Portfolio and our partners in CHOP’s Department of Child and Adolescent Psychiatry and Behavioral Sciences and Center for Violence Prevention break down what these challenges have looked like across four distinct developmental stages, review how providers can support children and their caregivers, and discuss where more research will be needed as we look beyond the pandemic.

Infants & Toddlers

Wanjiku F.M. Njoroge, MD & Ariel A. Williamson, PhD, DBSM

Given that 90% of brain development occurs during the first five years of life, pandemic-related impacts of illness, social and physical distancing, and gaps in child care may be especially apparent for families with young children. These disruptions have resulted in greater stress and worse mental health for families, which can lead to  negative caregiver-child interactions and parenting practices with long-term, adverse impacts on child mental health. Families with infants and toddlers have struggled with whether to return their child to child care, and how to do so safely. Diminished educational and socialization opportunities, child care loss, and social and physical distancing may also have significant consequences for young children during this sensitive period of development.

Research documenting the direct impacts of COVID-19 on infants and toddlers is limited, but previous research on illness-related social isolation and natural disasters suggests that young children may show increased behavioral problems as a result of this major life stressor. As the pandemic continues, families of young children and early childhood clinicians and care providers can take steps to promote positive caregiver mental health and parenting and support young children’s healthy development. Adjusting to the changing pandemic restrictions and to eventual post-pandemic life will take time, and research is needed on how we can continue to support our youngest children in making these transitions.

We do know that this period of development is ripe for intervention, and that with support and resources, very young children and families can thrive even in the face of challenges!

Preschool to Second Grade

Rebecca Kanine, PhD

Preschool to second grade is a period of substantial cognitive, language, motor and social-emotional growth.  Preliminary research has documented increases in emotional and behavioral problems during the pandemic, particularly among families with young children. At CHOP’s Parent-Child Interaction Therapy (PCIT) clinic, parents have expressed difficulty balancing work, caretaking and schooling their young children. The pandemic has also limited access to behavioral health care services due to pauses in in-person therapy and school-based services, through which many children receive mental health care.

School and early childhood education closures, and resulting online learning, have been reported as a significant public health crisis for young children and their families. Experts predict that the interruption of formal education may negatively impact children’s learning outcomes, especially for children with unequal access to educational resources. Given that preschool to second grade is a pivotal time for educational and social growth, young children may be particularly vulnerable to the lack of in-person schooling. During stay-at-home requirements, young children who receive early intervention (EI) or special education services were not receiving the same level of support. At CHOP, some parents reported that EI services have gone virtual or dropped off completely and that their young children struggle to engage virtually due to their inability to maintain focus. Parents have expressed concerns about the long-term impact on their children’s development.

As we return to normal, or perhaps adapt to a new normal, researchers should continue to study pandemic-related risks and protective factors for young children, and clinicians should provide interventions to address their developmental and behavioral health needs in the aftermath of the COVID-19 pandemic.

Third to Seventh Grade

Jason Lewis, PhD

The pandemic’s impact on the emotional well-being of late elementary to early middle school-aged children has been far reaching. Even during typical years, children between ages 7 and 13 are influenced by many different milestones and transitions. From the development of peer networks to the transition from elementary to middle school and the start of puberty, children at this stage are often faced with stressors, most of which have been intensified by the COVID-19 pandemic.

For example, children within this group are generally beginning to develop more sustained relationships with individuals outside of their family, but unlike adolescents, are often not able to interact as easily with their peers virtually. As a result, the necessary physical and social distancing mandates that have led to increased social isolation for so many have been significantly impactful for children in this age group. Early indications highlight that rates of depression, anxiety and other childhood mental health disorders have increased since the start of the pandemic. Additionally, COVID-19 has impacted the normal routines for most families. Children within this age range often rely upon the structure of routine for safety and security, without which there have been increases in overall child and parental stress, sleep difficulties, appetite disturbances, and academic problems, among other things.

As we progress through the pandemic and develop plans for a full return to education and extracurricular activities, it is important for researchers, clinicians, educators and policymakers to consider the specific needs of school-aged children. A clear focus on their mental health, as well as their resiliency and coping, will go a long way towards setting these youth up for success. 

Teens

 Polina Krass, MD & Kavita Tahilani, PhD

Teenagers have faced unprecedented stressors over the past year. COVID-19 restrictions have limited in-person schooling, the development of age-appropriate social relationships, milestone celebrations and participation in usual activities. Pediatricians and behavioral health clinicians at CHOP and across the U.S. have seen teenagers with increased depression, anxiety, school avoidance, conflict at home and social isolation, and who have been acting out. 

Health care providers can support adolescents during this time by helping to facilitate age-appropriate communication. Parents can be encouraged to engage in active listening: reflecting, validating and respecting adolescents’ point of view. Research has demonstrated that asking direct questions about depression or suicide does not increase the likelihood of having suicidal thoughts or engaging in self-harm, so it is important that parents and health care providers ask these questions. Finally, providers can remind parents to engage in their own self-care. Modeling appropriate emotion-regulation is helpful for both parents and adolescents in improving mental health and reducing conflict at home.

Adolescents have shown remarkable resilience during the COVID-19 pandemic. Prioritizing adolescent health and well-being at this critical juncture will allow us to mitigate further negative consequences of COVID-19 on youth mental health and give this generation the tools they need to thrive.

Investing in Behavioral Health to Span All Ages

Despite differences in how children across multiple stages of development have been impacted by the pandemic, finding ways to reduce disparities and increase access to care will be crucial for supporting all youth during this challenging time. One potential approach is through telehealth services, which scaled up rapidly during the pandemic and have allowed continuity of care. It will be important to continue to evaluate the pros and cons of this option and the utility of continuing this form of service.

Additionally, communities should prioritize in-person learning for school-age children. This will require not only ensuring there is adequate financial support to safely return to the classroom, but also making plans to support the emotional well-being of youth as they reacclimate to in-person socialization and catch up on missed academics. Expanding the settings in which mental health services are delivered to meet families where they are, including in schools as students return to classrooms, can help ease this transition.

As we move forward, it will be important for us to evaluate the long-term health effects of the pandemic on children of all ages—both from a research perspective but also through continued screening efforts in schools and primary care settings—so we can identify children who need additional services and link them to care.