Angelica Wills, PhD1; Jennifer Chuang, MD2; Ramon Solhkhah, MD3; Raymond F. Hanbury, PhD,A.B.P.P4; Steve Kairys, MD5

[1] Department of Psychiatry/Psychology Section, Jersey Shore University Medical Center
[2] Department of Pediatrics, Saint Joseph’s University Medical Center & Children’s Hospital
[3] Department of Psychiatry at Jersey Shore University Medical Center and Meridian Behavioral Health
[4] Department of Psychiatry at Jersey Shore University Medical Center
[5] Department of Pediatrics at Jersey Shore University Medical Center

The pandemic has heightened the awareness of both physical and mental/behavioral concerns in the children and adolescent populations in the state of New Jersey. It has been over a year since Coronavirus has created the challenges families face, including illness, loss of employment, financial problems, lack of food, closed schools and loss of life. It has all taken a tremendous toll on our youth from a social, emotional and academic perspective. Children coping with trauma, illness and disruption will need more than the vaccine to work through the repercussions of this ordeal.

There is clearly a pressing need for coordinated and collaborative measures, actions and efforts to address the psychosocial and mental health needs of the youth both during and post pandemic. Parents and pediatricians play a paramount role in recognizing mental health problems, developing resilience, and coordinating care with programs that provide such services, such as the New Jersey Pediatric Psychiatry Collaborative program.

Having access to available clinicians to assess the specific needs of the youth either in person or via telecommunications, is absolutely essential in order to address concerns such as loneliness, isolation, trauma, relationship problems, grief, loss and all the current social issues.This article will address these issues and examine the relevant implementation and strategies for such intervention. In order to illustrate the need for pediatric mental health resources, we describe a case of an adolescent with depression who presented to the hospital with an overdose in a suicide attempt. Sadly, this case is one of many throughout the state since the beginning of the COVID-19 pandemic.

CASE PRESENTATION

A.L. is a 14-year-old male who was brought by ambulance to the Emergency Department after ingesting twenty 12.5 mg tablets of diphenhydramine. His mother notes that he has become more withdrawn over the course of the last year during the COVID-19 pandemic. She states that he has been having decreased appetite, difficulty concentrating, and trouble sleeping. A.L. has not been in in-person school for about one year, and he
has been having a hard time keeping up with remote schooling. His virtual school attendance has been poor because he does not wake up in time to log into his school day on his computer. He has not handed in dozens of assignments, and he recently learned from his teachers that he may need to attend summer school or repeat the ninth grade. At home A.L. has become more irritable, frequently getting into arguments with his mother and his younger sister. Many of the fights over the last few months have been because his mother has not allowed him to see his friends because of the pandemic, but he has seen his friends posting pictures of themselves hanging out.Tonight’s argument escalated when his mother saw his report card for this marking period and saw that he was failing several subjects. His mother states there was a lot of screaming and that A.L. went to the bathroom and slammed the door shut. She became worried when he did not come out
of the bathroom for at least half an hour, and she forced open the lock. She found him semi-conscious and with slurred speech on the bathroom floor with an empty bottle of diphenhydramine next to him, and she called 911. He was brought by ambulance
to the nearest emergency room where he was admitted to the general pediatrics hospitalist service. He was medically stabilized over the next 24-48 hours, and psychiatry consult recommended admission to an inpatient behavioral health facility. After a search for inpatient psychiatric beds in New Jersey, they were told that there were no available beds for that day.This information was not a surprise to the inpatient pediatric team, as they had several other patients on the floor who were also awaiting inpatient psychiatric beds.

INTRODUCTION

COVID-19 pandemic and lockdown has brought about a sense of fear and anxiety around the globe. This phenomenon has led to present day challenges, as well as some long-lasting and unaddressed complications, including short term and long term psychosocial and mental health sequelae for the youth in our communities. For just about a year, families across the nation are confronting and attempting to adapt to the evolving daily changes and challenges in everyone’s lives which has been caused by the COVID-19 pandemic. Some of these changes to our “normal” way of doing things and conducting our lives include isolation, economic closures, school closure at all levels, no physical contact, no public gatherings, restrictions on leisure time activities, and in many cases physicians’ offices closed.

All of this has created major challenges to the environment in which we live. It is reasonable and obvious to say that the Coronavirus has brought about a sense of stress, concern, anxiety, insecurity and fear. One needs to normalize these reactions and be grounded to reality but at the same time acknowledge the need to modify our response reactions and behaviors to such aspects as quarantine and physical distancing. As we know, children learn from example. When they see their parents reacting in a negative fashion to the difficult circumstances and stressful situations, the children are likely to absorb the vibes and exhibit similar behavior. The toll on children has been tremendous on all venues – social, emotional, physical and academic (WHO, 2020). Although evidence indicates that children are less susceptible to the more severe physical symptoms of COVID-19 than that of those reported in adults, emerging evidence seems to suggest that the impact of the pandemic will affect children’s health for a long time afterward.

Facts about mental disorders in U.S. children reported by the CDC

  • ADHD, behavior problems, anxiety, and depression are the most commonly diagnosed mental disorders in children
    • 9.4% of children aged 2-17 years (approximately 6.1 million) have received an ADHD diagnosis (Danielson et al, 2018)
    • 7.4% of children aged 3-17 years (approximately 4.5 million) have a diagnosed behavior problem (Ghandour et al, 2018)
    • 7.1% of children aged 3-17 years (approximately 4.4 million) have diagnosed anxiety (Ghandour et al, 2018).
    • 3.2% of children aged 3-17 years (approximately 1.9 million) have diagnosed depression (Ghandour et al, 2018).
  • Some of these conditions commonly occur together. For example:
    • Having another disorder is most common in children with depression: about 3 in 4 children aged 3-17 years with depression also have anxiety (73.8%) and almost 1 in 2 have behavior problems (47.2%) (Ghandour et al, 2018).
    • For children aged 3-17 years with anxiety, more than 1 in 3 also have behavior problems (37.9%) and about 1 in 3 also have depression (32.3%) (Ghandour et al, 2018).
    • For children aged 3-17 years with behavior problems, more than 1 in 3 also have anxiety (36.6%) and about 1 in 5 also have depression (20.3%) (Ghandour et al, 2018).
  • Depression and anxiety have increased over time
    • “Ever having been diagnosed with either anxiety or depression” among children aged 6–17 years increased from 5.4% in 2003 to 8% in 2007 and to 8.4% in 2011–2012 (Bitsko et al, 2018).
    • “Ever having been diagnosed with anxiety” increased from 5.5% in 2007 to 6.4% in 2011–2012 (Bitsko et al, 2018).
    • “Ever having been diagnosed with depression” did not change between 2007 (4.7%) and 2011-2012 (4.9%) (Bitsko et al, 2018).

Protecting and maintaining the mental health of the future adult generation is only possible with the coordination and collaboration of many agencies and institutions and healthcare systems. It is essential to have adequate resources to overcome this crisis.

SILENT EFFECTS OF COVID: EXAMINING THE PSYCHOSOCIAL

COVID-19 was declared a global pandemic on March 11, 2020 (Di Domenico, Pullano, Coletti, Hens, & Colizza, 2020). The worldwide impact of coronavirus disease 2019 (COVID-19) is unparalleled by any other global event. As of June 2020, more than 8 million COVID-19 cases have been reported, with deaths reaching nearly 500,000 (O’Conner et al., 2020). Children prove difficult to assess when trying to minimize risk with COVID-19, because they are likely to be asymptomatic and less likely to have severe complications (American Academy of Pediatrics [AAP], 2020).The impact of COVID-19 can be measured in other ways including, but not limited to loss of jobs, closing of businesses, increase in mental health issues, as well as changes in the way we interact socially. It is probable that the effects of COVID-19 will continue to change the course of daily living for the foreseeable future.While we have gained some insight and medical data on COVID-19, currently no data exists which measures the changes in behavior, in particular the long-term effects, with regard to children and adults during a health crisis (O’Conner et al., 2020; Di Domenico et al., 2020; Lee, 2020).There is no population that is immune to the physical and psychological effects of COVID-19. With schools reopening, it is important to address previous and current concerns, but also examine potential future concerns that will affect both children and adults.

On April 8, 2020, schools were closed nationwide in 188 countries. Over 1.5 billion students enrolled in school are lacking face-to-face education (Lee, 2020; Nichols, 2020).This lack of face-to-face education has raised concerns related to abuse and neglect. Social isolation, due to physical distancing, can lead to increased rates of forms of child abuse and neglect, as evidence by China reporting a tripling of domestic violence rates since February 2020 (Gordon, 2020; Lee, 2020). Additionally, we also saw an increase in child abuse, neglect, and instances of exploitation during the Ebola outbreak in Africa from 2014-2016 (Lee, 2020). Schools being closed for children and adolescents result in lack of access to resources that schools can typically provide.These resources may include reduced cost/free lunches, access to special services and child study teams, sports and other extra-curricular activities. Approximately 370 million children rely on school to receive reliable and nutritional meals (Nichols, 2020).

As the pandemic continues, it is important to address the hidden issues and impact of COVID-19 and lockdown orders. These issues, which Gordon (2020) refers to as “deaths of despair” could manifest in increased drug and alcohol abuse, an increase in suicide rates, unemployment, fear, anxiety, and isolation. Kawohl and Nordt (2020) suggest that suicide rates increase 6 months before a rise in unemployment. Additionally, children and adolescents are also facing potentially unaddressed grief and loss resulting from the loss of a loved one due to COVID-19, the loss of financial income or a parent, as well as the child and adolescent’s own concern of their health which may be minimized in a time when so many crises are co-occurring.

Several organizations, such as the AAP, have provided guidelines for re-opening schools, for full-time, in-person education, in a safe manner (2020). The AAP stresses, in addition to education, schools provide critical support in addressing racial and social equality. Schools may consider addressing, and continuing to monitor differences that may prevent children from following the same guidelines provided by the CDC, in matters such as wearing masks.These guidelines may be challenging for individuals with disabilities, psychological concerns, and medical conditions. Effort should be made to address, and not stigmatize, any differences.The AAP (2020) also acknowledges that extended time away from school and interruption of services could lead to social isolation, which in turn, could lead to the “deaths of despair” discussed earlier (Gordon, 2020).

Several organizations, such as the American Psychiatric Association’s Council on Addiction, have addressed the need for integrative access to healthcare, which should include mental health care. Removal of obstacles to healthcare, such as prior authorizations, referrals, and other administrative requirements that discourage patients from receiving timely treatment can make access easier (Gordon, 2020). In the state of New Jersey there is the NJ Pediatric Psychiatry Collaborative Program which was established for the purpose of providing a resource for pediatricians to refer their patients who may be experiencing a mental health concern to a Hub (a hospital based site) for a complete assessment and psychiatric evaluation when needed. Bridging the gap for educational systems to aid in making access to healthcare could also prove beneficial. Educating faculty and staff at schools to recognize signs of psychological stress, through resources like Psychological First Aid, could prove useful as well. Helping families and medical providers have a better means of communication could also limit the length an individual experiences psychological distress before being linked with treatment.

CHALLENGES

One major challenge post pandemic will be the sequelae that will remain, namely the mental health of the children as well as that of the families. COVID-19 pandemic and lockdown has brought about a sense of fear, anxiety and tremendous uncertainty on so many fronts.(Singh et al, 2020) The quality and magnitude of impact on children and adolescents is determined by many vulnerability factors like developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection or fear of infection. (Ghosh et al., 2020)

The youth are vulnerable to the many psychosocial aspects that have a significant impact as a result of this pandemic. Being quarantined in unsafe and or unstable homes and institutions may impose greater psychological burden than the physical sufferings caused by the virus. School closures, lack of outdoor activity, aberrant dietary and sleeping habits are likely to disrupt children’s usual lifestyle and can potentially promote monotony, distress, impatience, annoyance and varied neuropsychiatric manifestations. Incidences of domestic violence, child abuse, adulterated online contents are on the rise. Children of single parents and frontline workers suffer unique problems.The children from marginalized communities are particularly susceptible to the infection and may suffer from extended ill-consequences of this pandemic, such as child abuse, neglect, child trafficking, sexual exploitation and death (Ghosh et al, 2020). Parents, pediatricians, psychologists, social workers, hospital and state and federal authorities have important roles to play to mitigate the psychosocial ill-effects of COVID-19 on children and adolescents. Providing for the basic needs, such as medical care, mental health services and to minimize the inequities among the children of the different strata of the society are foremost priorities.

IMPACT OF COVID-19

The unexpected disruption of the social fabric and norms has affected the behavioral and mental health of the public, including children.The mental health of children has been influenced in several ways, as this unprecedented situation changed a way they typically grow, learn, play, behave, interact, and manage emotions. Children with pre-existing psychiatric disorders such as attention- deficit/hyperactivity disorder (ADHD), anxiety, depression, mood disorders, and behavior disorders could be adversely impacted during this stressful situation. (Sprang & Silman, 2013) Mental disorders are the leading cause of disability worldwide in adolescents and children.About 15% of children and adolescents in the world have mental health disorders or conditions. Nearly 50% of mental disorders start to affect the children by the age of 14.

Children are likely to be experiencing worry, anxiety and fear, and this can include the types of fears that are very similar to those experienced by adults, such as a fear of dying, a fear of their relatives dying, or a fear of what it means to receive medical treatment.
Given schools have closed as part of necessary measures, then children really no longer have that sense of structure and stimulation that is provided by that environment, and now they have less opportunity to be with their friends and get that social support that is essential for good mental well-being.

As the coronavirus (COVID-19) pandemic sweeps across the world, it is causing widespread concern, fear and stress, all of which are natural and normal reactions to the changing and uncertain situation that everyone finds themselves in.

“The issue facing each and every one of us is how we manage and react to the stressful situation unfolding so rapidly in our lives and communities. Here we can draw on the remarkable powers of strength and cooperation that we also fortunately possess as humans. And that is what we must try to focus on to respond most effectively to this crisis as individuals, family and community members, friends and colleagues,” said Dr Hans Henri P. Kluge, WHO Regional Director for Europe.

“With the disruptive effects of COVID-19 – including social distancing – currently dominating our daily lives, it is important that we check on each other, call and video-chat, and are mindful of and sensitive to the unique mental health needs of those we care for. Our anxiety and fears should be acknowledged and not be ignored, but better understood and addressed by individuals, communities and governments,” Dr Hans Kluge noted.

IMPACT OF THE COVID-19 CRISIS ON CHILDREN’S MENTAL HEALTH

This is indeed an unprecedented time for all of us, especially for children who face an enormous disruption to their lives. Children are likely to be experiencing worry, anxiety and fear, and this can include the types of fears that are very similar to those experienced by adults, which were mentioned earlier. If schools have closed as part of necessary measures, then children may no longer have that sense of structure and stimulation that is provided by that environment, and now they have less opportunity to be with their friends and get that social support that is essential for good mental well-being.

Being at home can place some children at increased risk of, or increased exposure to, child protection incidents or make them witness to interpersonal violence if their home is not a safe place. This is something that is very concerning.

Although all children are perceptive to change, young children may find the changes that have taken place difficult to understand, and both young and older children may express irritability and anger. Children may find that they want to be closer to their parents, make more demands on them, and, in turn, some parents or caregivers may be under undue pressure themselves.

Simple strategies that can address this can include giving young people the love and attention that they need to resolve their fears, and being honest with children, explaining what is happening in a way that they can understand, even if they are young. Children are very perceptive and will model how to respond from their care givers. Parents also need to be supported in managing their own stressors so that they can be models for their  children. Helping children to find ways to express themselves through creative activities and providing structure in the day – if that is possible – through establishing routines, particularly if they are not going to school anymore, can be beneficial.

Mental health and psychosocial support services should be in place, and child protection services need to adapt to ensure that the care is still available for the children of families who need it.The literature shows that children and adolescents are experiencing mental distress due to the disruptions of the closure of schools, activities, and maintaining social and physical distancing (Singh et al, 2020; Merrill 2020). Schools hold a lot of resources, especially for children and adolescents with special mental health needs. For example, children with autism spectrum disorder are at high risk.Their routine has been disrupted. Research shows that they easily get irritated, frustrated, and short-tempered. Not being able to do their routine activities has greatly impacted our children and young people.

It is clear through this pandemic, that everyone has been affected but each person in their own way. Each segment of the population has reactions that are similar as well as different and unique to that individual.The core of all reactions is related to the level of stress that is being manifested and has impacted the young children, school aged children and adolescents (pre-school, elementary, high school and college), youth with special needs, underprivileged children and parents, and care givers.The stress factors exacerbate the mental health concerns for all, specifically, increased anxiety, depression, substance use and suicidal ideation.

Early diagnosis and appropriate services for children and their families can make a difference in the lives of children with mental disorders. Access to providers who can offer services, including screening, referrals, and treatment, varies by location. Having access to and available mental health professionals is absolutely crucial in dealing and coping with the many facets of this pandemic. Acknowledging the need is an essential component of developing strategies and programs addressing the emotional and behavioral issues that are evident in society.

In response to the growing national crisis in access to child mental health services, many children with mental health issues go untreated and there is growing pressure on pediatricians to serve children in need with very limited clinical and consultative resources. Hackensack Meridian Health (HMH) established the New Jersey Pediatric Psychiatry Collaborative (PPC) Program in 2015 with funding from the New Jersey Department of Children and Families (DCF). The PPC has been implemented in all twenty- one counties in the state of New Jersey and has screened over 182,000 children and adolescents with over 12,000 being referred for clinical services.

The purpose of the PPC is to improve the identification and treatment planning for psychiatric illness in a pediatric primary care setting by using a collaborative care model between pediatricians and child & adolescent psychiatrists. Pediatricians are being educated on the implementation of mental health screening measures and monitored for the use of such assessments in everyday practice. A goal of the program is to assist pediatric providers in the identification and treatment of mental health problems in their patients by increasing the providers’ use of screening measures and providing consultation and case management services. Additionally, this can include assisting families obtain therapy services for their children, determining the level of care needed, offering education about mental health issues, and providing pediatricians with medication management assistance.When the PPC program is consulted by a pediatric provider, these patients are monitored across time to determine treatment adherence, as well as identify barriers to treatment.

Pediatric primary care is ideally provided within a patient’s medical home.The medical home model promotes care that is: accessible, continuous, comprehensive, collaborative, compassionate, culturally competent, and family-centered.

Collaborative mental health care partnerships are crucial to integrating mental health into pediatric primary care and improving access to timely and appropriate behavioral health services. Successful partnerships are characterized by effective collaboration, communication, and coordination between CAPs and PCPs in consultation with children, adolescents and their families.Through these partnerships, CAPs can have a significant positive impact on the psychiatric care of larger numbers of children, adolescents and their families through the promotion of prevention, early intervention, and treatment of childhood psychiatric illness.

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