Title:The impact of COVID-19 on the young

In recent months, pediatrician Elizabeth Chawla (M’09), MD, FAAP, has treated two children for a disorder she had not encountered previously—a phobia of vomiting, resulting in a refusal to eat.

“Although it’s fairly common, I’d never seen it in 10 years of practicing,” says Chawla, a primary care physician at MedStar Georgetown University Hospital’s outpatient pediatrics clinic and associate professor of clinical pediatrics at the School of Medicine.

For Chawla, this phenomenon is just one piece of evidence suggesting the profound impact of the COVID-19 pandemic on children’s mental health. “We’re seeing so many anxiety symptoms in children manifesting in all different ways,” she says. She initiated a research study to verify what she has witnessed anecdotally, conducting chart reviews of clinic patients under 5 to determine if there has been a statistically significant increase in symptoms of stress during the pandemic.

“It’s a very uncertain time, and even little children are picking up on that. So even if they can’t articulate that they feel worried or scared—or that the world seems chaotic— they’re showing us with these increased signs of distress.”

Laying the Groundwork

Evidence suggests that the pandemic has exacerbated a disturbing trend: over the past several decades, the United States has seen a steady increase in the incidence of mental health issues among children.

“More and more children are in mental health crisis at younger and younger ages,” says Matthew Biel, MD, MSc, chief of the division of child and adolescent psychiatry at MedStar Georgetown University Hospital and associate professor of clinical psychiatry and pediatrics at the School of Medicine. He notes that the problem has been compounded by a severe shortage of mental health providers for children.

In response, Biel pioneered the creation of the Integrated Mental Health Clinic within the outpatient pediatrics clinic several years ago, adding a child and adolescent psychiatrist to the roster of practitioners. He invited Chawla, who now serves as co-director, to help develop the program.

Based on her own experience and reports from medical doctors nationwide, she felt it was essential to include a training component within the clinic, teaching pediatric residents how to recognize signs of mental distress and how to have an appropriate conversation with children and parents, as well as teaching intervention strategies.

“The amount of engagement in the curriculum has skyrocketed during COVID—the residents have heightened appreciation of the need for knowing these skills,” she says. “I think it’s a real strength of the MedStar Georgetown University Hospital residency program. I’ve presented nationally about our model, and people really see the long-term value.”

The clinic is only one of many innovative programs that Biel and other experts at Georgetown University Medical Center have developed to address pediatric mental health issues in the Washington, D.C., region and nationwide, making Georgetown especially well-positioned to help children navigate the pandemic’s unprecedented challenges.

In September 2020 for example, the U.S. Department of Health and Human Services tapped Georgetown’s Center for Child and Human Development (CCHD) to co-lead a new initiative—the National Center on Health, Behavioral Health, and Safety—focused on COVID-19 recovery for children enrolled in Head Start and Early Head Start.

“We know the issues from a systems level, but also from a frontline level—from folks who have worked in Head Start for a very long time,” says Neal Horen, PhD, director of CCHD’s early childhood division. “So when the opportunity came up, people looked to us. I do think people see our center as the place that knows more about early childhood mental health as it relates to Head Start than most everybody else.”

Lives Upended

When the country locked down in March 2020 at the start of the pandemic, the impact on children was mixed. “Things were all over the map in the first few months,” Biel says. “Some kids really, really struggled to navigate the disruption. Other kids actually experienced some relief, because they were having a lot of stress related to school.”

As pandemic conditions continued to worsen, children’s lives were completely upended. In addition to coping with the extended loss of familiar routines and activities—no chatting with friends on the playground, no hugs from grandparents— they increasingly had to worry about a parent losing their job or falling ill with COVID-19.

“There was a real crisis for lots of kids in lots of populations all across the country,” Biel says. For example, the Centers for Disease Control and Prevention found that from April to October 2020, U.S. hospitals reported a 24 percent increase in the proportion of mental health emergency visits for children ages 5 to 11, and a 31 percent increase for children ages 12 to 17.

“Emergency rooms across the county have been full of kids requiring acute psychiatric care and oftentimes there are no services available,” Biel says. “It’s very common to hear about kids spending days or weeks waiting for a bed to become available to treat their psychiatric crisis.”

Perhaps most concerning is the trend for pre-adolescents. “Over the last 10 years, we’ve seen a general trend of increases in suicidal thoughts and even suicide attempts and completed suicides in kids younger than puberty, those who are 9, 10, 11 years old,” Biel says. “And that has been noticeably true during the pandemic as well, particularly for kids of color.” He notes that rates of suicidal behaviors have traditionally been lower among African American, Native American, and Hispanic children, but these populations are now seeing the most rapid increases.

Biel, who works with school and community programs in D.C., has seen first-hand the impact of COVID-19 on underserved communities. “There was a lot of fear and uncertainty about the ways the virus was particularly affecting communities of color, who already suffer from a lack of access to health care. There’s also been a lot of financial insecurity—parents feel that, so the kids feel that too. These factors have been a huge strain on the most vulnerable and most stressed communities in the city.”

Missed Opportunities

Even for children who have managed comparatively well during the pandemic, longer-term effects are already coming into play. A recent analysis by McKinsey, for example, showed that the impact of the pandemic on K–12 student learning was significant, leaving students on average five months behind in mathematics and four months behind in reading by the end of the 2020-21 school year.

“For very young children, lots of parents have been coming into the clinic worried about developmental delay,” says Chawla. “So another study we’re doing right now is looking at that group of 5 and under to see if there are any differences between this year and last. Just looking at the preliminary data, it seems that the biggest difference is language delay.

“It makes sense if you think about it,” she continues. “We have noticed that children have had an exponentially increased amount of screen time during the pandemic, especially young children. And there are already some fairly good studies showing that excessive amounts of screen time, as well as the decrease in the amount of individual interaction with adults and peers, can lead to language delay.”

Biel notes that colleagues nationwide are concerned about these missed opportunities for stimulation outside the home. “I think we’ll only know over time whether it has a meaningful impact on a population level, for that cohort of kids who’ve experienced prolonged social isolation and quarantine during early developmental stages,” he says.

“We know those stages are really, really important for key social and emotional skills, but we also know that kids are very pliant and resilient. There may be a great catch-up that happens if that age group is reintroduced to more stimulating environments. That’s why this fall is so important. We’re all on pins and needles hoping that schools will be able to stay open.”

Caring for the Caregivers

Children, of course, are dependent on adults. If an adult— whether a parent, caregiver, teacher, or health care provider— is not doing well themselves, they very often do not have the emotional resources necessary to meet a child’s needs.

Georgetown has built an extensive infrastructure of programs to support professionals in the field, both on the regional and national level, which have gone into high gear during the pandemic. “We’ve done a great deal of work on disaster recovery over the years, so it’s very much akin to that in terms of being an emergency response,” says Neal Horen of the new Head Start national center that CCHD is co-leading.

The center is conducting ongoing professional development training for the 12 Head Start regions in the country, which include the Tribal and Migrant and Seasonal Head Start programs. It is also developing a host of educational materials on how to address the mental health aspects of the pandemic.

“Our partner on this, the Educational Development Center, is the health and safety side of our national center, and we’re the mental health side,” he says. “What we’ve done as a center is to say, it’s all connected. We did a lot of work after Hurricanes Maria and Irma in Puerto Rico and the Virgin Islands, and one of the things we’ve learned is that oftentimes people neglect to address mental health, particularly for the staff in Head Start.

“Every single time we asked a staff member how they were doing, they would say, ‘I’m doing awful, I haven’t been able to address my own wellness,’” Horen says.

“Similarly with this pandemic, what we’ve emphasized as a national center is you can’t talk about health and safety without talking about mental health. In our training, for example, we discuss how to address vaccine confidence, which is really a mental health issue,” he says.

Read more about Georgetown’s work to optimize collaboration on pediatrics across campus >

In the Washington, D.C., region, the WISE Center (Center for Wellbeing in School Environments), a multidisciplinary mental health team at MedStar Georgetown, has provided invaluable support not only to students, but also to parents and teachers, throughout the pandemic. Both Biel and Horen are part of the WISE team.

“We provide services in over 50 public schools in D.C., and we maintained those services all throughout COVID,” Biel says. The WISE Center had already developed programs focused on adult well-being, and continued that emphasis during the pandemic, addressing issues such as teacher burnout.

“Teaching and parenting are very difficult jobs—it requires all of you. It can be rewarding, but it can also be very draining,” Biel says. “One of the key findings with stress and adversity is that your kids are going to do better when you take better care of yourself. It’s an extension of the view that you put on your own oxygen mask before you put it on your child when you’re on an airplane.”

He adds that when navigating adversity it’s important to “establish a narrative about that adversity: who is my community, what are we going through, what are our sources of support and help during times of trouble? Applying that to COVID, it’s been really helpful as well,” he says. “Here are healthy ways to cope with the stuff that life is throwing at you, here are people you can rely on, here are things that I know help me personally navigate my own stress, whether it’s exercise or listening to music.”

Providing access to and reducing stigma around therapy is also critical, he notes. “We’re doing therapy for teachers in schools, and therapy for parents in our child psychiatry clinic—helping them recognize that part of getting my kid help is getting myself help.”

Read more about advice to parents and caregivers >

Addressing Inequity

The pandemic has brought much-needed attention to the nation’s lack of resources for children’s mental health and health equity issues more broadly.

“We as a center have an opportunity to really contribute to a much larger body of work that lots of folks at Georgetown have been attempting to address around health equity, within the District and on a national level,” says Horen. “It’s an opportunity to really dig in and work on these issues.”

“This topic is on the minds of policymakers and families all over the country,” says Biel. “The winds are blowing— between COVID-19 and the long overdue attention on the impact of race on health—to make this an unavoidable topic. We have to do a better job of solving this as a society. We need to take better care of our kids.”

Photos: Kirsten Hawkins, MD, MPH and iStock