By: Caitlynn Iddings, MD
You don't have to be a pediatrician to see the large impact the COVID 19 pandemic has been having on our children and teens. Multiple studies released over the past 10 months show that anxiety, depression, substance abuse, child abuse, and suicide attempt/self-harm are on the rise since March 2020. As a General Pediatrician I can attest to the large rise in office visits to address concerns of anxiety, depression, nervous tic disorders, and overall underachievement in school which has been ever more prominent even since school started back this fall. Of course, I don't think this really surprises anyone or should. In general, adults also report increased anxiety and depressive symptoms. I think personally as a parent I like to give myself the false reassurance that I have been superior in sparing my children from any excessive anxiety surround the virus, but let me be honest, kids are sneaky. Their presentation of anxiety and depression are not as typical as what we see in adults.
Let me explain why kids may be more depressed and anxious than we realize and the science behind why this may be. There is a specific area of the brain known as the "Pre-Frontal Cortex" (PFC). This is the area of the brain that is responsible for multiple functions. It is the "football coach" or the "orchestra conductor" part of the brain. The most typical psychological term for functions carried out by the prefrontal cortex area is "executive function." Executive function relates to the ability to differentiate among conflicting thoughts, determine good and bad, better and best, same and different. It is responsible for recognizing future consequences of current activities, working toward a defined goal, predicting outcomes, knowing expectation based on actions, and social “control.” It allows the ability to suppress urges that, if not suppressed, could lead to socially unacceptable outcomes.
Back before we better understood brain anatomy, doctors often would take the "clinically insane" person and do something called a frontal lobe lobotomy where they would scramble the forebrain or prefrontal cortex to make patients "more controllable." Sometimes lobotomy would leave a patient docile and childlike, with significant inability to care for themselves but often this would leave patients with a variety of issues including difficulty sleeping, apathy for previously enjoyed activities, significant personality changes, inability to sustain focus or commit things to long term memory, and increased reckless behaviors such as impulsive gambling, eating, thrill seeking, etc. In depression not only is there under activation of the PFC across all age groups, but its volume has been found to be reduced as well in persons who are more prone to depression. A depressed person with an underactive prefrontal cortex of reduced volume is not going to demonstrate the rational problem-solving abilities of someone without such deficits—this causes the brain to have a reduced capacity to support resilience.
Why does the prefrontal cortex matter specifically regarding kids, the pandemic, and mental health? The PFC is one of the last parts of the brain to physically mature. This is why a 4-year-old struggles with patience and the concept of "time" and why offering toddlers "delay reward or gratification" is rarely effective in mitigating undesired behaviors. For a toddler and young elementary school aged child, the ability to think days, months, or even years into the future is virtually impossible. This isn't for lack of intelligence but simply because their forebrain is still so relatively immature. So, if you tell your 4-year-old "Maybe next Christmas we will be able to go see Santa in person when Coronavirus is gone" they have no ability to conceptualize what a year from now means. They may start to ask you every day if it is next Christmas or if "coronavirus is gone yet" (if only, right?!?!). In their little mind it sets an unattainable goal that can lead to anxiety and sadness. In young kids the following can be signs or symptoms of struggling with anxiety or sadness:
- fussiness and irritability, startling and crying more easily, more difficult to console
- difficulty falling asleep and waking up more during the night
- Feeding issues such as reflux, constipation, loose stools, or frequent complaints of belly pain
- Increase separation anxiety, being more clingy, hesitant to explore and play
- hitting, biting, and more frequent or intense tantrums
- bedwetting or frequent accidents when they have previously been potty-trained
- constantly looking for words or affirmation or urgently expressing needs while seeming unsatisfied when needs are met
- And conflict and aggression or themes of illness or death during imaginative play time
As we grow older our prefrontal cortex continues to mature, but there are plenty of studies that suggest the PFC does not reach full maturity until close to age 25 (especially in males!). Therefore, it doesn't matter how smart your middle school or teenager is or how high of a score they manage to get on their ACT or MAP testing. Good judgement is just NOT something they can easily excel in, at least not YET. Studies show that as adults we tend to think or activate the prefrontal cortex, or the "rational part" of the brain and teenagers process more information with the amygdala or the "emotional part" of the brain. In adults the connections between these parts are well established but in teens those connections are still being made, and not always at the same rate for each child. Therefore, when we ask a teenager "What on earth were you thinking!?!?" we are often met with blank stares because it isn't as much about what they were THINKING as what they were FEELING at the time. They intrinsically lack a brake pedal when it comes the being able to stop and think though long-term consequences of their actions. They are hopelessly "near sighted" beings.
As adults we all recognize what it is to have a bad day. Overslept the alarm, late to work, bombed the big presentation, spouse calls upset because the pipes burst, the dog got hit by a car, daycare calls and the baby has a fever and needs picked up early. The rational part of the brain allows us to think more long term though. Adults who are not clinically depressed or anxious themselves know today was bad but tomorrow is another day and can be better. Adults can typically compartmentalize, adjust, and rationalize (assuming they have a healthy and functional PFC). When a teen has a bad day (failed their math test, got kicked off the basketball team, girlfriend dumped them, parents grounded them because they failed their test) thinking of the future can be a challenge. The ability to reason that a good day could be just around the corner is impaired and the perfect storm for impulsivity and overreaction is set up. This makes teens much more likely to act on thoughts of self-harm and suicide than their adult counter parts. All the big emotions in the moment can be overwhelming and without the appropriate support system, teens are struggling even more.
Unfortunately, with the pandemic one bad day for most has become a string of bad days. Kids and teens have also had their social support systems ripped away by taking away in person school, in person sports, in person music activities, and in person religious group meetings. Most have been home, isolated, and lacking the ability to see a possible tiny light at the end of the tunnel. In teens a couple weeks of seeming down due to a perceived disappointing or bad event is to be expected. But as a parent if you see a significant mood or behavioral change that lasts more than 2 weeks, it could mean something else is going on. Classic signs of depression and anxiety in older children and teens include:
- mood changes that are not characteristic for your child including excessive anger or rage, irritability, increased conflicts or fights with family or friends
- changes in behavior, such as stepping back from personal relationships. If your ordinarily outgoing teen shows little interest in texting or video chatting with their friends, for example, this might be cause for concern.
- a loss of interest in activities previously enjoyed. Did your music-loving child suddenly stop wanting to practice guitar, for example? Did your All-Star basketball athlete suddenly quit and refuse to go to practice or see their friend?
- A hard time falling or staying asleep, or starting to sleep ALL the time
- Changes in weight or eating patterns, such as "never being hungry" or constantly overeating
- problems with memory, thinking, or concentration.
- less interest in schoolwork and drop in academic effort
- changes in appearance, such as lack of basic personal hygiene (within reason, a lot of teens are not dressing to the 9s for their virtual zoom classroom meetings)
- increase in risky or reckless behaviors such as drug or alcohol use, sneaking out at night
- thoughts about death or suicide or talking about the world being better without them in it.
If you notice some of the red flag symptoms above in your child don't hesitate to reach out for help. School counselors and teachers may be helpful in gathering information as to the level of concern you should have. Ask your child if there is anything bothering them. Be willing to be a listening ear. Often times our impulse as parents it to immediately "try to fix" the problem presented but for teens they often don't want you to fix it. They want validation that they are hurting or confused. They may not talk to you but may talk to a friend or another responsible adult (youth pastor, teacher, athletic coach) so sometimes reaching out to these people to see if there is any reason for concern and need for further medical or mental evaluation is key. The rule in pediatrics is that if you are worried or concerned as a parent, we as Pediatricians want to see you and your child and help evaluate what needs to be done. Remember depression and anxiety typically are multifactorial and therefore, require a multifactorial approach. Pediatricians have been equipped with validated screening tools and resources to get your child plugged in to a mental health provider or provide other medicines or therapy that could drastically improve your child’s overall mood and quality of life during this very stressful time.
Lastly, it is time to destigmatize mental health issues as well. As a parent if you are open about the importance of mental health and supportive of your child it will make all of the difference in their ability to approach you or someone they know to ask for help. If a child has a sore throat and fever and gets brought to the doctor and diagnosed with strep throat, they would get medicine to treat the symptoms and also help clear the infection because it is understood that untreated strep throat can be potentially deadly or have life-long consequences. If a child is severely depressed or anxious it should also be encouraged to bring them in to get them therapy or possibly medication that they need to prevent potential deadly or life-long consequences.
All kids need to learn how to cope with challenging things. One of the best possible gifts a parent or care giver can give to a child is to allow them to learn coping skills. These are things all people have to learn eventually to be capable and productive members of society. I always say it is better to learn these skills when you are 10 years old and have fewer responsibilities than when you are 20 or 30 or 40 years old. It’s about equipping kids to be resilient and giving them the mechanism to excel even when their prefrontal cortex has not quite caught up yet. COVID has taken so much from us as a society. It is time to start regaining ground and getting kids the help they truly need to come out of the other side of this pandemic with less trauma and less baggage. But no one can do that alone, it takes a team, and we have a pretty spectacular team of people waiting to give kids the tools they need. Give us a call to schedule an appointment so we can help!
· 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.
· Loades ME, Chatburn E, Higson-Sweeney N, et al. Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19 [published online ahead of print, 2020 Jun 3]. J Am Acad Child Adolesc Psychiatry. 2020;S0890-8567(20)30337-3.