“Llama! Llama!” shouts a 5-year-old on a walk through the park with her dad.
An average adult llama is five to six feet long — her family’s light-hearted way to measure physical distance in public. Later at home, she does yoga while her older sister dances. It’s important to frame serious conversations, including those related to coronavirus, in developmentally appropriate terms without being too dramatic or ambiguous. And, building physical activity into daily schedules helps relieve stress while providing structure. No one understands this quite like their father, Dr. John Ackerman, a clinical child and adolescent psychologist and suicide prevention coordinator at the Nationwide Children’s Hospital Center of Suicide Prevention and Research (CSPR) in Columbus.
“Across the country, rates of anxiety and distress — dealing with isolation, uncertainty and lack of connection — seem to be increasing,” Ackerman says. “We are not necessarily seeing an increase in outreach to suicide crisis lines and ER visits for behavioral issues, but that might be misleading. A lot of people are focusing on pressing health and physical needs and probably not attending to the stress and trauma aspects that may unfold over time.”
Anxiety, depression and suicide are a growing concern for youth. At this time of heightened stress, special consideration must be given to help children, especially those who already are at increased risk.
“How kids are responding depends on a lot of factors, including whether they are stressed or not already,” says Dr. Brittany Myers, licensed pediatric psychologist at MetroHealth Medical Center and assistant professor of psychiatry at Case Western Reserve University School of Medicine. “It varies by age, understanding of situations, and the support and resources they have. For instance, a lot of kids and adolescents find social distancing difficult, missing friends and grandparents. Some feel overwhelmed, bullied or ostracized at school, so being home with family is a relief. Others have more stress at home with family conflict and look to get out of the house. Limiting physical access to school and friends now puts them at higher risk (for anxiety and depression), given those triggers.”
A Closer Look at Anxiety, Depression & Suicide
Anxiety disorders are common, affecting one in eight children. While anxiety is a normal part of childhood, anxiety disorders are characterized by “persistent, irrational and overwhelming worry, fear and anxiety that interfere with daily activities,” according to the Anxiety Disorders Association of America. Symptoms vary and may include irritability, sleeplessness, jitteriness or physical symptoms like headaches and stomachaches. Anxiety disorders in children include generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, social anxiety disorder and specific phobias. Each one has specific symptoms. If left untreated, anxiety can lead to depression, substance use and increased risk for self-harm and suicide. Depression for kids does not always look like it does in adults, Myers says.
“For adults, we are used to looking for signs of sadness and low energy. For children, it can be rapid mood swings, angry outbursts, withdrawal and appetite or hygiene changes,” she says. “Statements about death and dying should be taken seriously during all times.”
Other warning signs that an individual may be experiencing depression or thoughts of suicide — and are in need of intervention — include giving away possessions, risky or reckless behavior, energy changes and decreased interest in usual activities.
“Research is rapidly evolving on the topic of anxiety and depression in youth during a pandemic,” Ackerman says. “Therapists, medical providers and crisis line workers are telling us that stress and agitation have increased in youth, and this may be because we’ve added a few other big mental health risk factors, including lack of social connection; worries about health, death and dying; sleep disruption; and physical inactivity. As (economic stress and) loss in families and the community occurs, there is potential for trauma on top of unaddressed trauma.”
Suicide is the leading cause of death for Ohioans ages 10 to 14 and the second leading cause of death among Ohioans ages 15-34, according to a November 2019 report from the Ohio Department of Health. One youth dies by suicide every 33 hours. In Cuyahoga County, about one in four high school students reported depressive symptoms in the last 12 months, as measured in the CDC’s 2017 Youth Risk Behavior Survey, and Cleveland high schoolers have one of the highest suicidality rates in the country.
Who is at Highest Risk?
Ackerman warns that suicide risk may increase the most for those already at risk, including children and adolescents with mental health disorders like mood and anxiety disorders, a history of abuse or mistreatment, substance abuse, impulsivity, easy access to means (e.g., firearms), and identification as LGBTQ. While no one is immune, it is not a level playing field.
Myers notes this is particularly concerning in places where research shows children are exposed to higher rates of adverse childhood experiences (ACEs), ranging from physical, emotional or sexual abuse; physical or emotional neglect; domestic violence; parental mental health, substance abuse, incarceration, and separation or divorce; in addition to higher rates of poverty and exposure to community violence. ACEs are linked to chronic levels of stress impacting rates of anxiety, depression and suicidality.
“Now being cooped up, there is increased risk of domestic violence, child abuse and substance abuse,” Myers says. “Ohio has seen a concerning reduction in reports of child abuse, which could lead to increased rates and we will not know it given reports usually come from school, friends and neighbors outside the home.
Ackerman adds, “Not all families navigate conflict well. Even though calls are not up, instances of abuse, neglect and domestic violence may increase over time. With an increase in firearm sales also comes potential for greater violence.”
Mental Health Providers Adapt to Meet Needs
Ackerman says “people are worried, terrified even, to go into a health care setting” and urges families to keep regular appointments and reach out for new help as needed. Medical providers across the country have quickly adapted to meet those needs.
“I know many local and national crisis lines have expanded capabilities,” Myers says. “For MetroHealth, now almost all services are made available by telephone or video. If someone is experiencing increased anxiety and depression, he or she can have a same-day follow-up call with a MetroHealth psychologist.”
Elizabeth Wolanski, child and adolescent services director of the Mental Health, Addiction and Recovery Services (MHARS) Board, and chair of Lorain County’s Suicide Prevention Coalition, also is seeing an uptick in stress-management needs for families, but not an increase in local crisis calls from parents or for children. She notes that clinicians are still seeing their young patients and are adapting care to fit the current precautions for COVID-19. Sometimes that means options much like the therapeutic appointments children are used to, sometimes it means shorter, more frequent telehealth check-ins.
“Many of our clinicians who typically work in the schools are providing prevention resources for families, which helps them through a stressful time and strengthens their family bonds, as well,” Wolanski says.
Ackerman says Nationwide Children’s Hospital has done one of the most massive shifts to tele-behavioral health.
“We went from having a minimal tele-behavioral health presence to doing over 20,000 visits in the first few weeks and we now have well over 50,000 visits since the order was initiated,” he says. “Although it takes a little getting used to, this treatment is acceptable to families and is effective. Over time, these offerings can increase access to more rural areas and build connections not previously established.”
Helping Children Cope
To best support children, pay attention to how you are coping first, in addition to modeling appropriate behaviors and facilitating developmentally appropriate communication.
“During this uncertain and challenging time, expect meltdowns and support kids in sitting with tough feelings or overwhelming fears rather than jumping in to solve everything. Not every thought or feeling deserves our full attention or energy,” Ackerman says. “Creating space to work this out is really important.”
He suggests parents draw upon a variety of proactive and reactive strategies to help children manage stress and anxiety:
- Facilitate physical strategies, including exercise and relaxation techniques like deep breathing, yoga and meditation. Ensure proper diet and sleep.
- Use cognitive strategies. If worries or negative self-talk occur more than usual, consider paying attention to when they happen and what they are signaling. Is there truly evidence to support them or is the brain only sending negative information and ignoring the bright spots? Identify and challenge potential catastrophic or irrational thoughts. Is it harming you to spend so much time in “worry-mode” and can we interrupt this, or can it be ignored and we move past it?
- Practice mindfulness. Be present in the moment and focus on one thing at a time, not the bad things that already happened or could happen in the future.
- Improve how we communicate and spend time with others to stay connected. Ask, “How do I get what I want from people around me that meets my needs and theirs?” Be empathetic, yet assertive.
- Hone emotional regulation skills. Give children language to identify emotions and know what to do within their control to manage feelings and behaviors. Help them break it down: “When I have these thoughts, this emotion happens and here are ways to deal with it.” Understand anxiety and stress will not last forever, and sometimes we must ride the wave until we are in a better position to manage our stress and fears. Younger children have difficulty self-regulating and rely on adult models to coach them. Make sure our expectations of what kids can manage are realistic and fair.
- Have an updated proactive safety plan for young people with a history of self-injury or suicidal thoughts to manage a crisis. This includes trusted adults to verbalize feelings, and, for older children, numbers to call or text. Make sure they know what to do and where to go even though physically connecting with friends and family is less of an option. Also, be aware of lethal means in the environment so they can be stored safely, particularly if a young person is in distress or showing warning signs of suicide.
“In early childhood, kids take cues from adults in their life,” Myers says. “Think about how a parent reacts when a child falls and scrapes a knee can impact whether the child cries, or sniffles and goes right back to playing. In therapy, we work on emotion identification, vocabulary to share feelings and calm down skills, including walking away and taking deep breaths when angry. Just as parents teach children how to share and wait in line, they should teach them about emotions and coping.”
In a pandemic, there is a general sense of discomfort that can mirror many symptoms of a disorder.
“Identify when things are outside a level a child can typically manage to seek professional support,” Ackerman says. “Signs include not being able to take care of normal everyday responsibilities like schoolwork, not feeling good about things they are doing, not getting along with others, or if a person is frustrated, tense or agitated more often than not.”
However, he advises to keep it in context.
“When we are forced to be around each other [working and schooling from home], there will be more meltdowns and challenges, so give grace for that,” he says.
Silver Linings
It’s not all doom and gloom. In addition to growing tele-mental health options, Ackerman says the pandemic has created novel opportunities to increase social connection through technology and options to create new routines that make mental health a priority.
“I see many people being resilient in the face of adversity,” he says. “I’ve watched online and in neighborhoods people using creative ways to connect, slowing down and exploring what makes meaning for them.”
Myers highlights examples of neighbors helping neighbors and finding new and innovative ways to celebrate, from car parades to virtual parties.
“Model for kids what you value as a family and keep doing that,” she says.
Talking to Your Child
Research has shown addressing negative emotional states reduces the overall intensity and longevity. John Ackerman, Ph.D., a clinical child and adolescent psychologist and suicide prevention coordinator at the Nationwide Children’s Hospital Center of Suicide Prevention and Research (CSPR) in Columbus, offers eight tips for talking with children about their feelings:
- Frequent, shorter check-ins are more powerful than one long conversation.
- Use open-ended, rather than “yes/no” or leading questions (e.g., “What worries you?”). Sit next to them and help identify the emotions (e.g., “I noticed you seem to be more edgy than usual. Tell me about what’s been going on.”).
- Listen actively, let your child lead, and model calmness.
- Have compassion, but don’t try to solve problems all at once.
- Avoid questioning or accusing. (e.g., “You have so much. How can you feel this way?”)
- Help the child feel in control. (e.g., “Yes, this is upsetting and difficult for all of us. We are pulling together, and things will not always be this way. What things can we do every day despite being isolated?”)
- Let the child talk through what they are most concerned about, whether that is the health of grandparents, never going back to school or missing a best friend’s birthday party.
- For high school seniors, especially, acknowledge these students have been robbed of rites of passage, perhaps jobs or educational opportunities, and celebrations with family and friends. Online activities cannot replace certain milestones, so expect heightened anxiety and allow them to grieve the loss.
Are you or your child experiencing a mental health crisis?
Contact your mental health provider, county crisis line or one of these free, confidential resources:
Text “4HOPE” to 741741 to reach the Crisis Text Line in Ohio.
Call 800-273-TALK (8255) to reach the National Suicide Prevention Lifeline or use the Lifeline Chat web chat service online.
Call 800-985-5990 to reach the Disaster Distress Helpline, which provides 24/7, 365-day-a-year crisis counseling and support to people experiencing emotional distress related to natural or human-caused disasters or traumatic events like the coronavirus.