THOUGH THE PHYSICAL effects of COVID-19 have generally not been as severe for most children compared to adults, the mental health impacts of the pandemic are just as severe. And that has laid bare an ongoing epidemic in children's mental health. That's according to a panel of experts who recently participated in a U.S. News & World Report webinar on "Managing Children's Mental Health: A Pediatric Hospital Imperative."
The challenge is daunting: "How do we address this wave of children's mental health in the context of the trauma that we're all experiencing?" said Dr. Karin Price, chief of psychology at Texas Children's Hospital in Houston, during the webinar, which was part of a U.S. News series on Pediatric Priorities: Improving Children's Health in the COVID-19 Era.
The first portion of the session explored child abuse, trauma and so-called adverse childhood experiences in a conversation with Dr. Melissa Merrick, president and chief executive officer of Prevent Child Abuse America, a nonprofit dedicated to addressing child trauma.
Merrick discussed how such experiences can have lasting detrimental health effects well into adulthood. These include the traumas that cause children to feel unsafe or uncertain in their environments, ranging from abuse and neglect to violence or a family member's mental illness or incarceration.
"The more adverse childhood experiences, or ACEs, that children have," the more stress hormones are released in the body, which can set the stage for various health conditions including cardiovascular disease, depression, anxiety and other negative health outcomes, Merrick explained. "Over 40 health outcomes to date have their roots in childhood."
But ACEs aren't just one thing, Merrick said, and they can be defined in a few different ways. One is as "adverse colonial experiences," she noted, which refers to how the negative impact of systemic oppression and historical trauma can be passed down from generation to generation. Another way to look at them is as "adverse community environments," which encompass issues like unstable housing or lack of access to health care, both of which "can really set our children up for negative or positive health impacts later," Merrick said.
These days, the acronym ACE may also refer to "adverse COVID-19 experiences." The deaths, illness, economic and housing instability, and loss of the daily school routine have been especially hard for many children, providing the destabilizing trigger for a wide range of ACEs to arise in kids everywhere, she noted. Society will likely be grappling with the after-effects for decades to come.
The good news, Merrick explained, is that "ACEs can be prevented," and that can have a powerful impact down the line. She noted that a Centers for Disease Control and Prevention study she worked on in a prior role found that "if we could prevent ACEs, we could prevent 44% of adult depression."
This means that rather than simply intervening as soon as possible – which is a good policy – it's better to try to prevent ACEs from occurring at all. That means screening for ACEs and providing the support and assistance that families at risk need to help keep their children safe and cared for.
This can be easier said than done, especially during the pandemic, when many children have been away from school and out of touch with adult allies who might normally spot signs of abuse and neglect.
Renewed Focus on Prevention and Early Intervention
During the second part of the webinar, a panel of children's mental health specialists delved into how the pandemic is impacting pediatric hospitals and strategies for helping support children and families in crisis.
While the COVID-19 pandemic has put a spotlight on ACEs and children's mental health, these issues aren't new, said Dr. Michael Sorter, director of the division of child and adolescent psychiatry at Cincinnati Children's Hospital Medical Center.
"We were in crisis even before the pandemic," he said. "Most children who need mental health services or behavioral health intervention don't receive the care they need. Over half do not. One in five children really have a diagnosable condition."
To address these needs, children's hospitals have had to adapt quickly to the pressures of a pandemic world – where an increased demand for services is outstripped by what an in-person model can deliver. Enter telehealth, which, on the whole, has expanded some hospitals' ability to deliver care and increased their capacity to assist patients in need.
Price noted that in 2019, across both psychology and psychiatry practice areas, Texas Children's conducted fewer than 500 telehealth visits. "In 2020, we did more than 25,000. And that was really turning on a dime and adapting everything that we did in person to be available as much as possible virtually."
Similarly, Dr. Abigail Schlesinger, chief of child and adolescent psychiatry and integrated care at UPMC Children's Hospital of Pittsburgh and Western Psychiatric Hospital, noted that her institution had used telehealth for fewer than 1,000 visits in 2019. That number skyrocketed to "76,000 in one year," she said.
At the same time, "there still was a large need for in-person care," she said, and those increases have "just begun to scratch the surface" of the care that's needed and where it can best be delivered. "We've got probably decades worth of learning to do there," she said.
While the quick pivot to providing services virtually was good for many kids in need, it also exposed a major health disparity: that access to technology is not equitable across all segments of the population. That fact has exacerbated health disparities for some, noted Dr. Ukamaka Oruche, associate professor and director of global programs at the Indiana University School of Nursing.
This issue extends beyond telehealth visits to school itself, she said. "We have kids who are failing school" in large part because of technological disparities. "We have kids in households where you have one iPad and you have four kids sharing it," and there may be no Wi-Fi available at home "so the parent has to drive to the school parking lot to get internet access. This is a major problem" that leads to feelings of isolation and failure for some kids, which contributes to poor health outcomes, she explained.
While telehealth promises to be an important tool in the future, Oruche noted that "we have a lot to learn yet," and there are "some mental health conditions that are not conducive to" telehealth. A hybrid in-person/virtual model and alternative approaches may help reach children who still need additional support or don't have regular access to the internet.
Supporting Caregivers and Lessons Learned
Schlesinger noted that amid this push to help kids, it's important that the caregivers themselves not be overlooked. "If our health care providers aren't healthy, they can't respond to trauma appropriately," she said.
To address potential caregiver burnout and better support the staff at her hospital, Schlesinger said her organization has been doing regular check-in meetings with clinical staff members to ensure they're OK and have access to the resources for self-care that they need. "It's just amazing, in the last year, how much we've really had to think differently, do differently" a situation she hopes will continue after the pandemic ends.
Indeed, all the panelists expressed hope that the lessons learned over the past year can help inform a more thoughtful and lasting discussion on how to better support children and families in the future. Despite the challenges, real progress has been made, and the goal is to carry those innovations forward to further strengthen children's mental and behavioral health care.
But that's only going to happen with continued vigilance and an emphasis on improving systems. "Child mental health has been on the back burner for so many years, and it would only arise when there would be a crisis," Sorter said. "It's really imperative for us to make sure that we continue to keep this on the forefront of people's minds."