The coronavirus 2019 (COVID-19) pandemic has created profound challenges for communities, families and individuals, leading to a range of emotional and behavioral responses.
Emotional and behavioral health challenges, and associated disparities were of growing concern before the COVID-19 pandemic. The public health emergency has acutely exacerbated these challenges. The pandemic has exacerbated preexisting disparities in morbidity and mortality, access to health care, quality education, digital access, affordable housing and safe environments, which create more challenges and stressors for many families and communities. It also highlights the inequities that result from structural racism, which increase vulnerability to emergency situations. Additionally, COVID-19 has contributed to increased racism and xenophobia against individuals who are of Asian descent. Pediatricians have the opportunity to serve as both educators and advocates in addressing these stressors, the effects they have on child and adolescent developing brains and the disparate outcomes these effects may have well beyond the COVID-19 pandemic.
While some of the challenges that characterized the initial phase of the pandemic have eased in their intensity, such as the need for quarantine and physical isolation, new challenges that threaten the well-being of youth and families continue to emerge. These include the continued exposure to COVID-19 during in-person school attendance resulting in inconsistent attendance, the challenges and consequences of remote schooling, the increasing reliance on and use of social media for communication, vaccine refusal and questions about masking, and an overall strain on hope, resilience and perseverance. The full impact of the interruption of normative socialization and learning during critical developmental stages is yet to be realized.
The pandemic has underscored the urgent need to continue to integrate emotional and behavioral health into standard pediatric care. Pediatricians, professionals, families and agencies must partner together to support the emotional and behavioral health of our nation’s infants, children, adolescents and families. Of importance is the appropriate allocation of resources to address the growing behavioral, emotional and mental health needs of our nation’s children and families.
Emotional and Behavioral Responses Among Children and Adolescents
Range of symptoms and signs associated with emotional and behavioral reactions to stress
Reactions to stress among children and adolescents have some universal themes but are also age and context dependent. This was demonstrated in studies conducted since the pandemic started and showed the different ways that children in different age groups and different developmental needs have reacted to the pandemic.
- Infants and young children were found to be impacted by the stress of the pandemic and manifested distress through disruptions of physiologic functions like sleep, toileting and feeding. They may have difficulty with separation and regress in their skills or become more irritable or socially withdrawn.
- Emotional and behavioral reactions that have been observed among school-aged children during the pandemic include clinginess, attention seeking and increasing dependence on their parents.
- Globally, 1 in 4 youth are experiencing clinically elevated depression symptoms and 1 in 5 are experiencing anxiety. These estimates are double the pre-pandemic estimates. Children and adolescents experiencing anxiety and depression at baseline are at even greater risk for an exacerbation of those symptoms.
- Adolescent presentation to the emergency department and primary care clinics for behavioral and mental health problems as well as suicide attempts have increased significantly during and following the acute phase of the pandemic. These crises have strained further an already challenged behavioral health infrastructure and underscore the severity of the behavioral health crisis that is unfolding. Primary care providers and other child-serving systems, such as emergency departments, are being called on to increase their attention to screening for and identifying mental health emergencies and must prepare themselves accordingly.
- According to the Centers for Disease Control and Prevention (CDC), emergency department visits among adolescent females (ages 12–17 years) increased for 2 mental health conditions (eating and tic disorders) during 2020, 4 (depression, eating, tic, and obsessive-compulsive disorders) during 2021, and 5 (anxiety, trauma and stressor-related, eating, tic and obsessive-compulsive disorders) and overall mental health visits during January 2022, compared with 2019. The proportion of ED visits with eating disorders doubled among adolescent females. The AAP has resources for clinicians and families.
- Children with special health care needs including neurodevelopmental disorders such as autism, ADHD and intellectual disability and preexisting mental health disorders were found to be more vulnerable to uncertainty and disruptions of routines and are more dependent on resources and support that was interrupted during the pandemic. These children are at greatest risk of exacerbation or relapse of behavioral symptoms, which may, in turn, trigger more stress and conflict with caregivers and further increase the stress for both caregivers and children.
Other factors that can influence the impact and manifestations of stress in infants, children, and adolescents
- Environmental context: The emotional well-being of children is inextricably dependent on their parents’ well-being, and children are said to be the emotional barometers of the family. As the physical, environmental, relational and financial stressors change over time, parents and caregivers and other supportive adults who are expected to be the safe haven for children are, themselves, increasingly struggling to cope and be nurturing and emotionally available to their children. The increase in substance use during the pandemic demonstrates the severity of these challenges. As a result, infants and young children experience stress both directly and vicariously, and without the maturity to process their experiences, they often adapt by internalizing the impact.
- Individual factors: Children and adolescents enter stressful situations with a particular temperamental style determined by their biobehavioral reactivity, defined as the extent or intensity with which a child responds physiologically, emotionally and behaviorally to a range of environmental stimuli. For example, children who adapt more easily to change may be able to adjust to remote learning and new daily routines, whereas children with less flexibility may struggle with change.
- Loss and grief: It is currently estimated that over 149,000 children in the United States lost a primary or secondary caregiver to COVID-19. Globally, this number is estimated to be over 10 million children. The risk as well as the impact of losing a parent during the pandemic is likely higher in communities of color, immigrant communities and under resourced communities. The emotional impact of losing a parent, including trauma and grief, is often compounded by the loss of material stability and economic hardship and has been associated with poor educational outcomes and long-term mental health consequences. All children and youth may present with behavioral issues that may be misinterpreted and, in fact, may represent a response to trauma, grief, or loss.
Assessing the impact of the COVID-19 pandemic on emotional and behavioral health
Pediatricians are experts in providing surveillance and screening around developmentally appropriate behaviors. During the COVID-19 pandemic, it is especially important that pediatricians continue to inquire about child, youth and family functioning across multiple domains.
Social determinants of health
Assessment for social determinants of health, including food insecurity and unstable housing, takes on an added urgency as the pandemic has resulted in significant economic impacts on families. These impacts are especially true for historically under resourced populations facing inequities. Families experiencing additional stressors, (ie, related to multigenerational living and employment as an essential worker) may require additional supports. The level of concern by families for these issues can be further elicited. Internet connectivity has become necessary for socialization, remote learning, employment and access to health care and must also be included in the evaluation of social determinants of health, especially given the increasing digital divide.
Trauma informed approach
Taking a trauma-informed care approach begins with recognizing that emotional and behavioral symptoms in children may be related to COVID-19 related exposures and events. Similarly, distress bought on by the pandemic may trigger other stress responses related to past traumas. Using open-ended surveillance questions to identify if children have experienced COVID-19 or other traumas and considering the use of trauma symptom screening tools to help assess presence and severity of symptoms, will allow for a tailored response. For many of those impacted, office-based guidance (reassurance of safety, returning to routine, simple relaxation and regulation techniques) have been sufficient support for recovery. For those who are more impacted, referral to mental health services, particularly evidence-based trauma therapy, in the community may be necessary. Ultimately, promoting a positive expectation of recovery and reassurance that with support children can do well may be the most important message.
Surveillance and screening for childhood mental health and well-being
Because of the pervasiveness of the changes associated with the pandemic, it is likely that all children and families have been affected. Behavioral and mental health surveillance and evidence-based screening should, therefore, be integrated into every office visit. Surveillance can take the form of incorporating questions about the impact of the pandemic on the well-being of the child (including any behavioral difficulties) and family. Screening utilizes evidence-based social, emotional and behavioral screening tools. Families may be reluctant to bring up behavioral concerns in their children and may consider them circumstantial and temporary without realizing the severity or enduring nature of symptoms. Implementing a universal surveillance and screening strategy helps to overcome these barriers.
Increased stress associated with the pandemic may cause or exacerbate emotional vulnerabilities and distress in parents and other caregivers. Parents/caregivers struggling with their own mental health problems, health issues or substance use will have more difficulty responding sensitively and supportively to their children’s reactions to stress. There is also a substantial cohort of adults who continue to have ongoing symptoms related to COVID-19 that have affected their physical and mental health, and their ability to function, work and parent their children as they had before the illness.
Checking in with parents/caregivers regarding their own emotional reactions to the pandemic, the effects of unemployment and economic stressors, availability of their own social support networks and their awareness of the implications of parental well-being on the family are critical. Parents may be struggling to balance taking care of their own, possibly elderly parents along with working and caring for their own children. Pediatricians can provide support to parents by actively listening to the family’s story, offering empathy and promoting resilience by recommending that parents/caregivers dedicate time for self-care and mindfulness and offering hope. Pediatricians may consider discussing counseling with caregivers, because families may be more accepting of referral resources for adult mental health and substance use when presented by a trusted pediatric provider. Screening for parental well-being, including perinatal depression and intimate partner violence, can be combined with assessments of social factors and may facilitate referrals to community resources.
Return to school
The impact of the year(s) of remote/hybrid learning on academic progress, emotional health and social adjustments in children will continue to unfold for years to come. These impacts may not be uniform across all children and may differ based on individual as well as environmental factors. Children who were at critical learning stages such as kindergarten and first grade and those who have learning, developmental or cognitive disabilities or attentional deficits may be at higher risk of being negatively impacted by the interruption of formal in person schooling. Schools must be diligent in assessing the impact of the pandemic on learning and provide assessments and interventions to help children who need them to narrow the gap. Many schools are incorporating wellness modalities into their daily flow, and older children and adolescents should be encouraged to take advantage of these resources.
Children and youth with special health care needs
Children and youth with special health care needs depend on uninterrupted access to specialized medical, educational and/or mental health services. Interruption of services for these children, in addition to respite services for families, can increase stress on the family and place the child at risk for skill regression. It is important for the pediatrician to inquire about continued access to these services, to support families experiencing an interruption of services by offering interim solutions and to advocate for continued services. As much as possible, children and adolescents with behavioral challenges should continue to follow structured routines and reward systems and those with fear, anxiety or depression should be encouraged to practice mindfulness and reframing. It is essential to ensure continuation of pharmacologic treatments and that parents have the financial and prescriptive access to ongoing medication management.
Special popualtions including LGBTQ youth, youth in the juvenile justice system or long-term care facilities and chidren and families involved with the child welfare system have unique needs with complex trauma and loss.
Management: Advice, Education, and Anticipatory Guidance
General anticipatory guidance related to emotional and behavioral health
Pediatricians play a critical role in the assessment, and guidance around developmentally appropriate behaviors in children and youth. During the COVID-19 pandemic, it is especially important that pediatricians continue to advise families about emotional and behavioral responses and needs in the context of typical development.
It is not uncommon for children to have developmental regression during times of stress. Transient changes may not be detrimental, especially when paired with supportive and attentive caregiving. Infants will continue to require secure attachments to nurturing, emotionally available adults to gain confidence in the world around them. This holds true even more during times of stress, when nurturing adults serve as vital buffers for children. Toddlers will continue to require structure and predictability to help them navigate their many internal and external stimuli as they strive to master autonomy. Sticking to routines as much as possible will assist them during this stressful time.
The pediatrician can highlight the key role of the parent in supporting the overall development and growth of children and adolescents. It may also be helpful to remind parents and caregivers that behavior is a manifestation of emotional reactions, and that children and adolescents are doing their best, given the circumstances, to convey social and emotional need. All types of behavioral expression merit sensitive exploration. Helping parents understand the range of manifestations of stress may equip them to interpret specific behaviors and address them appropriately, whether they are expected and manageable or are clues to a more significant problem.
Pediatricians can help parents/caregivers individualize their support for their children and adolescents. For example, some children or adolescents may require more time and space to express their feelings or may require gradual conversations and nonverbal activities such as painting, drawing or physical activity to allow them to express themselves and manage stress. Others might more readily accept direct conversations or activities. Many adolescents are capable of a more nuanced conversation about the pandemic and its effects. They may need to talk to a trusted adult about how to maintain social connection safely and their feelings of boredom, fear, loss and even guilt when they do not maintain physical distancing. Adolescents who are faced with so many restrictions may need space and private time to decompress from their day. This behavior may not be an indication of a problem. However, if withdrawal seems excessive and accompanied by other symptoms, it may warrant further exploration. While providing this guidance to parents, it is important to be empathic and supportive, reminding parents that this is an extraordinarily tough time for all parents and normalizing feelings of parenting stress and inadequacy.
Communication with children and adolescents
Caregivers should be encouraged to have open and honest conversations with their children and adolescents about what they are hearing in the media. Avoidance of such conversations does not protect children. Instead, parents/caregivers should answer children’s questions honestly and concretely.
Managing and communicating uncertainty
The often mixed or conflicting messages communicated during the ongoing COVID-19 pandemic, including the evolution of new COVID strains and development of new vaccines and treatments, cultivate a perception of unpredictability and uncertainty. This can be anxiety provoking, and children and families may need to limit how much information they expose themselves to. Guidance on the uncertainty and communicating it to children may be helpful for families and would include acknowledgment and acceptance of the lack of control, open communication, practicing mindfulness, and focusing on things that families do have control over, such as healthy habits and spending time doing things that bring them joy. Being able to accept and adapt to uncertainty have been linked to developing a more resilient approach to life.
Guidance on physical distancing
Older children and adolescents often found the social isolation related to the pandemic overwhelming. Socializing with peers is a mainstay of child and adolescent development. Following local, state and national guidelines for physical distancing should be considered, while families help find paths for youth to socialize safely. As weather allows, children and adolescents can be encouraged to spend time outdoors participating in physical activities, as long as appropriate risk mitigation strategies are followed. Participating in physical activity allows youth to improve their cardiovascular health, strength, body composition and overall ﬁtness. Mentally, youth may experience beneﬁts from the increased socialization with friends. These psychological and physical beneﬁts can help support their developmental growth. Exercise also has immune system beneﬁts.
Guidance on screen time
Parents/caregivers should continue to explain to children and adolescents that screen time has its benefits as well as real risks. They should explain the need to be selective in how we use screens and media. Programs and apps that children and adolescents are accessing should be age appropriate. “Real-time” communication with friends and family as well as active engagement should be prioritized over passive viewing. Parents should have conversations with their children about excessive viewing of television and video game playing that interrupts schooling and sleep, the impact that social media can have, including bullying and ostracism and contact with strangers online. Children may not realize that some of these contacts may be dangerous.
For all ages and stages, facilitating resilience is key and includes promoting adaptation to change, using strategies to buffer the stress that comes with experiencing trauma and recovery in a reasonable time frame. Pediatricians can remind families about the strength they provide for their children by being present, empathic and nurturing. Practicing techniques together such as mindfulness, relaxation and focusing on the present moment can help the entire family build coping skills to deal with uncomfortable and frightening feelings. When practiced regularly, children and caregivers can build skills that promote self-regulation and greater awareness of their feelings and the feelings of others that last long beyond the duration of the pandemic. Building networks of social support have also been found to be central to promoting resilience,
Children and adolescents can be encouraged to explore their creativity, passions, and strengths to help others, volunteer and contribute to their community. Reframing and taking control of small things, such as participating in volunteer opportunities to help the community, can help children and caregivers feel less vulnerable. Such a strength-based approach will help mitigate risks to emotional and behavioral health and accentuate strengths during crisis. Pediatricians can help families identify their strengths, particularly during these times when they may not feel obvious. Pediatricians can help families find the courage they need to persevere and overcome any feelings of embarrassment and guilt that can interfere with asking for needed help.
Community-engaged solutions – ie, resources and programs that are created by or with the community that families identify with – are especially critical to address health inequities. These culturally effective solutions should foster and support resilience building strategies, such as familial support and educational advocacy. Before pediatricians seek to develop new solutions for families, they can reach out to local community-based organizations or partners to identify existing resources. After school programs, where children spend unstructured time may provide opportunities for incorporating resilience promotion and mindfulness training.
Considerations for Referral and Follow-up
Pediatrician follow-up for emotional and behavioral health challenges
Pediatricians should follow up with infants, children and adolescents experiencing emotional and behavioral health challenges during the COVID-19 pandemic frequently despite the constraints of our current health care crisis. Children and adolescents who are sub-threshold for diagnosis or are otherwise not being referred to mental health specialty colleagues can be supported with the common factors approaches and brief interventions provided in primary care. Common factors uses a HEL2P3 mnemonic (Hope, Empathy, Language, Loyalty, Permission, Partnership and Plan) to operationalize family-centered techniques to build a therapeutic alliance with parents and children and facilitate communication. Resources for these approaches and guidelines for managing conditions such as ADHD and depression in the primary care setting are available. Children who do not respond to these interventions or have a significant change in functioning should be referred for additional supports, which may include using new or existing relationships with behavioral health providers in the community and/or schools. Pediatricians should become familiar with resources in their state, such as Pediatric Mental Health Care Access Programs.
Telehealth and well-being assessment
Telehealth technology has been used successfully to improve access to health care during the pandemic and offers a particularly attractive option for a more frequent and convenient contact with providers. Although in-person health care visits have increased, telehealth continues to be a viable alternative especially for mental health services, and especially in certain remote and under resourced populations. It is critical that pediatricians are aware of mental health resources in the community, particularly those that offer telehealth services. Lack of access to technology may result in widening health disparities. Added efforts to assist families with access and usability of their patient portals are needed now more than ever. Some families may prefer to be seen in person or by telehealth.
Children and families at risk for abuse and violence
Many known risk factors for child abuse and violence, including poverty, stress and isolation, have been exacerbated by the pandemic. Loss of contact with teachers and physicians may have made detection more difficult. The role of the pediatrician may include surveillance of high-risk families, vigilance and recognition of signs of abuse and inquiring about intimate partner violence, guns in the home, parental mental health and well-being, self-care and struggles with child and adolescent behavior and discipline. Offering guidance on positive parenting strategies will serve families regardless of risk for abuse. Support of families through empathy, education and connection to community resources can be effective in mitigating some of these risk factors. Reporting to child protective services agencies is mandatory when there is reasonable concern for any form of child maltreatment.
Children, adolescents and families who experienced the loss of a loved family member or friend to COVID-19 are at increased risk for negative emotional outcomes and may need special attention and professional counseling to manage their loss and grief. This is especially important for infants and children who may have lost a parent and, thus, lost the main source for emotional and material support. Racial/ethnic disparities in the rate of deaths from COVID-19 makes it more likely that the burden of parent or caregiver loss is higher on families of color, immigrant communities, and those facing inequities and discrimination.
Rates of suicidal thoughts, ideation, and attempts among youth have been increasing significantly over the past decade. The stressors of the pandemic have increased the risk for suicide or its precursors. In addition to screening for depression, screening for suicide may improve the detection of this often-hidden risk. Resources for pediatricians on screening for suicide are available. Resources for families on suicide prevention should be shared widely, even in the absence of screening.
Anxiety and depression
Children whose lives have been touched by COVID-19 and are traumatized by these losses may have increased anxiety and depression. Surveillance should be considered in light of the high prevalence of anxiety at baseline and the exacerbation of anxiety-provoking circumstances during the pandemic. Pediatricians should be alerted to the presence of psychosomatic symptoms, including pain, appetite changes, irritability and sleep disturbances, which may be linked to anxiety.
Health systems challenges
The impact of the pandemic has been compounded by an interruption in vital supports and services for families including school, health care services and other community supports. Many of these services have experienced significant shortages in both funding and staffing. Parents and health care providers alike are feeling the despair of having increased need for mental health supports with decreased availability. Pediatricians, as well as parents, teachers and children themselves, have experienced significant burnout as a result of all of these factors. Being aware and sensitive to this dynamic and taking steps to acknowledge and provide support for parents and children when needed is important. Additionally, it is essential to continue to advocate for systems changes to mitigate stress and provide support for pediatricians and other health care professionals.
The health and wellness of pediatric health care providers is a strategic priority for the AAP. The challenges to pediatricians in their personal and professional lives have increased and need to be recognized and addressed. Resources and supports are available.
- Telehealth: Improving Access to and Quality of Pediatric Health Care (AAP Policy)
- Supporting Healthy Nutrition and Physical Activity During the COVID-19 Pandemic
- Newborn Screening During the COVID-19 Pandemic
- Guidance on Providing Pediatric Well-Care During COVID-19
- Trends in U.S. Emergency Department Visits Related to Suspected or Confirmed Child Abuse and Neglect Among Children and Adolescents Aged <18 Years Before and During the COVID-19 Pandemic — United States, January 2019–September 2020
Interim Guidance Disclaimer: The COVID-19 clinical interim guidance provided here has been updated based on current evidence and information available at the time of publishing. Guidance will be regularly reviewed with regards to the evolving nature of the pandemic and emerging evidence. All interim guidance will be presumed to expire on June 30, 2023 unless otherwise specified.
American Academy of Pediatrics