The devastating toll of the pandemic has underscored the critical importance of connecting what science is telling us to the lived experiences of people and communities. In March of 2020, we recorded episodes exploring the impact the coronavirus pandemic could have on child development. Now, a year later, we wanted to continue these conversations and discuss what we’ve learned, what needs to change, and where we go from here.
In the final episode in this special series, host Sally Pfitzer speaks with Dr. Nancy Rotter, a pediatric psychologist and the Director of Psychology in Child and Adolescent Psychiatry, Ambulatory Care Division at Massachusetts General Hospital. They discuss how the pandemic changed conversations around mental health, why we need to integrate mental health into the context of overall health, and what caregivers can do to help children prepare for the lessening of restrictions and the return to school.
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Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host Sally Pfitzer. In March of 2020, we recorded episodes exploring the impact the coronavirus pandemic could have on child development. You may remember we discussed the importance of self-care for caregivers, and the importance of physical distancing, not social distancing. And now a year later, we wanted to continue those conversations and discuss what we’ve learned, what needs to change, and where we go from here.
Joining us on today’s podcast, we have Dr. Nancy Rotter. She’s a pediatric psychologist and the Director of Psychology in Child and Adolescent Psychiatry, Ambulatory Care Division, at Mass General Hospital. Thanks so much for being with us today, Nancy.
Dr. Rotter: Thanks for having me, Sally.
Sally: So, the pandemic has made conversations about mental health more common and perhaps even less stigmatized. How do we make sure that this perspective and these conversations continue even as vaccines become available and restrictions are lessened?
Dr. Rotter: You know, I agree that there has been some shifting over time in terms of awareness and acknowledgement about mental health and specifically children’s mental health. I think the pandemic has really raised these conversations to a higher level. I think that there’s certainly been comfort in talking about heightened distress that people have experienced due to the pandemic secondary to the many stressors that families have experienced. I think about things like loss of typical childcare support, like daycare, in-person school, or even grandparents caring for children, unemployment or shifts to having to work at home, social isolation. And I think all of these things are widely understood as contributing to how people are coping and to mental health. I think sometimes people find it easier to describe experiences of anxiety and depression in the context of stress and the stress perhaps experienced by the pandemic. You might not hear those words as much. You might hear things that sound less stigmatizing—that people might talk a lot about stress or isolation or fatigue, rather than referring to specific mental health conditions themselves.
I do think that it might be a good direction to go in to think about how we can acknowledge mental health conditions as an aspect of overall health so that we can increasingly talk about things like depression or anxiety or substance use disorders in the same way that we speak about diabetes or heart disease. Shifting towards a more specific and accurate language for mental health conditions can really make a difference. because I think if we do so we can really add clarity for diagnoses, which then result in leading to more effective evidence-based treatments to treat these illnesses. Again, thinking about these like we do other health conditions.
I think the continued progress, to kind of get to the other part of your question, towards the de-stigmatization of mental health conditions will really require increased and ongoing discussions about emotional health, and to have this happen in schools, in the media, within families, and certainly when children go to see their pediatrician. I think that pediatricians more and more are providing mental health screenings at routine exams, asking developmentally based questions to both parents and children or adolescents to screen for things that are concerning—anxiety, depression, suicidality, substance use disorders. And I kind of like the idea of thinking of that type of screening as mental health vital signs. And for me, that fits with the concept that when you go to your pediatrician or you go to your doctor, there’s always vital signs. They take your heart rate and your blood pressure, and it seems to me that using that kind of language really is helpful and is something that’s understandable to everyone and can help to really de-stigmatize the concept of mental health. And I do hope that we continue to work in the direction of integration of mental health into the context of overall health.
Sally: Yeah, absolutely. So many important points, and I especially love that idea of the vital signs. Nancy, from your perspective, has the pandemic exposed any weaknesses in our mental health care systems, particularly for young children? And how should we take those into consideration as we move forward?
Dr. Rotter: I would describe the primary challenges in our mental health care system for young children as twofold. The first relates to access to mental health care and the second is for increased need for prevention and early intervention services. While thinking about the importance of mental health care for children, I think it’s really important to be aware of some of the prevalence rates. For example, 50% of all life-time mental illness begins by age 14 and 75% begins by age 24. So, it’s very clear that making sure that we are keeping an eye on and assessing children and adolescents is key.
I have to say that the pandemic has impacted access to mental health care in somewhat of a complicated way. On the one hand, unfortunately, there’s been an increased need for mental health services for everyone, and specifically for children, and the need has really outstripped the availability of services. This has occurred in the setting of overall improved ability to access care via telehealth. Telehealth, through both the use of video and telephone visits has improved access in many ways. Families who struggle with transportation, that don’t have the time, that have financial limitations—it’s allowed them to access behavioral health care more readily. However, this is further complicated as telehealth access has not been equitable. Black, Latino, and non-English speaking patients, and patients living in communities hardest hit by the pandemic demonstrate consistently lower rates of use and access to video-enabled technology.
And while overall access to care has been a problem during the pandemic and it’s not easily solved, there’s been some hopeful news in Massachusetts. Effective January 1st of this year, the state legislature passed a bill requiring insurers to pay for services conducted by either telephone or by video technology at the same rate of reimbursement that they cover in-person visits. And I do think that’s really going to make a difference. That isn’t going to solve our immediate problem of access during the pandemic, but hopefully that knowing that that’s going to be an option down the road that that will allow for additional ways that we can help people.
In terms of prevention and early intervention, I think addressing the mental health needs of young children when they present with mild symptoms—like sleep or feeding, or toileting, anxiety or behavioral issues—sometimes might not get identified until they reach a level that really requires urgent intervention. However, preventative and early intervention when the initial or the mild symptom becomes apparent can be extremely useful, and my thinking is that it can be improved by having mental health professionals in the clinic, with the pediatricians so that there’s behavioral health care integration. And that way, making services available in the context of the yearly pediatric checkup, which families typically come to, that there would be screening and opportunity for intervention when families are coming every year or even for other visits.
In my work at MGH, in pediatric behavioral medicine, we’ve been very successful at embedding psychologists in specialty medical clinics like gastroenterology and diabetes and food allergy, which is where I work. Sometimes, for example in food allergy, I will meet with a family where a child is very anxious about having a blood test. And so, I can—at a minimum—meet with the child then and if they’re not ready to do a blood test that day with intervention, that now they know me and they can come back a couple of times to see me and I can help prepare them for that. And so, catching families where they’re going to get their medical care and being able to help them in that context is really important and really useful. This is something that has been established in many primary care clinics and hospitals across the country. The idea is to really think about a variety of services that might best meet the needs of the family by offering some in-clinic consultation, some brief treatment, access to parenting groups, and potentially digital health interventions in addition to the more traditional therapy and medication treatments that we all know about.
Sally: I really love this idea of integration. In particular, at the Center, we talk a lot about the need for responsive relationships and I hear a lot of what you’re saying there is that if you’re able to build those responsive relationships early with kids, you have a better chance at allowing them to benefit from your services if they know you better.
Dr. Rotter: Absolutely. And you know, one of the other statistics that I think is so powerful is that when referrals are made by anyone—by physicians or pediatricians—to a mental health professional, approximately 50% of those do not follow through. And so, by having someone actually live in the clinic to meet the family—sometimes even what we call as a warm hand-off—where they just are introduced, they get to see a face and a name, and there’s a connection that can really reduce the gap we have sometimes when they’re referrals that don’t make it to the referral source.
Sally: So, in a Q&A for Mass General Hospital on preparing children for when their parents return to work, you said, and I’ll quote you here, “Parents may experience their own anxiety about having children return to daycare due to the worries about COVID and may inadvertently send signals to children about their own anxiety.” Could you give us some ideas on how we can support caregivers during this adjustment period?
Dr. Rotter: Absolutely, in supporting parents and caregivers, it’s important to be aware that they may have their own mental health needs and perhaps had mental health issues prior to the pandemic. The toll that the pandemic has had on caregivers and parents has been tremendous. Caregivers have been required to step into roles that they were neither trained to do nor prepared for, such as becoming teachers to their children, providing full-time childcare while at the same time working a full-time job or perhaps coping with stress of unemployment or the loss of loved ones.
Self-care strategies can range from taking a few minutes to read an email from a friend, a section of the paper. Additionally, self-care can come in the form of family activities, creating scavenger hunts or obstacle courses for children, or even coming up with healthy cooking projects can combine self-care with family time. And I think that sometimes there are things that we might do that are really self-care that we may not consider self-care. They might be small, or they might be small and done every day and even that sense of routine can provide a break, can provide some comfort, and can provide some predictability. I think we’ve all been dealing with the lack of predictability in quite a profound way during the pandemic. And I’m not sure that’s going to change quickly as things open up in different pieces and in different ways.
Sally: I really appreciate that lens on the caregiver, and I wonder if you could talk a little bit more about how caregivers can ease their children back into normal life, while at the same time remaining cognizant of the stressors of this past year. And if you could speak specifically to infants and toddlers, I think their fears are sometimes a little less obvious to us.
Dr. Rotter: Absolutely, young children may exhibit distress through behavioral changes or shifts in their typical functioning, which can include sleep, eating, toileting, anxiety, tantrums, or increased irritability. And it’s hard to know when that happens what that could be a function of. It’s really important that if there are changes—abrupt changes or unusual changes in a child’s functioning—it’s really important to seek out consultation from your child’s pediatrician in order to rule out any underlying medical issues as a first step. And if at that point in conversation with the pediatrician, the belief is that perhaps what is being experienced by the child are indicators of stress or anxiety, that’s a time where a referral to a mental health professional from your pediatrician can be very helpful.
Many children and families are currently adjusting to the increased amount of time children are spending in-school and/or activities that were not happening during the pandemic restrictions. It’s typical and expected for infants and toddlers to experience discomfort when separating from their parents or caregivers, and this may in fact be exacerbated by the extended period of time they spent at home during the pandemic with parents or caregivers. So, it’s helpful to have a plan in mind. For older children, maybe toddlers, talking with them about familiar school activities that they may remember from when they were in school in the past, such as things that they played with or listening to stories, can help them prepare for their new schedules. But it’s also useful to think about what might be different, like the teacher will be wearing a mask, and there might be new hand-washing rules. They might tell their child, “we’ll wake up in the morning and have breakfast together and then you’ll go off to school, where you’re playing with your friends and you’ll be with your teachers and have lunch with them. And then you’ll return when it’s about time for dinner, we’ll all have dinner together.”
Additionally, for older children, sometimes the process of rehearsing going to school through play with dolls or figures can help reduce the stress. Reading books about returning to school can be useful as well. When possible, even for very young children, doing a short visit to school or daycare to acquaint or reacquaint the child with the classroom and the teacher can ease the transition as well. Even starting back in a more gradual manner can be helpful if that’s an option—going for a couple of hours the first few days and then working up to longer periods of time at the daycare center or preschool. Parents might also find talking with their children in the direct, but simple way about the coronavirus and how their child’s school or daycare has rules to make sure everyone is safe and healthy. For example, they may tell their children that their school is listening to the things that the doctors and the scientists are saying about going to school safely, and those are the things that they’re doing at school.
Sally: I know a lot of kids have been really isolated the last year, some maybe have only one friend or no younger children that they see. So, could you talk a little bit more about that social isolation or maybe potential anxiety that might be resulting from that?
Dr. Rotter: Yeah, I think social anxiety is a concern that many caregivers and parents have and some children have. I think for children who are naturally slightly more shy or anxious, particularly in new situations, that reentering social environments can be quite challenging. I would think a lot with the family about ideas such as previewing what to expect. Sometimes for young children looking at pictures of someone they maybe haven’t seen in a while, thinking about things they did before with that child that might have been fun or interesting when we’re thinking of young children.
Another thing that I talk a lot about with families when children have some anxiety about social situations is the structured play date. I think the idea of having a very specific plan in mind for an activity that’s really time based, so it’s not a long unstructured period of time, but it might be that a child comes over for lawn bowling and cookies and lemonade. And then that’s the end of that particular playdate. Or a specific arts or crafts activity or something along those lines, but that everyone knows what the expectation it, that there’s it’s something else to focus on, and sometimes that really helps to sort of build things. And often, what we’ll find is in those situations, that once children are comfortable with each other or reconnect in the case of they haven’t seen each other in a while that they can sort of take it from there. But some children need more, more structured play dates to help build in that comfort in a social setting.
Sally: There’s so many people, who I think will be comforted by your examples, because you gave really clear ideas on how to move things forward. So really, we’re really delighted.
I’m your host, Sally Pfitzer. The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, Instagram @DevelopingChildHarvard and LinkedIn, Center on the Developing Child at Harvard University. Brandi Thomas is our producer. Dominic Mathurin is our audio editor. Our music is Brain Power by Mela from freemusicarchive.org. This podcast was recorded at my dining room table.