Anxiety helps us stay vigilant for potential future threats, and the COVID-19 pandemic brings with it significant uncertainty. We certainly expected a spike in reports of anxiety symptoms like worries, fear, irritability, and low mood in the children and adolescents we care for in the clinic and our homes. 

This happened in China, where about one half of adolescents reported moderate to severe anxiety, depressed mood, and stress. Those with family in poor health, who were economically impacted, or who had general risk factors for anxiety had more reported symptoms. Those who maintained some routine or non-COVID-19 focus, physical exercise, or a sense of control had less reported symptoms. 

Though the information from the United States isn’t yet well reported, we should expect similar levels of anxiety and similar risks. After all, these types of spikes have happened in every past major viral outbreak. Certainly there has been no slowing in demand for pediatric mental health practitioners at any time during the pandemic. Being mindful of a few core principles will help us meet the needs of our patients and own families. 

DEVELOPMENT CHANGES ANXIETY SYMPTOMS, COVID-19 ADDS A TWIST

Pathologic anxiety tends to follow a developmental progression, from anxious temperament to separation anxiety to generalized anxiety to social anxiety disorders. Understanding this progression helps us be sensitive to how anxiety presents during different times in life. Roughly, young children may seem inhibited or clingy, school-age children more sensitive to somatic symptoms, worries about competency, and simple phobias, and adolescents have more abstract worries and focus on their friends’ judgments. Certainly COVID-19 stress may intensify these symptoms. 

It also adds a few complications. Many anxiety symptoms, like irritability, sleep problems and tension, are not specific to anxiety disorders. For example, in the first month of social distancing, I treated several anxious teens who seemed to be having worsened primary anxiety and depressive disorders. However, they turned out to be withdrawing from nicotine and cannabis, which were less available to them. For clinicians, our typical review of general symptoms and asking about COVID-19 impacts will help us catch these complications. Many clinical groups have also found newly developed, broad surveys help them identify COVID-19 related impacts for children and adolescents.

MIND THE CHANGES IN FAMILY AND PEER RELATIONSHIPS

One huge impact of COVID-19 is a change in the time spent and structure of a child’s social circle and family life. Clinicians can easily imagine exacerbations of pre-existing “cyclical maladaptive relational patterns,” with increased isolation and stress on families. In other words, problems that exist within families can become worse. Often taking a moment to simply be aware of a pattern and forgive it as a normal response to stress is enough. When it is not, it is time to get help.

Many youths have missed out on major social activities and rites of passage, like graduation. Many are unable to see friends. Social media or online gaming seem to have buffered these impacts. For socially anxious youth, being away from feared social demands may seem like a relief. However, this may result in difficulty for these youth when re-entering school or confronting other social situations.

It is important to recognize that our loved ones and patients may have trouble expressing their anxiety verbally. Many online guides for parents, like those from the Centers for Disease Control and Prevention, suggest that families seek clinical help when they notice these warning signs:

• Worsened negative mood (sadness, anxiety, irritability)
• Withdrawal from activities and people or inability to enjoy things
• Regression (for example, a return to bedwetting)
• Oppositional behavior and temper outbursts
• Trouble with focus and attention
• Physical symptoms like headaches and stomachaches
• Substance use

Families work as a whole unit, so it’s important to keep in mind that a child’s symptoms might be reactions to the parents’ anxiety or even an attribution of anxiety experienced by the parent to the child. 

PROMOTING HEALTHY OCCUPATIONS AND A POSITIVE IDENTITY

We all invest in and are affected by what we are doing and who we think we are. Children are no different. Most clinicians are sensitive to these shifts and their impact on anxiety. The amount of time spent on screens, social activities and exercise has markedly changed for most anxious youths. For some, inactivity, isolation and sleep disruption may worsen anxiety and depression, and make treatment planning difficult. Flexibility in developing treatment plans that truly meet the children, adolescents and families where they are is critical. 

These times challenge adolescents’ natural investment in identity formation. Overall, adolescents have an undeserved reputation for being angsty. Instead, most youths passionately and flexibly search for roles and meaning. Seeking out and staying engaged in meaningful roles and activities is helpful. For any adolescent, discussing a positive focus is certainly a point of each clinical interaction. For those prone to anxiety, discovering such outlets is an important buffer against anxious rumination. 


Joel Stoddard, MD
Assistant Professor, Department of Psychiatry
University of Colorado Anschutz Medical Campus


MIND THE BRAIN PODCAST

Dr. Neill Epperson and Dr. Joel Stoddard discuss the impact the COVID-19 pandemic has had on child and adolescent anxiety. 

Mind the Brain CME Information:
CME Survey for the June 23, 2020 Edition

 

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