COVID-19 Special Edition: Mental Health in a Locked-Down World

Speakers

Additional Resources

• International Society for Traumatic Stress Studies: Self-Care for Providers
• International Society for Traumatic Stress Studies: Vicarious Trauma Toolkit
• Massachusetts General Hospital: How to Talk to Your Children About the Coronavirus (COVID-19)
• Massachusetts General Hospital: Parenting At a Challenging Time: Supporting children facing the illness/ loss of a loved one
• Massachusetts General Hospital: Psychiatry guide to Mental Health Resources for COVID-19
• National Child Traumatic Stress Network pandemic resources
• SAMHSA Disaster Distress 24/7 Helpline: 1-800-985-5990 or text ‘TalkWithUs’ to 66746

Transcript

Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Since our last podcast series was released, things have changed drastically as a result of the Coronavirus pandemic. During this unprecedented time, we’d like to share resources and provide guidance that you may find helpful. So, we are creating a series of podcast episodes that address COVID-19 and child development. This episode is the fifth in our series, and todays guests are Dr. Karestan Koenen, Professor of Psychiatric Epidemiology at the Harvard T.H. Chan School of Public Health, and Dr. Archana Basu, Research Associate at the Harvard T.H. Chan School of Public Health and the Clinical Psychologist and Massachusetts General Hospital. Thank you both for being here I’m really looking forward to the conversation.

Dr. Koenen: Thank you Sally. It’s great to be here.

Dr. Basu: Thank you so much.

Sally: So Karestan, what makes this pandemic different from other traumatic events that many people have experienced in terms of mental health?

Dr. Koenen: There are a number of characteristics that make the COVID-19 pandemic different than other traumatic events, even than other disasters. I actually lived in New York City during the 9/11 terrorist attacks, and I’ve seen some similarities in terms of this in that things were shut down, there was a pervasive feeling of threat, there was loss of life, and it was very disruptive and it was something that people really – in New York, anyway – talked about for a long time. It persisted and affected everyone in the city. What’s different about this is the length of time people are being affected, how pervasive it is in terms of our community but the state, nationally, and globally it’s the first time that I’ve had experienced a traumatic event that my colleagues in Africa are experiencing some version of it, my colleagues in Mexico, and then I think because it affects so many different aspects of our lives. We talk about trauma, and we think of things that are unpredictable and uncontrollable and overwhelm our ability to cope. This has certainly been unpredictable; a lot of things feel out of our control and on top of that we have other things that can in themselves be traumatic like unexpected bereavement, job loss, a stigma people are experiencing. I think the sheer pervasiveness of it – how it’s affected every aspect of our life. Finally, I think one of the things we know about disasters is that social support is so important for resilience, for people’s recovery, and to buffer them from the effects of disaster. In the middle of this, we’re being told to physically distance to prevent the spread of COVID, and that really cuts into our ability to get social support or to socially support each other, so that is something certainly different than I’ve experienced before or anything I’ve studied actually.

Sally: So Archana, I know you work with children and families on all of these issues around grief, which I know we were just kind of referencing. I’m wondering if you can talk a little bit more about the different kinds of grief that families might be experiencing at this time.

Dr. Basu: I guess I’d like to start by acknowledging that loss is a very common part of human experience, even outside of the pandemic. As an example, in the U.S. each year more than 600,000 people die of heart disease alone. This is not to minimize the losses that we’re experiencing now, but only to say that we as humans are used to experiencing losses and adapt to it on a pretty ongoing basis, and there’s a large body of evidence to suggest that we are adaptive and resilient. This is especially true for children because child development inherently offers many opportunities for change and positive adaptation with appropriate support. That being said, as Karestan highlighted, there are many unique elements to the pandemic in terms of the pervasiveness and the unpredictability as well as the limited or lack of access to typical support systems or resources, for instance due to physical distancing requirements. That certainly makes it unique and challenging. As of today, more than 80,000 fatalities have been reported in the U.S. alone. Families are certainly worried about their own health, their loved one’s health and well-being, or are coping with a death of a loved one. Right now, with travel restrictions, not being able to come together as families or with friends, that’s definitely a pretty big challenge. Many families have been unable to engage in typical funeral rituals, and parents are wondering how to support kids, and some are even wondering whether to say something. Generally, the research supports the idea that open age-appropriate communication can be very valuable in helping children. There are some specific helpful resources; really practical tips in terms of what language or words parents can use to explore how their kids are understanding these experiences, what worries they might have, and we can certainly provide links to that in perhaps the website to our podcast. Briefly, I will just say that open communication really helps to understand what children are observing and experiencing and can help them not be alone in their worries. I would say that would be the number one goal is to help children recognize what they’re feeling, validate those emotions, and for them to feel that they are not alone in this experience. The other element is what you referred to in your question is outside of bereavement, all of us are experiencing losses in our everyday lives. I think one way in which we support each other through tough times is by reaching out and connecting with our friends and family, by holding hands, by giving each other a hug, and we can’t do that right now. Also, I’ve been hearing from younger adults graduating; seniors in college, that they’re experiencing a pretty tremendous sense of loss around routine rituals that form a sense of community like graduation ceremonies. They don’t have that sort of eager anticipation as they’re launching into adulthood. Overall, I guess I would say children can be resilient, but the way forward may not always look and feel that easy. They’ll be moments of frustration and confusion. We would expect that – there is nothing normal about what we are experiencing, so to acknowledge and validate even these everyday experiences of loss would be quite valuable in supporting kids and families.

Sally: I’ve been thinking so much about how so many different people that I know have been experiencing this grief in different ways. You think, “Those high school students – that’s so hard”, or you think, “Oh, those college students – that’s so hard.” There’s so many different traditions and cultural pieces that we are missing right now, and that just changes how we are in our society. Karestan, I’m wondering if you could provide some specific examples; our listeners have often found it helpful to have some concrete ideas about how mental health experts are supporting families now, and then also how they’re preparing for those long-term health impacts.

Dr. Koenen: So, what’s been remarkable to me in terms of the pandemic is how the mental health community, and I mean that in academics, but frontline practitioners and students and people just interested in mental health, or companies that are interested in mental health have really stepped forward to offer resources from something like Headspace is offering free services to health care workers, and we’ve been offering these mental health forums at Harvard Chan School of Public Health. ADAA and CDC are offering all kinds of mental health resources. People have really stepped up to put those resources online, and I think that’s been unparalleled. I’ve never seen, again I worked in New York after the 9/11 terrorist attacks, and there was a cooperation around the mental health community, but I didn’t even see it at this scale then. I guess the other piece is the global collaboration I’ve never seen before. I’ve been on email chains with colleagues from Italy, China, South Korea; some of whom I knew before, some of them I didn’t. Figuring out what they are seeing and what has helped in terms of mental health locally. One center that I am affiliated with at Harvard decided to have a panel of people from China and South Korea talk about going back to work. Using the fact that it is global, and that countries are in different stages to problem-solve some of the things that would come up. Not that necessarily whatever they do would work here, but it would at least perhaps give us some ideas. Another thing has been a sort of rapid move to telehealth, which is something that actually insurance providers have been quite challenging to get reimbursed prior to the pandemic. It seemed like within weeks people had moved their practices to some form of telehealth, which could mean video, or it could mean telephone. That is something that I think has made services to people, especially to people who already had them, more accessible. Those are some things the community has done, and I think is a really positive thing going forward.

Sally: Absolutely. I’m wondering if you could help us think about what parents and other caregivers could do, specifically what they could do right now to support children’s emotional and mental wellbeing.

Dr. Basu: Foremost, readjusting expectation. Whatever little the parents can do to support themselves really matters because they are right now in fact the primary support system for kids. Obviously, parents are the most influential in terms of child development, but right now when kids don’t have access to other support systems, I would say it is even more important. As parents, we are not that great with prioritizing our own needs. It’s sort of kids, and work, and what everybody else needs in the household. Maybe, their own parents, and then if you get 5 hours of sleep, you’re lucky. I get that this is not an easy thing to focus on, but it’s sometimes just helpful to remind ourselves that every little bit counts even if it’s just twenty extra minutes of sleep, if it’s seven minute cup of coffee in the morning, maybe that sets the tone for the start of the day – simple, deep breathing. Another element could be focusing on what kids and families can control. So, thinking about your own routine – what’s helpful for yourself. Doing what works but keeping it simple – basic stuff. Managing sleep routines, eating, exercise, maintaining virtual social connections through technology. All of those things help. So, readjusting expectations and taking the time to sort of figure out routines that can be helpful, help us think about what we can control, and talking about it and checking in to see what’s working. These are some of the basic things I would highlight, and of course one of the biggest advantages right now to telemedicine is that it is more accessible if you have a phone, a computer, or a tablet. Get in touch with a primary care provider to seek guidance and support if this remains challenging, which would be quite understandable.

Dr. Koenen: Outside of COVID, providers are being underutilized. My colleagues who study health care services report that I think that it is down to somewhere 30% of capacity for non-COVID related medical calls, so thus, people should not hesitate as providers are actually available. One of the things that Archana and I have talked about, because we both have sons but they are very different ages, is that kids tend to be most concerned about what directly affects them, while adults we can get concerned about all of these things that might be abstract. One of the examples we have given is that when my son’s school was cancelled, the first thing he worried about was whether the homework due on Monday was going to be due, and whether it is going to be graded, and if they’re going to have to go to school longer. These very specific things, not to say he doesn’t worry about other things, but they are specific things. The younger kids – the playground that they usually run up to there’s yellow tape around it, so there’s these very immediate things. I think as a parent myself, I sometimes can trivialize these things. I find myself being like, “You’re worried about that, we’re in a pandemic, why are you worried about that?” But kids do worry about what is most direct and sometimes most concrete, and so by acknowledging and responding to those concerns which may seem kind of silly in our adult heads, that can provide a lot of comfort to them too.

Sally: Absolutely. You’ve both touched quite a bit on this, but I think I’ll throw this question to both of you to answer. We’ve been talking a little bit about how you’re saying that kids are responding to things that are most direct in their environment, and we know that the toll in this pandemic hasn’t been evenly distributed and will likely continue to not be evenly distributed. Some people are at much greater risk for both medical and economical consequences, and are you seeing that to be true for emotional and mental health consequences as well? If so, what could be done about that?

Dr. Koenen: Great question. When some of the groups we are seeing as most at risk for mental health consequences are 1 in 5 people in the U.S. – adults in the U.S. – live with a mental health disorder, so people who already had a prior mental health disorder or mental health condition, the conditions of the physical distancing for people with a mental disorder removed social supports and things that also may be accessed to other care groups – day programs, etc. Those people have been particularly affected had they already been socially isolated. The Kaiser Family Foundation came out with some statistics, and some of it’s not surprising. It’s families, actually parents, parents are reporting more mental health issues and people who experience economic downturn or job loss. We know from the 2008 recession that job loss and foreclosure are associated with increased risk of mental health issues. Thirdly, low income in communities of color have been disproportionately affected. I saw some data from a colleague published in New York which showed that higher mortality from COVID was related to income. We know that there’s been disproportionate mortality for communities of color. Also, in such communities, there is a greater digital divide, so we talk about a lot of these resources have been put online and there’s a lot of virtual support. But, we also know that 15% of Massachusetts households kids don’t have computers or didn’t have computers before this. And those again tend to be disproportionately in low income and communities of color. Those are some of the people I think disproportionately affected with risk of mental health problems who are disproportionately experiencing the COVID as well as the financial consequences.

Dr. Basu: I think the family focused care piece is really critical, and this is again very consistent with the Center’s philosophy around multi-generational models to support kids and families. I can’t really say this enough – I think supporting kids also needs to involve a model that supports parents. I would say that type of family focused care as one possible model moving forward is very key. The second one that Karestan and I and others have talked about, and maybe Karestan can chime in on this, is the aspect that there are many other communities or system within which kids and families live, work, and develop. That includes schools and community-level organizations, and faith-based organizations. I think part of supporting mental health care would involve partnering with these community-based organizations. This might include formal leaders and key stakeholders, but also potentially developing collaborations with more informal key stakeholders. There’s a lot of evidence that we can provide effective mental health care by not just working with specialists like psychologists and psychiatrists which is absolutely necessary, but also with more community-based healthcare workers, for example, and Karestan can speak of what we can learn in terms of the global context.

Dr. Koenen: Sure. Something that I hope that can come out of this pandemic is the better recognition that mental health is critical as the foundation of all health and the foundation of a healthy society. Rather than treating mental health like a side issue that we deal with when it’s an apparent big problem, we think of it more proactively. The burden isn’t left on individuals or even on families to seek help when things get to the crisis point. I think one of the things we can learn from our global partners and countries, where there may be 60 psychiatrists in the entire country treating a population and very few other trained medical professionals, is people having to introduce other models where community health workers or just leaders in the community, people who the community would acknowledge they look up to, training them in mental health practices that can then be disseminated into the community.

Dr. Basu: I think what Karestan highlighted in her previous comments is that there is also a lot of research to suggest that longstanding systemic issues can manifest in mistrust of health systems and beliefs about mental health that can impact engagement with care. So, engaging in the ways that Karestan highlighted, where people trust. Those are really valuable ways to engage people in just thinking about social and emotional health – engaging and starting that conversation.

Sally: Interesting. A lot of times at the Center when we’re talking about stress effects or stress response, we also like to talk about resilience. I’m wondering what you would say in terms of resilience around this pandemic.

Dr. Koenen: One of the things that has come up for me in terms of resilience is flexibility. We’re being called on to be very flexible, and we don’t always think of that in terms of resilience, but I think in this it is particularly true. I give my own example, one of my main coping strategies that works tremendously well 95% of the time is that I am a planner and I can see my plan backwards. I really had to be like “I plan, God laughs right now”, because so many things change all the time and as a parent now, we don’t know what this all brings. Having to be flexible myself, and model flexibility for my son who’s doing online school, he doesn’t know what the week is going to hold. The schedule is different everyday for his school, etc. Learning to roll with it and change your expectations. The other thing is I’ve been trying to figure out is, “What are the things that are most important to me? What are the priorities for my family, for myself”, and keeping them simple and only having a few of them. The normal expectations of everything we’re going to get done is not going to happen, and I also think that as a parent you have to choose your battles. An example is, well if your kids doing all their work and been on their Zoom calls for school and did all of their homework without complaint, does it matter if they got dressed? Maybe it does, maybe it doesn’t, but do you want to fight over what they’re wearing? Maybe you do, maybe you don’t. There are probably other things about having to choose what you’re going to focus on, and are you going to let go of some of the things or some of the time to make it more manageable.

Dr. Basu: To follow up on one of the things that Karestan started with was this idea of flexibility and it’s really something in our work with kids and families we talk up front about. One of those ideas is developing a toolbox of things that work for you as a family, and really think about what works for your child. I will often ask parents and older kids, “what has worked for you in the past?” So, we may not have been in the pandemic before, but we certainly experienced transitions and stressors and challenges in other ways. Asking them what has worked for you in the past and then thinking about how we can adapt those for right now. Also, recognizing that especially with kids, what works this morning, may not work at night or the next day, so thinking of it as a toolbox of skills or ideas they can use to cope is very helpful and certainly along the lines of having a flexible approach and definitely underscoring readjusting the expectations. I would definitely agree with both of those. I think the other thing that I would say is that individual resilience partially depends on systemic resilience. Really thinking about what are ways in which we can support families and schools and some of the other community-based organizations because those are the contexts in which children and families and all of us live our lives. There’s a recent study that found that among adolescence who received any mental health services between 2012-2015, that for 35% of the kids the only point of contact for getting mental health services was from their schools. So, forming partnerships with schools is actually really important because kids may not even access care through hospitals or specialists, but for a large portion of kid’s, schools might be the only point of service for them.

Sally: Excellent. I think that there are so many listeners who are especially going to relate to that readjusting expectations piece. That one really resonated with me as well. Well, thank you both so, so much.

Dr. Basu: Thank you so much.

Dr. Koenen: Thanks, Sally.

Musical interlude

Sally: 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, and Instagram @DevelopingChildHarvard. Brandi Thomas is our producer, and Charley Gibney is our producer and audio editor. Our music is Brain Power, by Mela from FreeMusicArchive.org. This podcast was recorded at my dining room table.