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Mental Health Impacts of COVID-19 on Children in the School Setting

Kim Gushanas, PhD

Psychology Fellow

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• Describe the role of school nurses related to mental health

• Explain stress models that are relevant to COVID-19

• Recognize symptoms of stress by varying developmental levels

• Understand tools to evaluate risk factors

• Identify strategies to support students dealing with stress, anxiety, social distancing and possible family abuse

OBJECTIVES

PSYCHOLOGY

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LET'S TRIAGE

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Did you know?

In 2014, approximately 5% of adolescents ages 12-17 in the U.S. had a substance use disorder (SAMHSA, 2017)

Suicide is the second leading cause of death among children aged 10-17.

Causes 5-10 were diseases or chronic illnesses with a behavioral or mental health component.

-Center for Disease Control and Prevention (CDC)

… and 75% by age 21with 46.6% lifetime prevalence,

but…

- U.S. Dept. of Health & Human Services

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Child and Adolescent Mental illnessPrevalence is increasing at rapid rates

Untreated symptoms compromise development

Places children at risk for:◦ School Drop-out (~ 50%)

◦ Incarceration (~ 70%)

◦ Substance abuse

◦ Community Violence

◦ Sexually Transmitted Infections (STIs)

◦ Teen Pregnancy

◦ Severe, chronic mental illnesses: Eating disorders, Depression, Anxiety/OCD, PTSD

◦ Early death due to:

◦ Suicide

◦ Unmanaged chronic illness

◦ Accidental overdose

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A public health issueApproximately 32% of pediatric primary care Chief Complaints re: psychosocial concerns

1/3 of primary care visits are to receive antidepressants and ADHD medication for children.

Mental illness is the leading cause of disability in ages 15-44 (NIH).

Untreated mental illnesses in the U.S. cost more than $247 billion with an additional $100 billion a year in lost productivity for adults (NAMI).

Rated top 5 most expensive childhood conditions (Soni, 2014)

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Why aren't kids getting the care they need?Lack of evidence-based mental healthcare training in direct-care providers

Systemic disorganization

Resource limitations (e.g. limited access, insurance hurdles, time, childcare, school restrictions)

Stigma of mental illness◦ Can make families and youth reluctant to seek help◦ Prohibits communication Lack of knowledge, education◦ Lower acuity/prioritization◦ Implicit bias of providers

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Why schools?“Mental health is critical to academic success.”

-National Association of School Nurses, 2013

“Quality screening and early intervention should occur in readily accessible, low-stigmasettings, such as primary health care facilities and schools."

- President Bush’s New Freedom Commission on Mental Health (2003, p. 60)

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Mental health in schoolsSchools currently function as the

mental health system for up to 80% of children who need help.

-American Association of Pediatrics

50% of youth with severe mental illness identify school nurse or

counselor as their ONLY provider.

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SCHOOLS ARE A FIRST LINE OF DEFENSE.

YOU ARE THEIR FIRST-RESPONDERS.

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The value of school nurses

Trusted

Safety

Normal

Experts

Wellness

Prevention

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School nurses already spend over 33% time addressing student behavioral health issues (Bobo & Shubert, 2013).

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Building Resilience1. Sensitive, responsible caregiving2. Meeting basic needs3. Emotional support for children4. Support for caregiver well-being5. Social connectedness

Bartlett, J.D., & Vivrette, R. (April 2020). Ways to Promote Children’s Resilience to the COVID-19 Pandemic (Child Trends)

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The role of school nurses in mental healthcare

1. Identifying students at risk

2. Providing brief interventions

3. Coordinating referrals to mental health providers in the school and community

4. Continuity of care

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Knowing the signs, symptoms, & risk factors

1. IDENTIFICATION & ASSESSMENT

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Impact of stress on the brainChanges in structure and functioning

◦ Hippocampus◦ Prefrontal cortex◦ Amygdala◦ Increase in cortisol

Impacting executive functioning (working memory, cognitive flexibility, inhibitory control, abstract thinking, & emotion regulation)

Resilience can occur with supportive/responsive individuals in the environment

Cross, Fani, Powers, & Bradley, 2017

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Stress and learning: Biopsychosocial model

Psychological functioning is related to academic achievement

◦ Reduced reading skills◦ Peer rejection◦ Increased absences ◦ Decreased graduation rates

Early detection, assessment, and linkage to treatment significantly improves health outcomes, mental and physical (AAP on School Nursing, 2013)

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COVID: A recipe for stressPhysical confinement, Less social contact

Changes in routines, structure, stability

Increased academic strain- remote learning, SpEd

Financial stress (unemployment, poverty)

Parental mental health concerns (neglect, substance use, unpredictability, abuse)◦ Increased rates of abuse, neglect, and exploitation during prior public health emergencies (e.g. ebola)◦ Social distancing – isolation in abusive homes

Lee, 2020 – Mental health effects of school closures during COVID-19 PSYCHOLOGY

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What are possible symptoms of stress nurses may observe

after return to school?

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Symptoms by Developmental Stage

Preschool School-aged Adolescent

Fear of being alone, regression (toileting, speech, thumb sucking),

appetite changes, increased tantrums, clinginess, play themes

Irritability, clingy, nightmares, sleep/appetite changes, physical

symptoms, withdrawal, competition for parental attention, forgetfulness,

feel helpless

Physical symptoms, sleep/appetite changes, irritability, withdrawal or

risk taking, concerns about stigma/injustice

Helping Children Cope with Changes Resulting from COVID-19 – NASP (updated March 25, 2020)Educator’s Guide to Supporting the Social and Emotional Needs of Students: COVID-19 Information and Resource

Materials (Michigan Department of Education and Michigan Department of Health & Human Services)PSYCHOLOGY

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EPIDEMICS & TRAUMAThree risk groups:

◦ Direct experiencing/suffering from symptoms and treatment◦ Witnessing the suffering from, struggle against and death due to the infectious disease◦ Realistic or unrealistic fear of infection, social isolation, exclusion, and stigmatization

Survivors reported highest prevalence of PTSD, followed by victim families, then medical professionals.

◦ Female, elderly, children, less educated, low-income groups are most vulnerable

Prevalence of PTSD among health professionals was approximately 21% (ranging from 10 to 33%), and 40% of them reported persistently high PTSD symptoms 3 years after post exposure.

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Brief overview of traumatic stress reactionsCOVID = global, community trauma

◦ 22.6% of students reported depression & 18.9% of students reported anxiety following quarantine (~1 month) (Xie, Xue, Zhou, Zhu, Liu, Zhang, et al., 2020)

Acute Post-Traumatic Stress Reactions v. Maladjustment

4 core symptom categories of PTS:◦ Reexperiencing

◦ Avoidance

◦ Negative shifts in mood/cognition

◦ Hyperarousal/Hypervigilance

Consider traumatic separation & traumatic griefPSYCHOLOGY

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Risk factors for increased Stress responseTrauma History

Premorbid mental/behavioral health concerns

◦ Anxiety or Depression History **especially suicidal ideation**

Premorbid health conditions, chronic illness

Learning & attention disorders

Inadequate environmental supports

Loss of work/income for parents

Family members who are particularly vulnerable to COVID

Family members who are healthcare workers, or who work in occupations with high exposure rates (e.g. public services, custodial staff)

Whose parents are divorced, separated, or live in different locations

Experiencing less supervision because of caregivers’ work schedules

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*FREE* Screening & measurement ToolsAvoid Bias. Always Ask.

UCLA Brief COVID-19 Screen for Child/Adolescent PTSD◦ Non-COVID-Specific: The Child PTSD Symptom Scale for DSM-5 (CPSS-V SR)

Bright Futures’ Pediatric Symptom Checklist (PSC-17)

American Psychiatric Association PROMIS Study Measures: “DSM-5 Online”◦ Level 1 Screeners◦ Level 2, Symptom-specific measures

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