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Children's Mental Health During the Pandemic

Electronic Winter 2021  |  Issue 49

The Crisis in Children's Mental Health During the Pandemic - How Psychiatrists Can Help
By Matt Cohen, J.D.
Founder, Matt Cohen and Associates
Chicago, Il.
The Coronavirus pandemic has had a cataclysmic impact on our society and the rest of the world.  One of the groups most profoundly affected by the pandemic has been children, especially because of the closure of the schools and a resulting disruption of academic growth and emotional functioning. Notably, the pandemic has caused a massive intensification of mental health problems in children, including both increased numbers of kids with mental health problems, increased prevalence of more severe psychiatric emergencies, and growing prevalence of serious emotional problems in younger children. The situation is so bad that the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry have declared a National Children’s Mental Health Emergency. The AAP/AACAP statement of emergency noted that:
“The pandemic then brought on physical isolation, ongoing uncertainty, fear and grief. Centers for Disease Control and Prevention researchers quantified that toll in several reports. They found between March and October 2020, emergency department visits for mental health emergencies rose by 24% for children ages 5-11 years and 31% for children ages 12-17 years. In addition, emergency department visits for suspected suicide attempts increased nearly 51% among girls ages 12-17 years in early 2021 compared to the same period in 2019.”  (https://publications.aap.org/aapnews/news/17718/AAP-AACAP-CHA-declare-national-emergency-in?autologincheck=redirected)
       These indicators of the pandemic-driven mental health crisis for children emerge locally, as well. For example, recently the Evanston public schools reported that the number of suicide risk and safety assessments have more than doubled this fall compared to the same period in 2019. (https://dailynorthwestern.com/2021/11/17/city/district-65-board-hears-updates-on-mental-health-and-special-services/) The pandemic and remote learning have simultaneously produced more mental health problems for children generally and at school, while simultaneously undermining the existing school and community-based service delivery systems, due to loss of staff and constraints on in-person services due to the need to maintain social distancing.
This alarming situation creates both a challenge and an opportunity for child psychiatrists. The challenge has many elements, including increased need for child psychiatry services, already in limited supply, and the need to address the crisis while the pandemic poses the same life challenges for child psychiatrists as it does for everyone else, such as the need to cope with illness of family members and colleagues and the need to adapt to the new restrictions in in-person treatment services.
Given both the reality of this crisis and the constraints on available psychiatric care, there is also an opportunity and calling for child psychiatrists to step into this clinical breach and use their skills to take full advantage of the school resources that are or should be available and provide the clinical information and advocacy needed to assist families to access school services and protect kids from avoidable losses and even punitive measures in the schools. This article will highlight some of the problems tied to school related mental health problems and identify ways psychiatrists can assist families in accessing greater support within the public school system.
At the outset, it is important to recognize that the pandemic and resulting remote-learning model triggered increased range and severity of mental health problems in children, including in relation to school functioning, while the delivery of services by the public schools was dramatically constrained, resulting in a temporary suspension of all evaluation/Child Find programs and a reduction or elimination of many counseling and therapy services. The need grew, while the ability or willingness to identify problems and respond to them shrunk.
  • The role of the psychiatrist in promoting diagnosis and services for children with school related mental health problems.
  • Historically, schools have had the obligation under special education laws to identify and evaluate all children suspected of having a disability that might qualify for special education and related (therapy) services. This is called Child Find. Once a child is determined eligible, the school is required to provide needed educational and instructional services. As mentioned above, at the outset of the pandemic, schools were briefly allowed to suspend their Child Find activities, due to the risk of transmission arising from in person evaluations. However, by September 2020, the federal and state government directed that schools could and should reinstate their Child Find/evaluation procedures, using a combination of remote and in-person evaluation methods and completing as much of the normal evaluation process as was safely possible. This included the ability to use tele-health procedures to gather information, interview the student and family, and conduct formal assessments. This included both initial evaluation for special education eligibility and the reevaluations that are minimally required at least every three years and can happen more often as needed.Unfortunately, many schools continued to refuse or delay the evaluation process both for children not yet eligible for services and for those already eligible, but whose needs may have changed. These delays and denials were improper, though that remains a concern to a lesser degree. Child psychiatrists can help to break this logjam by:
    • helping their clients understand that the pandemic/remote learning is no longer a basis for delaying or denying evaluation and encouraging their clients to seek school evaluations if their children are having emotional/behavioral problems
    • providing in depth evaluation reports/referral letters not only providing basic diagnostic information but explaining why the child’s psychiatric problem impacts their school performance and even may be getting caused or aggravated by school problems
    • providing concrete and detailed recommendations for services, including therapy services (such as counseling or social work services), implementation of behavior intervention plans, use of a 1-1 or class aide to provide support, untimed tests and other accommodations to that are NECESSARY for the student to function successfully at school.
  • Sadly, some students with emotional/behavioral problems resulting from or aggravated by the pandemic, may get into disciplinary trouble, refuse to come to school and/or require a higher level of intervention than is typically available in a public school. In addition to the provision of therapy services at school, there are many other school-based interventions that can be useful and, where appropriate, should be included in recommendations for what a student needs at school. These can include the development of local school-based behavior intervention services (typically preceded by the completion of a functional behavioral analysis), provision of positive reinforcement systems, access to trusted adults and safe spaces at school to calm or reintegrate, and even provision of parent training and counseling to assist in coordinating home and school-based interventions. For kids with the most severe psychiatric problems, they may need placement in a therapeutic day school, residential treatment program, home bound educational program or an alternative non-special ed school that offers an environment and educational program that fits the child’s needs when they are not making it in the public school. Here the child psychiatrist can also play a key role both in delineating the nature of the child’s school related emotional problems and in offering detailed recommendations for the types of intervention and level of programming and placement that the child NEEDS.In making these recommendations, it is always important to emphasize those recommendations that are NEEDED for the child to be able to manage and progress versus those that simply might be useful or helpful. The latter recommendations are often dismissed by the school team, as they perceive their legal obligation to be providing the services and ONLY the services that the child needs versus those that are simply beneficial, but not necessary.
  • The role of child psychiatrist for kids at risk of being suspended or expelled for COVID related or aggravated behavioral problems.
  • While the Coronavirus has not yet been identified as directly causing behavioral and social problems, there are a variety of obvious behavior issues that are arising in response to children’s COVID and remote learning experiences. These may include:
    • development or aggravation of severe anxiety problems due to fears of transmission, absence leading to increased school refusal
    • problems readjusting to the structure of school and social life after a prolonged, resulting in increased disruptive or oppositional behavior
    • feelings of diminished self-esteem, heightened depression and/or increased distractibility due to the time doing limited computer-based instruction and resulting loss of educational progress, loss of prior educational and social skills and inability to even engage with the educational process.
  • In these situations, the child psychiatrist can play an important role in determining that the child does or does not pose a significant risk of harm to self or others, that the behavior at issue was directly caused by or related to their psychiatric condition or disability (if that’s true), that the student requires appropriate intervention to address the problem or behavior even if they are safe to return to school, spelling out the nature of those interventions, and that it would be (if this is true) contraindicated to place the student in a program or setting with children that might model inappropriate behavior or engage in aggressive or disruptive behavior that the student should be protected from. Again, the focus should be on what the student NEEDS.
  • Psychiatric involvement in return to school and mask related issues.
    • Several novel problems have arisen from the requirement for masking at school that may involve a psychiatric component and require assessment and recommendations from a child psychiatrist.First, it is current policy that all kids must attend school and wear masks unless the child falls into a very limited medical or religious exemption.While medical documentation of the need to either remain at home or be allowed to return to school without a mask may be obvious in relation to children with immune disorders (who are at risk if they go to school) or with breathing or allergy issues (who therefore can’t wear a mask at school), there are some children that either are scared to go to school or frightened by wearing a mask at school, related to an underlying psychiatric problem. These children can also qualify either for home bound services or a mask exemption, if they have proper documentation of the need for the home service or exemption from their psychiatrist.
    • This documentation needs to include the nature of the underlying psychiatric problem/explanation of diagnosis, an explanation of why the condition prevents the student from being able to attend school and do so with a mask, and why it is necessary for them to receive the exemption/accommodation requested. Ideally, for those students that can’t attend school, such recommendations should also indicate the importance of the student having access to as full an alternative educational program as possible, including a full day of instruction and services, virtual access to school therapy services, and even participation by two-way remote in the activities of the classroom, social groups, etc.
    • A second novel problem involves those students that attend school, but due to their psychiatric problem are not willing to wear a mask consistently or at all. This might include children reluctant to wear the mask for some anxiety related reason, those engaging in some form of oppositional defiant behavior, and those who have ADHD and a high degree of impulsivity and/or attention seeking behavior and have trouble complying with the masking rules at school. While students with a legitimate upfront medical prescription waiving the need for a mask may be entitled to go mask free, some students may not have such documentation up front and may then get into disciplinary trouble when school staff insist that they wear a mask and may move to discipline or even exclude them from school due to the refusal to wear the mask. Psychiatrists can help, even retrospectively, to establish that non-compliance or refusal is caused by the student’s psychiatric disability and offer recommendations/strategies for teaching/ reinforcing appropriate compliant behavior, rather than suspending or expelling the student from school.
  • Systems Change
  • Beyond the new and expanded ways that psychiatrists can serve individual children with mental health needs, there is also a need for advocacy for systems change, as the educational and mental health service delivery system is highly flawed, and the pandemic has brought many of those flaws into stark relief. A few system changes would include universal annual mental health screening of children through the public schools, increased funding of school mental health diagnostic and treatment services for children, increased integration of child and adult services, with the schools as a hub, to promote better coordination of care, improved training of the educational community about identification and treatment of mental illnesses and best practices, and increased funding to accomplish these changes to allow for them to be implemented in the real world rather than just as pilots to be forgotten once the trial funding expires. The psychiatric community can play an important role in advocating for these changes.
  • There is a wide array of problems that have developed or been intensified for students with mental health problems due to the pandemic and the resulting remote learning plans that have been implemented. This situation is causing new demands for child psychiatrists and full engagement by the psychiatric community is critical to managing this crisis. For psychiatrists treating children and adolescents, this also creates an opportunity and, arguably an imperative, to broaden the ways that they support kids and families and interact with schools to provide a clinical road map for what the child needs and how those needs can and must be met by the public school system and the family.
Matt Cohen is the founder of Matt Cohen and Associates, a Chicago based special education, disability rights and human services law firm. He is a former president of CHADD, a long time founding board member of the Council of Parent Attorneys and Advocates, and the author of “A Guide To Special Education Advocacy- What Parents, Clinicians and Advocates Need to Know” (Jessica Kingsley Press, 2009). His web site is www.mattcohenandassociates.com.  He can be reached at matt@mattcohenandassociates.com.
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