A recent headline in the Atlantic proclaiming “The Kids Aren't All Right” suggests that the mental health implications of the coronovirus (COVID-19) for the youngest members of our population are dire. Indeed, the United Nations Secretary-General identified an urgent need to address the increasing mental health sequelae from COVID-19, particularly for children. Emerging estimates suggest that mental health difficulties, including emotional and behavioral difficulties in children since COVID-19, have increased significantly.1 Furthermore, 83% of children with preexisting mental health difficulties have reported worsened mental health symptoms,2 and calls to youth crisis lines in North America have increased by 64%. Taken together, there will be an intense and sustained need for mental health services during and after COVID-19. Unfortunately, because of an already overburdened health care system, many children will not receive the services they need to manage their mental health. Here, we argue that to effectively reach and support children struggling with emotional and behavioral issues during this pandemic, it is essential to support the parents and caregivers who care for them.
As clinicians who are providing health services to vulnerable children and families during COVID-19, we have observed a striking pattern: many parents are not alright. Indeed, 50% of our mental health referrals thus far are for parenting-related concern. As governments and policymakers heed the call to address the mental health needs of children, it will be imperative to recognize that the kids will be alright if the adults who care for them are, too. As the medical home for many families in North America, health professionals (i.e., pediatricians, family physicians, nurses, and mental health workers) have a unique opportunity to provide support and strategies to parents that may reduce the development or exacerbation of further child mental health difficulties. Accordingly, we further discuss the stress that parents face during COVID-19 and offer strategies that can be implemented by health care professionals to promote the mental health and well-being of the entire family unit, during and beyond the pandemic (Table 1).
Although it is clear that there have been substantial changes and ramifications from COVID-19 for children internationally, the stress of these disruptions has largely fallen on the adults who care for them. Indeed, parents have been thrust into managing and balancing the tasks and responsibilities that would typically be shared by multiple individuals (e.g., teachers and coaches) and multiple systems (e.g., schools and communities), and it is taking its toll. Although elevated parental stress and mental health difficulties are concerning in their own right, the science of stress has long established that when parents are stressed, children become stressed too. Indeed, physiological studies have demonstrated the contagion that occurs from parent to child in the parasympathetic nervous system, with parents being a driving force for stress and a regulator of their child's stress.3 Thus, parents and caregivers constitute the primary context and the most proximal influence on children's health and can serve as a primary source of prevention for promoting child mental health, especially in the face of the pandemic when many children's mental health concerns will not be addressed because of an overburdened health care system.
As we begin to address the wave of emotional and behavioral difficulties in children due to the pandemic, health professionals will likely be the first point of contact for most families. Thus, they have the largest potential reach and influence on the family unit. Frontline health care providers can provide both emotional support and evidence-based strategies that can help to reduce parent stress and increase parent and child well-being. It will be particularly important to “check in” and support parents who are marginalized, including those with mental health difficulties, low income, poor social support, and the presence of financial strain.
In Table 1, we provide a 3-step checklist for providing support to parents in the context of primary care telehealth or in-person visits that can be used universally but are particularly helpful in the context of COVID-19. First, listen to, acknowledge, validate, and empathize with parents and caregivers whose children are presenting with difficulties. This is the most important step in communicating with parents, and if time is limited or a parent is not receptive to discussing further strategies, the only required step.
Second, provide parent-specific strategies to address stress and increase coping strategies including strategies related to self-care, self-compassion, and stress management. Self-care, as defined by the World Health Organization,4 is the ability to promote health, prevent disease, and cope with challenges. By encouraging parents and caregivers to engage in activities that promote their own mental health and well-being, they may develop increased capacity to support and attend to the emotional needs of their children. It is also important to encourage parents to be aware of their limitations and reduce their expectations. In parenting terms, this means noticing the parenting successes, remembering there is no perfect parenting, and remembering that “good-enough” parenting will suffice during a crisis. Encourage parents to focus on being present and engage in quality interactions with their children, even if only in short bouts. Finally, encourage parents to identify how they might decrease current life demands, increase resources, or implement structure and routines to help manage and reduce stress.
Third, after addressing strategies for managing their own well-being, provide brief evidence-based suggestions for managing children's emotional and behavioral difficulties.5 There are general parenting approaches that have consistently been shown to improve child outcomes including maintaining routines, play and physical activity, and providing opportunities for social connections with supportive peers or extended family members. Children who are presenting with pandemic-specific worry or anxiety and increases in emotional and behavioral challenges may benefit from more specific evidence-based parenting techniques (e.g., Parent-Child Interaction Therapy or Triple P Parenting).
In sum, the need to prioritize the mental health and well-being of parents and caregivers is critical for optimizing children's well-being during and after COVID-19. As the primary point of contact for many families, health care providers have a unique opportunity to expand the reach of support to parents to in turn mitigate the child's emotional and behavioral difficulties. Advocating for greater availability and access to intervention programs and services will also be paramount to promoting family well-being in the aftermath of COVID-19.
1. Racine N, Cooke JL, Eirich R, et al. Child and adolescent mental Illness during COVID-19: a rapid review. Psychiatry Res. 2020;292:113307.
2. Lee J. Mental health effects of school closures during COVID-19. Lancet Child Adolesc Health. 2020;4:421.
3. Shih EW, Quinones-Camacho LE, Davis EL. Parent emotion regulation socializes children's adaptive physiological regulation. Dev Psychobiol. 2018;60:615–623.
4. World Health Organization. Self-care Can Be an Effective Part of National Health Systems. 2019. Available at: https://www.who.int/reproductivehealth/self-care-national-health-systems/en/
. Accessed May 25, 2020.
5. Szabo TG, Richling S, Embry DD, et al. From helpless to hero: promoting values-based behavior and positive family interaction in the midst of COVID-19. Behav Anal Pract. 2020:1–9.