This article was originally published by the Anxiety and Depression Association of America (ADAA) and has been re-published on Mental Health America's website with permission. Click here to read the original article.
by Richa Bhatia, MD, DFAPA
Fear, uncertainty, and anxiety are bound to be heightened with wide-scale disease outbreaks that are contagious, particularly when they involve a new, previously unknown disease-causing agent, as is the case with the novel coronavirus (COVID-19) outbreak. This fear and anxiety can especially affect people already suffering from anxiety, and repeated news cycles about the spread of coronavirus do not help this anxiety.
Children and teens may have a particularly hard time making sense of what’s happening in such a scenario, given their pending brain maturation, their lack of experience, and their inherent suggestibility and vulnerability. Seemingly endless news cycles may feel overwhelming, confusing and scary to a child or teen. Children typically possess lesser abilities to decipher and understand from the news, the extent of risk that a disease outbreak poses to them or to their loved ones and friends. This can create a sense of panic amongst children. This may be more challenging when a child/teen is already suffering from an anxiety disorder or predisposed to feeling more anxious in unusual or new situations.
How a child responds to news of novel coronavirus may depend on several factors, such as 1) age of the child, 2) language/comprehension abilities and developmental level of the child, 3) presence, severity and type of anxiety disorder(s) or other psychiatric conditions, 4) prior history of trauma or serious illness of loved ones or self, 5) occurrence of other recent stressors or major life events (such as parental divorce, death of loved ones, major move, change of school), etc. Therefore, a parent’s response would need to be tailored to the individual situation and context surrounding their child/teen.
The most important and impactful form of communication to your child/teen is your own behavior. Children typically tend to be perceptive and sensitive to the behavior of others in their surroundings. If you and other adults in the household are acting and behaving calmly, you are sending a clear message to your child/teen that there is no need to panic or worry. For this, you would need to watch and monitor your own feelings and reactions. Children can sense their parents’ anxiety even when parents are not voicing or expressing their anxiety related thoughts or fears. Carving a few minutes for yourself for mindful breathing pauses during the day may help you model calm for your child/teen.
Significant changes to daily routines or schedules are stressful for children and convey to the child that you are very concerned or there is a crisis. Try adhering to usual routines and schedules in the household as much as possible. Consistency is key. If your child/teen’s school is closed, helping your child/teen have structure during the day, may help anxiety. Sitting around idle without a plan for the day is likely to escalate anxiety, especially for teens already suffering from anxiety. On the other hand, if your child/teen happens to suffer from Obsessive Compulsive Disorder (OCD) related to maladaptive perfectionism and has a need for excessive structuring, adding more structure would not apply to your child/teen. In this case, you would need to work with your child’s therapist/psychiatrist to determine the best strategy to navigate this situation, taking into account the unique circumstances of your child.
Listen to your child/teen’s feelings, worries, fears and questions about coronavirus. Children may receive their news about coronavirus from school, internet, TV, home or elsewhere. They may worry that the worst may happen to them and/or their friends and loved ones. Ask questions in a non-judgmental and empathetic manner. Show your child/teen that you are present and interested in hearing their thoughts and feelings. This will make it easier for your child/teen to approach you with their thoughts and feelings in future as well. You can find more information on Active Listening at CDC (Centers for Disease Control and Prevention)’s ‘Essentials for Parenting Toddlers and Preschoolers’ here:
Acknowledge your child’s feelings. Be careful not to dismiss, invalidate, make fun of or reject their feelings. You may also inform your child that it is common to feel this way; many other people (including children) experience similar feelings. More about Validating Your Child/Teen: Many people worry that validating their child’s feelings would mean they are agreeing with those and that this may further increase those feelings. Validating someone’s feelings does not mean you agree with the beliefs underlying those feelings, but, it means you acknowledge the presence of those feelings and that you understand that such feelings are a part of the human experience. Validating is very powerful as it helps the person feel understood. This is especially important for children as they rely on and check with parents/teachers to make sense of their emotional experiences, particularly experiences or situations that are new or unusual for them. Validation can help the child feel calmer and enhance the child’s ability to process their emotions.Frequent invalidation of a child/teen can lead them to be confused about or doubt their own feelings as they grow up, and may contribute to low self-esteem or sense of self, besides potentially affecting or even rupturing your relationship with them in the long-term.
Help Sit with Anxiety:
Encourage your child to practice sitting with and experiencing the anxiety, rather than doing something to relieve it or distract from it. Sitting with the anxiety may be challenging for your child/teen at first (depending on the severity of anxiety), however, with practice, it will help your child/teen know that even though sitting with anxiety can be challenging and unpleasant especially in the beginning, it is doable, that this is a wave they can ride, and that these are feelings that will pass and these do not define them or their life. Help your child notice and verbalize the experience of anxiety rather than avoiding it. Putting anxiety related feelings in words facilitates faster and optimal processing of those emotions and experiences. Normalizing the experience of anxiety as one that many people around the world feel, can also be helpful.
Know the Facts and Direct towards Facts:
Your child/teen is likely hearing about the novel coronavirus outside home anyway, so, do not shy away from approaching or discussing it. Be proactive in talking to your child/teen about facts regarding the coronavirus. For this, you will need to equip yourself with and read about the facts around coronavirus first. Ensure that you are getting your facts from reliable sources, such as the CDC:https://www.cdc.gov/coronavirus/2019-ncov/faq.html.
For an older child/teen, point them in the direction of scientifically authentic and reliable sources of news information about coronavirus. Inform your older child/teen that every new story may not be complete or show the big picture.Educate your older child/teen on distinguishing reliable and scientific sources of information about coronavirus from non-reliable ones. Inform your child/teen about the facts that you know about coronavirus, in a developmentally suitable way (in terms and amounts that they can grasp at their age and comprehension level). For an older child/teen, you may let them know that less than 1000 people (as of March 11, 2020) out of approximately 328 million people in the US currently suffer from the novel coronavirus, and that the chances of getting infected are low for most people, more so if simple precautions are practiced. Your child may ask you why the novel coronavirus is constantly on the news, if the likelihood of getting the infection is that low. Inform your older child/teen that this coronavirus is a new one that the world didn’t know about before, and therefore, countries and people want to watch it closely to prevent it from spreading further, and to understand it better. For young children, basic reassurance from parents that they and their loved ones are safe, is important. You may use story-telling and role play with younger kids to illustrate simple facts. Keep any information you give- simple, short and concrete with younger kids.
Children may have heard news about deaths from coronavirus. For older children who are more likely to understand the concept of death and its finality, you can educate them that most people do not die from this disease, rather, most get better. Regardless of the age of your child, if your child asks specific questions about deaths from coronavirus, do not avoid those; ask them what they think and know, and explain facts to your child in a simple way that is digestible for their age and developmental level, and is situationally appropriate. Ask them further about their concerns. Let your child/teen know that you are available if they want to talk further or have any questions.
Limit Excessive Reassurance:
Children or teens, who are feeling anxious or suffering from anxiety disorders, may repeatedly ask their parents for words or gestures of reassurance. Excessive reassurance may be in the form of repeated requests for gestures of comfort, repeated questions to verify safety of self and others, repeated requests for checking or repeating or asking you to repeat facts of the situation to reassure self, etcetera. While you may have an urge to provide such reassurance and such reassurance may give you the impression that it is helping at that moment, excessive reassurance actually serves to reinforce and increase anxiety in the long- term. Therefore, it is advisable to limit excessive reassurance. Also, aim to provide a high ratio of positive to constructive feedback for your child/teen when they engage in appropriate behavior. Parents who are suffering from anxiety disorders, may find it particularly challenging to limit such reassurance and may benefit from professional help for themselves to address these challenges.
Help Practice Relaxation Strategies:
Relaxation strategies that are mindfulness based, such as breathing techniques, may help your child/teen feel calmer. You can find more information about mindful breathing techniques at: https://www.seattlechildrens.org/pdf/PE698.pdf, https://www.seattlechildrens.org/pdf/pe727.pdf and https://www.headspace.com/meditation/kids.
They are more effective if practiced regularly. If your child/teen suffers from Obsessive Compulsive Disorder, keep an eye that these exercises do not become compulsive rituals. Most mindfulness exercises, be it mindful breathing, mindful walking or mindful eating, involve non-judgmental noticing and practicing being in the present moment.
Make it Educational and Interesting:
While the novel coronavirus does warrant seriousness, children understand and engage best through stories and play. A creative learning activity about COVID- 19, that is tailored to the age, developmental level and degree of anxiety of your child, may be a useful way to help your child understand the facts. If your child/teen’s anxiety is moderate to severe, any activity should be done only after consultation with their healthcare professional.
For instance, if your older child/teen is learning ratios, proportions, or percentages at school, you may ask them to read up about the numbers of people affected in the US at a reliable source, such as the CDC. When your child/teen calculates the proportion of people affected out of the whole population, etc., this will help them find out for themselves that the likelihood of being affected with coronavirus and especially being afflicted with the severe form of the disease, is low for most people.
For an older child/teen who has an interest in science, you may talk with them about antigens and antibodies. For those interested in history and science, you may give them reading material from authentic sources about how previous disease outbreaks in the world were handled. This may help your child/teen know how diseases were eradicated, how the world got through previous outbreaks, and therefore, can get through this one too.
For a young child, you may talk to them (or draw/paint pictures with them) about our body’s own strong warriors which spring forth to fight infections, and how eating healthy foods can make those warriors stronger. You may also talk to them about how many warriors outside, such as scientists, healthcare professionals and others, are working actively to protect people from acquiring this disease.
Watch Closely and Monitor:
If your child/teen suffers from Obsessive Compulsive Disorder (OCD) and tends to fixate or get stuck on certain things, you would need to take that into account while creating an activity or exercise. In that case, monitor so that this activity/exercise itself does not become a repetitive ritual. Children/teens with OCD may also struggle more than usual with handwashing, checking, counting and other compulsive rituals during this time, particularly as they hear recommendations for regular handwashing as part of prevention measures for coronavirus and as they hear about the rising numbers of people affected by the virus. In that case, you may work with your child’s therapist/psychiatrist to weave in and integrate the CDC precautions and recommendations into ERP (Exposure and Response Prevention), such that precautions are followed without turning into compulsive rituals. If your child/teen appears to have symptoms of an anxiety disorder or obsessive compulsive disorder (OCD), that are impairing or significantly interfering with their daily functioning at school and/or home, please consult a mental health professional at the earliest and work with that mental health professional closely.
Limit and Monitor News/Media Exposure:
The vast majority of children and adolescents in the US (and in large parts of the world) watch hours of TV and other media daily. Limiting and monitoring the exposure of your child/teen to news cycles can be one step towards helping them regulate their anxiety. The younger the child, the greater their need for limiting exposure to news. For older children too, parental monitoring and guidance to help navigate the confusing and often scary news about coronavirus, is needed.
Consult, Collaborate with Healthcare Professionals:
If your child/teen is suffering from an anxiety disorder or other psychiatric condition, talk to your pediatrician and arrange for a consultation with a mental health professional, if you haven’t done so already. Most treatments for anxiety in children and teens should involve psychotherapy. There are various modalities of psychotherapy that can be beneficial for anxiety; Cognitive Behavioral Therapy (CBT) is one form of psychotherapy that has substantial evidence of benefit for treatment of anxiety in children and adolescents. If your child/teen already is under the care of a mental health professional, work closely with that professional to help your child navigate this unusual time.
Widescale infectious disease outbreaks, such as the current one, are bound to be stressful and can be challenging to maneuver, particularly when they start to affect daily life or activities and more so, if your child/teen suffers from anxiety. Practice being kind, gentle and compassionate to yourself and to your child/teen. If you’d like to try compassion based exercises, you can find them here: https://centerformsc.org/practice-msc/guided-meditations-and-exercises/ and here: https://www.compassionatemind.co.uk/resources/exercises.
Note: For the sake of simplicity, the words ‘they’, ‘them’, ‘their’, have been used in this article as pronouns for child/teen. Please substitute these with the appropriate pronoun as it relates to your child/teen.