Mental health care in children during COVID-19 [PODCAST]

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“Our country, and the world, is beyond exhausted by COVID-19 and the utter chaos and destruction of lives it has caused. All people, including physicians, are being pushed beyond capacity. What do we mean, collateral damage? Originally related to war: the unintended result of a terrible, unprecedented event or action. We may not be in a traditional war, but make no mistake, we are in a war.

We can and must do better for our mentally ill patients. They deserve it. Their families deserve it. As physicians, we took an oath to care for all people, not just those with a ‘cool kid’s disease.’ It is time.”

Ann L. Contrucci is a pediatrician.

She shares her story and discusses her KevinMD article, “Mental health care is the not so silent collateral damage of COVID-19.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Ann Contrucci. She is a pediatrician, and she wrote the KevinMD article “Mental health care is the not so silent collateral damage of COVID-19.” And welcome to the show.

Ann L. Contrucci: Hi, Kevin. Thanks so much for having me. I’m super excited to be here.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you just share your story and your journey to where you are today?

Ann L. Contrucci: Sure. I am a board-certified pediatrician with almost 25 years of experience. I did private practice for a few years, then, due to having children and wanting to be a mom also, spent about 17 years in a huge pediatric tertiary care children’s hospital ER, doing ER, PDR, for about 16 or 17 years. Then I decided I was ready to go back into private practice. I’ve actually practiced in Canada for a couple of years, so I have kind of seen both systems, and I am back in the U.S. and came back about a year ago.

Kevin Pho: Fantastic. And how has the pandemic affected your practice? Tell me about the types of COVID-related cases that you’re seeing in your clinic.

Ann L. Contrucci: Gosh, how has the pandemic affected my practice? Well, I’ll tell you, I think the first thing that all of us can certainly go along with is when it first started. Being in more primary care, I wasn’t, quote, “front lines,” and when everything completely shut down, I mean, I was out of a job for several months, and I’ve never had that experience in my life, right, as most of us can probably attest to. And then it was sort of this almost “Oh my gosh, I need to be doing something, I need to be doing something,” but I wasn’t on the front lines. I wasn’t in New York, et cetera. So that was really difficult to come to terms with, and seeing my colleagues and their exhaustion. I’m in several professional physician groups, and several that are specific to COVID, you know, etc.

So I think it’s been really difficult. Currently what I’m doing is some locums work, so I have been working in a couple of different places, really since June, and it’s been a very long haul. I think that the pandemic fatigue is real. I think it’s certainly affecting us as professionals, us personally, families, parents, and kids. I know the word’s been used a hundred thousand times, but it truly is an unprecedented time, and I think we’re just all building this plane as we’re flying it. There’s no question about it.

Kevin Pho: I think we’re going to talk a little about pandemic fatigue and the long-term effects of the pandemic as we transition into your article, “Mental health care is the not so silent collateral damage of COVID-19.” Now, for those who haven’t read your article, can you just walk my audience through it and maybe share the story of why you decided to write it?

Ann L. Contrucci: Sure. So how long do we have? So basically, mental health care has become truly one of my passions in pediatrics, in children and youth, as I’ve done this for so long, including being in the ER. I’ve been in every situation. I’ve been in urban centers, suburbia, and remote rural areas. I’ve been in Canada. I’ve been in lots of different places. And the one binding factor is that mental health care and mental illness affect practically every single person, whether it’s them personally, somebody in their family, another loved one, or friends.

So as we started going through COVID and had some personal experiences as well, some friends with some personal experiences with their loved ones, we are in the midst of this pandemic, but yet other illnesses are still happening. And I think what brought me to write the article was, as I had some personal experiences, like I said, that this just ripped off the Band-Aid of how significantly under-resourced we are, and how under-treated children and adolescents especially are, and that transition from once you turn 18. So you’re still kind of a young adult. I mean, you’re still kind of an adolescent. We all know that the prefrontal cortex is not there until you’re about 24 or so. But if you have significant mental health issues, you can be thrown to the wolves.

And that was the thing, I think, that really made me write this article: realizing how much stigma is still associated with mental health, despite the fact that it affects almost everybody in some way or another. And that’s why I do refer to it, and I don’t mean it flippantly at all, but I call it, it’s not “the cool kid’s disease.” So I think that’s what sparked me to write it, that we really have some glaring deficiencies, including in our own profession. I’ve seen it with other physicians that I’ve had to educate about certain mental illnesses. Specifically, eating disorders are a very under-acknowledged and undereducated illness that affects so, so many. So I think that’s the main reason that brought me to it.

Kevin Pho: So you mentioned eating disorders being one manifestation of mental health issues in the pediatric population. Can you walk us through a couple of other cases and scenarios that you’ve seen clinically as it relates to COVID-19?

Ann L. Contrucci: Sure. I think one of the biggest things, and this could be, gosh, this is probably, oh my goodness, almost half of the kids some days that I see in the clinic. So not even that extreme where we have to go to the ER, right? And that was what my article was kind of talking about, the more extremes. But we have so many things with kids since the pandemic, developmentally, right, at different ages. Young kids are hearing all this crazy stuff on TV. It’s very scary: “My mom is going to work in an office, and people are really sick. Is my mommy coming back?” So you’ve got the young kids, with lots of separation anxiety coming up. Routines are completely thrown off, right? Who’s been able to do a routine through all of this, right?

And then the older kids, I think, as we’re seeing kids going back to school, just some of the anxiety. Kids who are hardwired for, and maybe have a little bit more of, an anxious mind have the very real anxieties that they see: “Well, this person’s not wearing a mask. Am I going to catch it from them? Am I going to bring it to my grandma? Maybe I’d better not go see my grandma.”

So I think, getting back to what I’ve seen, it is just a huge uptick in sleep issues, behavior issues, and excessive screen time, which is such a two-edged sword. I have my thoughts about that and the damage it does to children’s brains, no question. So I think, as parents and adults have had to navigate this craziness that we’re in, it trickles down to the kids and the adolescents, and depending on the age depends on what effects you’re going to see. But no question, I’ve seen a huge increase. If I had to say one thing, it would be anxiety. And maybe, like I said, not crippling anxiety per se that you have to go to an ER, but I’ve seen plenty of it. I mean, what is crippling anxiety? If you can’t focus to do your schoolwork, or if you can’t sleep, that can be a pretty crippling kind of thing, right? And then you see behaviors because of that. If you can’t sleep, you can’t focus. “Oh, well, then is it ADHD?” Well, probably not. So that’s what I’ve seen a lot of. Like I said, if I had to say one particular problem, it has been the huge uptick in anxiety, more than anything, and uncertainty.

Kevin Pho: Now, as a pediatrician, what kind of advice are you giving both to the kids and the parents when it comes to this increased baseline of stress and anxiety that they’re dealing with during the pandemic?

Ann L. Contrucci: Thank you for that question. So what I tend to focus on is, I consider myself pretty holistic. I haven’t done an integrative fellowship or anything like that, and I’m not a DO. Shout-out to all the DOs out there; I think you guys are great. I know there’s been bad press, but I think you guys are great. But I really try to practice very holistically, looking at the whole family system, looking at the whole child, and what’s going on inside the house.

This is very difficult in our current system. You have 10 or 15 minutes. A few weeks ago I had suicidal ideation in a 14-year-old, and I had 15 minutes for that. Really, do you think I only spent 15 minutes? Of course I didn’t. So then I’m running an hour behind, and you know that. So I think one of my thoughts with my colleagues is, I think you’ve just got to take the time when you get your spidey senses up that something’s going on. You’ve got to look at the whole picture. Are we sleeping? How much screen time are we doing? Are we getting proper nutrition? Are we getting any exercise at all? I know it’s been locked down. Lots of places are coming out of lockdown. You can go outside if you have the ability to do that, if you have a safe neighborhood that you live in to go outside, and kids can get outside and play, run around the house, play hopscotch, things like that. So I tell parents all the time, these are the simple things, but they’re not easy: sleep, exercise, and nutrition.

And I’ve really, really been studying over the last few years, and one of my big things with kids’ mental health is talking about mindfulness. You can get little kids to learn about mindfulness on their level and learn about breathing techniques, as we learn so much more about the connection, right, the mind-body connection. One of my best pictures ever in my office was from a little kid, about four years old, that I taught the take five breathing technique to. He drew a picture of how you do the take five breathing technique. He was four years old. So I think those are some of my biggest things: not just focusing on one little thing, “Oh, maybe we’d better put you on this medication,” but looking at the simple, yet not easy, things too.

Kevin Pho: We’re talking to Ann Contrucci. She’s a pediatrician, and she wrote the KevinMD article “Mental health care is the not so silent collateral damage of COVID-19.” Now, a lot of the audience here are parents. I’m a parent myself. I have a daughter who’s a sophomore in high school and another daughter in middle school. Now, as parents, what are some red flags that we should look out for that would classify our children as something a little bit more than baseline stress and anxiety? What are some red flags that would necessitate us to take them to professional help?

Ann L. Contrucci: That’s a great question. I think any kind of changes in routine that seem a little out of the norm for the moody teenager, right? We all say “moody teenagers,” but I think if you’re finding some obsessive-type things, with perhaps constantly being on their phone, only looking at YouTube, only doing TikTok, very, very little interaction with the family, or even decreasing interaction on FaceTime or Skype with their friends. Changes in appetite, and changes in sleep, I think, are huge, because changes in sleep become this vicious cycle and this snowball effect. If you don’t sleep well, you’re going to potentially be more anxious or more depressed, can’t focus, etc. But if you’re depressed and anxious, you can’t sleep well, so it kind of does that.

So I think what I have told parents for 25 years, and I tell this to my med students and my residents when I’m teaching, is that parents know their children. You know your kid best. If something doesn’t seem right, it ain’t right, and you need to listen to that, even if it’s just to go in. Especially the tweens and the teens, because sometimes, my kids were like that, they don’t talk to Mom, they’re not going to talk to Dad: “I’m not doing that.” But if they have a trusted adult, if they have a relationship with their doc, their family doctor, their pediatrician, they can go in. And I will often say, “Hey, I’m going to talk to Susie by herself, OK, Mom?” “Sure, sure.” And a lot of times, boy, kids are so amazing at what they pick up on, and they just want somebody to listen, and sometimes it just takes somebody outside of the family.

So I think the first step is you recognizing something’s a little more off, and being very open with children based on their developmental level: “Here’s what COVID is. This is what we’re doing to keep safe. This is what you need to do to keep safe.” Being very matter-of-fact about it, not sweeping things under a rug. That’s one of my biggest things I’ve told parents over the years when I’ve got kids that have different types of mental health or behavioral health issues. The more you sweep things under the rug, guess what happens? There becomes a huge bump under that rug, and you trip over it. It doesn’t go away.

Kevin Pho: Now, so many kids across the country are learning remotely, and a lot of their social activities have been taken away from them, and obviously that leads to a lot of detrimental effects, both now and later on. What’s the single most important thing that we can do to help these kids out, to help prevent any long-term effects from this isolation?

Ann L. Contrucci: Oh, gosh, I don’t know if there’s one single thing or not. I think that the biggest thing is continuing to have communication with your kids, again, depending on their developmental level, and spending time with them. And this may sound a little bit paradoxical, but having self-care of yourself as well, doing good self-care. It’s like what they say on the airplane: Put your oxygen mask on before you put somebody else’s on. So I think it is touching base with your own anxieties about the pandemic and your own financial stuff, emotional stuff, isolation, blah, blah, blah, and kind of taking some inventory of that yourself, because kids will pick up on that, and you’ll project it, essentially subconsciously, right?

So I think that the things we can do are take care of yourself and try to stick to a routine. Again, going back to simple, not necessarily easy: Let’s have a routine. Pick up things as a family, like, “Hey, let’s cook through different countries together,” coming up with some creative things. “Let’s have a trivia contest.” “Let’s go out for walks.” Things like that, where it’s not just everybody in the same room looking at their phones, because there’s no connection there. I think that’s the biggest thing. This isolation has shown the pitfalls and the very real problems associated with isolation and lack of human connection.

Kevin Pho: And my final question, Ann: What’s your take-home message that you want to leave with the KevinMD audience?

Ann L. Contrucci: One of my favorite sayings is “We’re all just walking each other home.” And I think, when we talk about being healers as physicians, being a healer is helping make somebody whole. And I think that this pandemic has shown a lot of things, that we just need to help each other out. We are all just walking each other home, and we just need to be there. Human connection is where it’s at.

Kevin Pho: Well said, and thank you so much for sharing your time and insight, and thanks again for being on the show.

Ann L. Contrucci: Thanks so much, Kevin. Have a great one.

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