We stood at the bedside.  Our eyes met through plastic goggles and face shields.  Wordlessly, we acknowledged a palpable shift.  We three pediatric emergency physicians staffed our New York City ER that late fall day, caring for the third teen in a row echoing the same sentiments: I feel exhausted, hopeless, alone.

COVID-19 is wreaking havoc on the lives of children and teens in ways we are just now starting to comprehend.

Reflecting on March and April 2020, we recall our deep gratitude that COVID-19 had largely spared children from the unrelenting shortness of breath, chest pain, and hypoxia that was suffocating adults.

Many months later, though, as New York City contends with its second wave, it is clear from our vantage point that children have not been spared at all. The price for their safety, and the safety of their families, is profound isolation. Children are suffocating in their own rooms – not from lack of oxygen – but from loneliness.

Before COVID-19, we were already navigating a mental health crisis in children. In 2017, suicide was the second leading cause of death in children aged10-19 years old.  Pediatric ERs were an important safety net for the increasing number of patients with emotional and behavioral health challenges.  During COVID-19, the total number of children coming to the ER has fallen sharply, yet those with concerns about anxiety and depression are rising.

We are struck by the ripple effects of the pandemic waves on our youth.  Our patients express feeling crushingly isolated. Some confide they want to die.  We see young girls with newly diagnosed eating disorders; skin hanging from their arms, eyes sunken, pacing in tiny circles to burn calories.  We see too-many-to-count teens taking too-many-to-count pills, with too little professional support to get them through their day.

Access to outpatient mental health care has become more challenging, and many children have lost previously established connections when schools and clinics closed. According to a November 2020 report by the Centers for Disease Control and Prevention, “The proportion of all ED visits for children’s mental health-related concerns increased, reaching levels substantially higher beginning in late-March to October 2020 than those during the same period in 2019.”   What this report does not describe is the profound sense of loss, isolation, and lack of engagement our patients reveal when we face them at their bedside.

Children are suffering from the broken routines of their life and an inestimable sense of loss.

They have lost the rituals of childhood and adolescence that define their growth – missed birthday parties, graduations, and proms. They have been unable to celebrate special events with extended family – hug their grandparents or share a holiday meal with cousins. The tapestry of their lives is disrupted and incomplete.

Most importantly, children have lost the familiar routine that gives them a sense of predictability and safety; the regimen of leaving home each morning and going to school. So many have lost the chance to sit in a classroom and learn, to see their teacher’s smile of approval, to eat lunch in the cacophony of the cafeteria, hear the laughter of their friends, to giggle and whisper, to pass notes, to perform, to play sports, and to compete.  School breeds passion, desire, and plans for the future. School is the linchpin of a child’s societal norm.  It is a place, away from home, where children find comfort and achieve autonomy. It is the fertile ground where they grow and become their independent selves. The loss of going to school in person has bred a generation of students floating without an anchor.

And some are drowning.

Remote school has posed overwhelming challenges. A recent study in the Journal of Adolescent Health asked high school students in May 2020, “What are your three greatest challenges right now?”  Sorting the nearly 2,000 responses into domains, the authors found academics to be the most commonly cited, with more than 20 percent of all responses.

Virtual school has filled an important gap, but it is not equivalent to in-person school, and it is not without collateral damage. Some children have expressed anxiety about test-taking and failing grades. Some have stopped caring altogether. Parents tell us their children no longer participate or turn in their homework. They lie in bed during virtual class – distracted by social media and electronics.  The end product is apathy and depleted self-esteem. Another untold loss – the loss of joy-in-learning.

While the early phases of vaccinations for health care workers, elderly, and now teachers have provided some hope for improvement, the reality on the ground is an ongoing pandemic in most parts of the country and an uncharted path to school re-opening. Also, since the vaccine has only been tested on children 12 years and older, our youth will likely be one of the last groups vaccinated.

In March 2020, the revolving door of the ER stood still; today, it is spinning with children who have lost their love for life.  Everything important has been paused or vanished.  A recent article in Pediatrics shows that suicide attempts in children age 11-21 years more than doubled from March 2019 to March 2020. For us, these numbers are more than just data reported in studies. These numbers have faces and names – they are children with loving parents – children who just want to “disappear.”

Children are resilient. They survived 911, Hurricane Sandy, and even the first wave of COVID-19 – continuing to laugh, play, and discover joy in life. But they are not designed for prolonged isolation. Quite the opposite – they are wired to interact with the physical world.  It’s how they learn, how they experience happiness, and how they develop a sense of themselves. Children should not want to die.  They should have dreams and plans.

There is no quick fix to this sweeping crisis – no medication, no procedure. As ER physicians dedicated to healing children, we often feel impotent. Our patients are victims of COVID-19, and we must bear witness to their particular grief.  It is not the loss of life we have focused our energies on – death from respiratory illness, heart injury, or blood embolism – but it is just as deadly.

We must sound a call to action: Focus the spotlight onto our children. We must fight for them as fiercely as we have fought the pandemic. We must provide a solid foundation for children to regain their footing.  We must replace their losses with meaningful acts. We must harness their resilience and bolster their sense of self. They need to not only hear – but believe – they are still a priority during the pandemic. They need to be seen and not feel invisible. We need to reach out and throw them a lifeline: to acknowledge their struggles, listen, validate, nurture, give them space to catch their breath and allow them to heal. It is in our hands to ensure that future generations are healthy and whole.

A critical step includes the return to in-person school for the many who have endured months of remote learning.  As Dr. Anthony Fauci recently stated, we must “try as best as possible within reason to keep the children in school, or to get them back to school.”  This position, endorsed by the American Academy of Pediatrics and the Centers for Disease Control and Prevention, must be considered paramount in all discussions of pandemic safety.

We know the ER’s revolving door will continue to spin for so many children and adolescents who seek help in the heat of their personal crisis. Some will need to stay in the hospital – to heal their bodies and minds and even fight for their lives.  Some – the lucky ones – will be able to go home, but by no means are they out of danger. Their lives too are threatened, and they will need ongoing support from parents, family, friends, teachers, and mental health providers – who will likely care for them across a virtual platform.

Human contact has been gravely compromised this past year, and we, as pediatric ER doctors, as members of our community, and as parents, are seeing the fallout in the children we care for.

Our ER shift came to an end, and we exited through that same revolving door. The fall leaves swirled in the wind, carrying our good-byes, muffled further by our masks. We reassured each other over the din and distance: better days were ahead.

May those days come soon.  So much still hangs in the balance.

Rachel Kowalsky, Mary Birmingham, and Shari Platt are pediatric emergency physicians.

Image credit: Shutterstock.com