Dying of loneliness: the COVID-19 epidemic in children and adolescents [PODCAST]

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“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.”

Rachel Kowalsky and Shari Platt are pediatric emergency physicians.

They share their stories and discuss the KevinMD article, “Dying of loneliness: the COVID-19 epidemic in children and adolescents.”

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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 Rachel Kowalsky and Shari Platt. They are pediatric emergency physicians, and together with Mary Birmingham, they co-wrote the KevinMD article “Dying of loneliness: the COVID-19 epidemic in children and adolescents.” Rachel and Shari, welcome to the show.

Rachel Kowalsky: Hi, thanks for having us.

Kevin Pho: So before we get into the article, I’m going to ask each of you to share your story and journey to where you are today, and maybe one thing that surprised you over the past one-plus year of the pandemic. Rachel, why do you go first?

Rachel Kowalsky: Sure. I’m Rachel Kowalsky. I’m a pediatric ER physician at Weill Cornell Medicine. I’ve been there about 10 years, and one thing that really surprised me during the pandemic was the way in which people came together inside of the hospital. They kind of came out of their silos and worked together in settings they were completely not used to working in. We had all different types of surgeons and subspecialists come down to the ER to work alongside us. We shared space with other groups, and we just saw some amazing flexibility and teamwork.

Kevin Pho: And Rachel, that is one of the themes that I’ve heard many physicians say, about how everyone who previously was siloed came together really, really well during the pandemic. What are some examples of the clinicians and the administrators in your institution coming together during the most dire times?

Rachel Kowalsky: We really developed our telehealth program. We already had a telehealth program, but we really enhanced it during that time and built it up. Together with psychiatrists, ENTs, colorectal surgeons, and just people who were out because they themselves had COVID but weren’t as sick, we all staffed the telemedicine phone calls. So we were kind of on a text chain together, and we would ask each other questions and kind of support each other and check in with each other. It was just so interesting. I met dermatologists and people I really don’t typically work with in the emergency room, just through doing telehealth with them.

Kevin Pho: And Shari, can you just briefly share your story and journey to where you are today, and one thing that surprised you during the pandemic?

Shari Platt: Sure. So I’ve been at NewYork-Presbyterian/Weill Cornell Medicine since 2001, and I have gone through many disasters, but nothing even close to what we’ve just been going through with the pandemic. Something that surprised me, and I agree with Rachel, was the teamwork and the camaraderie. And I want to add something to the telemedicine story, which is that the pediatricians were seeing patients of all ages. Our oldest patient was 93 years old, which was a lot of fun and very interesting. But really, everybody, all specialists, came together to work for a unified goal. So I agree with that.

I think what was the hardest part for us was the effect of the pandemic on children. Initially, we were incredibly relieved, because as everybody knows, initially the pandemic, COVID-19, did not affect children in the direct way that it was affecting adults. As you know, then eventually they did develop MIS-C, or multisystem inflammatory syndrome. But at first, it was really hard to be a pediatrician, because we wanted to help, but we felt a little bit lost. There were no children coming into the ER, and there was definitely a sense of loss of our specialty and of our skill set. I think we felt a little bit like we were floating, like we wanted to be helping, but we didn’t exactly know how. It was definitely mixed emotions, but of course, there was tremendous relief that children were essentially spared initially, which leads us to the article, of course. But certainly, there was a lot of conflicting emotion at the beginning.

Kevin Pho: And Shari, tell me what the picture is now. We’re speaking in the middle of June. What’s the snapshot of the pediatric ER now?

Shari Platt: So overall, across the country, our numbers, our total volume in pediatrics, has dropped, but we’re coming back. The number of children that we’re seeing now is rising as social distancing and social isolation change. For a very long time, we were not seeing respiratory illnesses. We were not seeing injuries. Children were not in playgrounds, and they were not having head trauma, and all the very common things that are our bread and butter in emergency medicine were not coming into the emergency department. And last night, New York City came back open, which is very exciting. So I think as our country and our communities open up, our field will revive, and we’re grateful for that.

Kevin Pho: Now, both of you are co-authors, along with Mary Birmingham, of this KevinMD article, “Dying of loneliness: the COVID-19 epidemic in children and adolescents.” Rachel, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of how the three of you came together to co-write it?

Rachel Kowalsky: So Dr. Platt and Dr. Birmingham and I were working a shift together in the ER. This was in the fall of 2020, just before Thanksgiving. Over the summer, there had been a little bit of relief from COVID, because people were able to get outside and see one another outside and just get some exposure to sunlight, and rates went down a little bit. But in the fall, there was this sense of dread that a second wave was coming, and the weather was getting colder, and people were stuck inside more and more. So that’s sort of the context for it.

On this one particular shift, we just saw a lot of cases that were related to mental health and behavioral health, kids who were really struggling. And we kept meeting. We would go out to see a patient and then come back into the room where we all work, and we would sort of look at each other and say, “This is really different, and this is significant. This is a problem. We’re seeing a lot of children and adolescents who are in distress.” We felt like we needed to talk about it. The first thing that one can do, I think, if you want to change something, is to name it and describe it. So that was sort of what we set out to do here.

We described what that shift was like. We gave examples of some of the types of patients that we saw, and we talked about what it was like to see them right in front of us, as opposed to having seen data about the increasing rates of mental health emergencies. The children were right there in front of us, and so it felt very immediate and very striking. So we wrote about them, and we wrote about what seemed to be happening: that these children and teens were really disconnected from everything that mattered to them, from their schools, their social groups, their friends, and their extended families. And they were also disconnected at the same time from the same mental health services that might have been able to support them, because a lot of children became unable to access those supports as school went away and in-person medicine in large part went away.

So we described that, and we talked about our hopes for the future, specifically about how important it would be to get children back in school, and also about just shining the spotlight on children, turning to look at them and notice what it is that they’re going through. Because, of course, we were so focused on all the adults who were in respiratory distress, with severe cardiorespiratory problems from COVID. We just encouraged the readers to kind of turn back and look at children and make sure that we were thinking about them and supporting them.

Kevin Pho: And Rachel, without giving away too much identifying information, can you just paint us a picture of a sample case of some of these children that you would see in the emergency room?

Rachel Kowalsky: Sure. So it runs the spectrum from just increased visits for psychosomatic complaints, like some abdominal pain or headache, and children sleeping more than they typically would or less than they typically would. But then the spectrum goes all the way to real suicide attempts, serious eating disorders, and children cutting themselves. Yeah, we saw a lot of children who were really suffering.

Kevin Pho: And Shari, so now that you have this influx of children under mental distress because of the pandemic, tell us some of the questions you would ask them and some of the things that you would do next.

Shari Platt: Yeah, so I think part of the point of the article is to humanize it, right? Because I agree, there are studies out there, and there’s a lot of data, but this is a real thing that families are going through, children and their parents. It’s really devastating, and it’s not stopped. It is ongoing, every day. It’s been talked about on national forums that we are really in a serious mental health crisis for our teens, and even our young teens. We’re seeing eight-year-olds who want to die. You know, that’s not OK, and that’s not common. I mean, we were in a mental health crisis prior to COVID, but what we’re seeing now is a fallout of a year-plus of isolation, and we don’t have experience with this. We don’t know how this type of sense of loss of normalcy is going to really affect our children and our future generations.

So, opportunities to improve. Obviously, the very first thing, and we can’t have this without at least saying it once: Get vaccinated. For the children who are of eligible age and medical condition, we strongly urge the vaccine. It’s safe, it’s effective, and that is definitely the first step to really opening up the door to normalcy. Other things are to recognize it, to think about it, and to have those hard conversations. I think a lot of people tend to think, “Oh, kids are resilient. They’ll go outside, play ball, and they’ll be fine.” And I worry about that, because I think that we as a society really need to think about it and to recognize it, and to ask our kids, “How are you doing?” Ask open-ended questions, like, “This has been hard. How are you feeling?”

And it might not be a conversation for the dinner table. It might be a time when kids feel they can open up. You know your kids, when they open up. It might be late at night or on a car ride, or some time when they’re really feeling safe and want to open up. And for providers to include that as part of their screening process. Everything is different now, so I think it’s really important to ask kids. I’ve had kids who have not seen a friend in months and months. They don’t leave their room. They’re on Xbox. They’re on social media, which has its own story to tell. So I ask these questions all the time now in the ER. I’m always asking them: What’s school like? How are they feeling? Are they seeing their friends? Did they miss graduation? There are so many kids that, I think, we need to just think about it.

Kevin Pho: And Shari, when you ask these open-ended questions to these kids in the emergency department setting, what are some red flags that you’re looking for? And if you find these red flags, what kind of resources do you offer them?

Shari Platt: Great question. Red flags are kids who maybe don’t express it or are not as willing to open up. Some of them sound really confident. They say, “I’m fine. I’m seeing my friends. I’m doing things.” But you can sort of tell when kids are not able to really express themselves. And then there are definitely kids who come in who tell us that they want to die, or that they just can’t do this anymore, that it’s too hard. We need to think about that and take it seriously, obviously.

Resources is a hard one. We have children waiting for days in the ER for inpatient hospital beds. There are definitely fewer psychotherapeutic outpatient resources than we’ve had before, and many of them are virtual. So it’s a matter of reaching out to our psychiatry and psychology and social work colleagues, and trying to develop relationships and partnerships so that we can provide outpatient support for the children.

And then I think school is a really big thing. I hope the schools are listening and take it seriously, and recognize that kids who are dropping off in their academics, kids who were previously doing really well and now are just not submitting assignments, their grades are falling. We need to think about, instead of being punitive, being supportive. I think that’s really important for the schools to recognize.

Kevin Pho: We’re talking to Rachel Kowalsky and Shari Platt. Both are pediatric emergency physicians, and together they co-wrote the KevinMD article “Dying of loneliness: the COVID-19 epidemic in children and adolescents.” Rachel, we are slowly opening up, and I think that’s very, very encouraging. There are summer camps that are starting to open, and next year’s school probably will be in person. So can you foresee the next three to six months for these children? And what are some things that we could do as parents to help them recover from this mental distress?

Rachel Kowalsky: So I think it’s great that summer camps are starting to reopen. I work as a doctor at my son’s summer camp, and I can see how happy he and his friends are when they can be together outdoors. So I think over the next three to six months, we’re going to see children starting to feel better. I hope that that’s the case as vaccination rates increase and as the warm weather comes, so that children who aren’t vaccinated can still be together outdoors.

I sincerely hope that schools will open fully in the autumn, because I think that’s going to be really important as well for just returning children to routine, to normalcy, and getting them reconnected to their peer groups, with all of the psychosocial development that’s supposed to be happening during the years, to get them back on the rails. But I think we can be cautiously optimistic.

Kevin Pho: So I’m going to ask both of you for your take-home messages to the KevinMD audience, and maybe something that you’ve learned over the last year-plus that you could apply going forward. So Shari, let’s start with you. What’s your take-home message, and something that you’ve learned over the pandemic that you can apply going forward?

Shari Platt: Sure. So, I mean, with regard to children and mental health, I think our take-home message is to keep an eye open for it: to recognize it, acknowledge it, appreciate our kids, and keep an open line of dialogue so that children feel safe and supported and not invisible. I think that’s going to be the most important take-home message.

Kevin Pho: Good. And Rachel, what’s your take-home message to the KevinMD audience?

Rachel Kowalsky: Well, I completely agree with what Shari said. Just making sure that we continue to really look at our children and really see them and check in with them, and that we continue to do so even as the world opens back up, even as we are able to vaccinate them, because we still don’t really know how this lost year is going to play out as the years go by. One thing that I learned was just how resilient we are. It feels great to be slowly exiting this year-plus and seeing, “Oh, we did that.” And it kind of makes me think, “OK, we’re up to whatever comes our way.”

Kevin Pho: Rachel and Shari, thank you so much for joining me and sharing your insight, and thanks again for being on the show.

Rachel Kowalsky: Thank you so much for having us.

Shari Platt: Thank you. Have a good day.

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