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A Growing Second Pandemic: The Children’s Hospital and Board’s Role in Emotional Well-Being

The fourth quarter of the last academic year brought many changes for students. COVID-19 was a new pandemic that was already starting to heavily impact the United States. Many teachers quickly adapted their classes to fit a remote learning format, and distance learning soon became not only the preferred but the only way of providing instruction to students in many districts—a significant change from how students had learned in a classroom setting.

New information updates and learnings still occur daily. The virus does not behave the same way as previously encountered coronaviruses; it also displays crucial differences from influenza viruses, with longer times of incubation between cases and higher secondary-infection rates within individuals. As a result of these complications, there are, as of yet, no licensed vaccines or therapeutics to fight the disease.1

Time for a Broader Focus

Much of the emphasis to date has been on COVID-19 transmission, but going forward, there will need to be a much broader focus on how the pandemic is affecting kids.2 Population health focuses on both the conditions and factors that influence our society. During a pandemic, the physiological aspects of care become the immediate priority as a large-scale infectious outbreak causes economic, social, and political disruption in addition to an impact on health. Since March, the COVID-19 pandemic has taken a toll on our youth in a broader context with limited peer interactions, predominantly interfacing with a computer screen, and routines/structure taken away. Gatherings at events such as birthday parties, movie theaters, and eating at restaurants rapidly presented a risk of being in too close contact with others. All those events in combination became potential transmission activities. While youth may have verbalized that COVID- 19 wasn’t directly impacting them, the isolation, depression, social distancing, and time spent away from peers are all changes that have influenced the end of their academic year, summer, and are continuing through the new school year for many. As a result, their emotional well-being needs to become elevated as a concern for greater watchfulness and monitoring. The demise of emotional health from COVID-19 is quickly becoming the second pandemic.

The Concern of Youth Suicide Prior to COVID-19

Ten percent of high school students attempt suicide and more young people die from suicide than car crashes.3 One of the strongest risk predictors of future behavior is past performance. If a child has attempted suicide in the past, it is a high predictor of death. Hospitals have a responsibility to work with others in the community to form a network that can help protect youth who need services and support parents seeking help. Individuals with suicide attempts can receive treatment in children’s hospitals—both the emergency department and inpatient setting. Staff should remain diligent in assessing the past and present well-being of individuals seeking care in these settings. In the past decade, the number of visits of youth at risk has doubled while resources to this population have dwindled.4 For this reason, ensuring assessment happens at

Children’s emotional well-being needs to become elevated as a concern for greater watchfulness and monitoring. The demise of emotional health from COVID-19 is quickly becoming the second pandemic.

critical points of service is even more important to identify a highly vulnerable population.

Emotional Well-Being- Related Risks

Over half (53 percent) of Americans reported in July that their mental health has deteriorated during the pandemic—a 21 percent increase since March 2020.5 For adults, this includes difficulty sleeping or eating, increasing alcohol or substance abuse, and worsening of chronic conditions. Isolation and loneliness may be an increased risk factor for households with adolescents and the elderly.6 Existing and new barriers to accessing mental health services need to be considered when assessing individuals who are at-risk and helping them obtain the care needed.

September was suicide prevention month. Raising personal awareness and providing diligence in assessing every patient is just the beginning of adequately supporting the emotional well-being of youth during COVID-19. Most individuals with mood disorders are undertreated or untreated.7 Prediction of those who are at highest risk remains difficult; however, up to two-thirds of all suicides occur in individuals who have a mood disorder.8 The COVID- 19 impact on emotional well-being will not be time-limited to finding a treatment or vaccine for the pandemic. The consequences that occur from loss, financial, and social turmoil will last long after the post-peak and post-pandemic period.9

Trying to Navigate Adolescence When Teens Don’t Want to Talk

Absolute numbers related to suicide and COVID-19 will take some time to collect as the pandemic continues. Early insights can most readily be ascertained from calls to national suicide hotlines and crisis lines. Since the onset of COVID- 19, some support lines are already experiencing up to a 300 percent increase in call volume.10

The obstacles that youth face can differ from those of adults. Developmentally, as youth reach their teen years, they start to form their own identity. Adolescents are in a stage of trying to figure out who they are as individuals. This is often accompanied with an increased need for privacy; there may be less time spent with family and more time spent with friends. Keeping support systems in place such as family, friends, and the community remains important, and peer pressure may become heightened at this age. For teens that want to connect with another teen, Youthline is a free, national teen-to-teen crisis line that connects individuals. Youth can call, text, chat, or email, and the helpline is available to provide listening and support to teens during COVID-19. Any concern that is bothering a teen can be discussed privately. The helpline resource is staffed by volunteers and intended for use by youth ages 11–21. The chat function can be accessed by going to the Youthline Web site. (See sidebar for a listing of crisis numbers, as well as clinician resources.)

The Impact on College Student Well-Being and Addressing Racial Disparities

College students are returning to campus. This can be a time of confusion and heightened anxiety as peers may congregate in groups with or without masks, wanting to fit in, yet also wanting to remain self-protected with concerns of personal safety. Individuals may take social distancing to the extreme. More than half of college students participating in the American College Health Association’s Spring 2020 National College Health Assessment reported receiving mental health services from their campus health or counseling center in the last year.11

Higher levels of depression, financial insecurity, and mental health problems including disappointment, sadness, stress, and anxiety are leading to increased concerns beyond the transition to college or attending classes via remote learning. COVID-19 is also having a disproportionate impact on Black Americans and other people of color, who already have higher mortality rates from the virus and unemployment. Understanding COVID-19 in the context of disparities becomes important for adequate screening and partnering with resources in the community. Long- standing differences in racial and ethnic minority groups can create risk and inequality by not having the same opportunities to physical, economic, and emotional health.12 With schools moving to an online format, some will find difficulty making the transition. For example, the resources necessary for success can be constrained with 45 percent owning a computer or desktop and 66 percent having a broadband Internet connection, and many parents not being able to stay home, Black parents are at a disadvantage in educating their children. Individuals who do not have access to continued learning over the summer are also less inclined to maintain achievement made during the academic year.13

Why the Hospital Role Is Important

When individuals attend post- hospitalization mental health services, they have a 75 percent less chance of a future suicide attempt. Included in post-hospitalization planning and care is safety planning, after-care planning, mental health treatment, and strategies for prevention and improving mental health and well-being.14 It is a responsibility of hospitals and providers to identify individuals who need help and ensure that they obtain the care and services needed without falling through the gaps of our healthcare system.

There are steps that clinicians and hospitals can take to help individuals who are struggling during the pandemic:15

  • Review the suicide prevention literature and clinical resources. Become familiar with the most recent information and be up to date on approaches for intervention and treating suicide.
  • Become fluent in crisis response therapy and resources in the community. In addition to community support, are there supplemental ways of support that are being made available to individuals in the community such as through apps for contact between therapy sessions?
  • Be aware of those with a prior history of suicide or suicidal ideation, but also become hypervigilant in assessing for those who may be struggling. These are uncertain times. Those who may not have been at risk can easily be at risk with today’s environment and all the different challenges that individuals are facing. Screen every patient that you see in the clinic/care setting. If suicidal ideation is suspected, an action plan is needed.
  • Inquire about the importance of spirituality and assess the individual from a holistic perspective. Weekly religious service attendance has been attributed to a fivefold lower suicide rate. Many individuals have been separated from their congregations, ministry, and church support infrastructure. If this has become an area of lapse with COVID-19, connecting the individual with their congregation or religious leader may help combat feelings of isolation and hence suicide.16

School staff are trained in discerning at-risk and suicidal behavior. Teachers, school psychologists, counselors, social workers, administrators, and crisis response team personnel can be part of the broader network of support to youth both for directly providing them with support and as a link to other resources in the community. While many students have become remote learners, the infrastructure of support is still in place as an additional resource that can be leveraged for seeking help and facilitating outreach to other types of support.Even if minimal, once an individual has been deemed to be at-risk, the school, family, friends, and medical team needs to help build resiliency to lessen potential ideation and behaviors. Helping individuals to cope and recover from difficulties includes equipping youth with:17

  • Family support and cohesion, including good communication
  • Peer support and close social networks
  • School and community connectedness
  • Cultural or religious beliefs that discourage suicide and promote healthy living
  • Adaptive coping and problem- solving skills, including conflict-resolution
  • General life satisfaction, good self-esteem, and sense of purpose
  • Easy access to effective medical and mental health resources

The Board’s Role: Navigating Where You Are Now

Communities, hospitals, and health systems are still treating COVID-19 patients daily and maintaining a state of readiness for additional viral outbreak surges. To date, boards have been ensuring that there is an effective COVID-19 emergency preparedness plan; infection identification, management, and prevention; a crisis communication plan; safe, healthy, and sufficiently trained workforce; and ethical management of scarce resources. Additionally, the financial implications and hospital leadership’s response has likely been recently under consideration.

The board, along with senior management, sets the tone in addressing the pandemic. With COVID-19 levels starting to balance out to more manageable levels, boards should consider shifting to a “look-back” of what their response was during the pandemic. Doing this without delay is particularly timely, prior to the peak of flu season that often happens between December and February. While assessing the past six months, an evaluation of the response to COVID-19 should be done, gaining new understandings to lessons that can be learned, and any adjustments that are needed.

Leadership should be calm yet positive, and optimistic but realistic. Incorporating insights that have occurred into policies, processes, structures, communications, and having resources in place may be items to adjust as well. A consistent message to all stakeholders and the community can instill confidence that the organization is capable of successfully overcoming any challenge that presents itself going forward.

The COVID-19 pandemic brought changes that were not anticipated for this year. Not only has it caused social, political, and economic disruption in addition to having a widespread impact on health, the toll it has taken on the youth in society is yet to be fully realized. Adolescence is a time of transition and identity formation. During a time of crisis, this can be further fraught with anxiety, depression, and result in a loss of certainty about the future. Emotional well-being is the next priority for focus. Not only is this a responsibility for clinicians and others within the community, the board has a role ensuring a strong positioning for any further strain on resources, looking back and learning from the past months, and making any adjustments while also ensuring staff are working from a state of readiness to handle a potential influx of people in crisis who need help. Becoming fluent in the resources that are available, the current best practices of assessment and intervention as a clinician, and similarly the board safeguarding that workforces are adequately trained to handle a fragile population amidst what has been dwindling community resources over time, becomes a responsibility that each needs to shift toward as the present environment begins to stabilize.

1 World Health Organization, “Q&A: Influenza and COVID-19—Similarities and Differences,” March 17, 2020.
2 Nirmita Panchal, “The Implications of COVID-19 for Mental Health and Substance Use,” Kaiser Family Foundation, August 21, 2020.
3 Stephanie Doupnik, “Examining Hospitals’ Role in Preventing Youth Suicide,” Children’s Hospital of Philadelphia, September 10, 2018.
4 Ibid.
5 Panchal, August 21, 2020.
6 Ibid.
7 Ronald C. Kessler, Kathleen R. Merikangas, and Philip S. Wang, “Prevalence, Comorbidity, and Service Utilization for Mood Disorders in the United States at the Beginning of the Twenty-First Century,” Annual Review of Clinical Psychology, Vol. 3, 2007; pp. 137–158.
8 Erkki Isometsä, “Suicidal Behavior in Mood Disorders—Who, When, and Why?,” The Canadian Journal of Psychiatry, March 1, 2014.
9 World Health Organization, Pandemic Influenza Preparedness and Response, 2009.
1o Mariah DeYoung et al., a href=”https://www.pinerest.org/media/Preparing-Michigan-for-the-Behavioral-Health-Impact-of-COVID-19-Report.pdf” target=”_blank”>Preparing Michigan for the Behavioral Health Impact of COVID-19, Pine Rest Christian Mental Health Services, June 13, 2020.
11 American College Health Association National College Health Assessment III, SPRING 2020 Reference Group Executive Summary.
12 CDC, “Health Equity Considerations and Racial and Ethnic Minority Groups,” July 24, 2020.
13 Bre-Ann Slay, “COVID-19 Will Intensify Education Inequities for Black Students,” Diverse, May 20, 2020.
14 Doupnik, September 10, 2018.
15 Rebecca Clay, “COVID-19 and Suicide,” American Psychological Association, June 1, 2020.
16 Mark A. Reger, Ian H. Stanley, and Thomas E. Joiner, “Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm?,” JAMA Psychiatry, April 10, 2020.
17 National Association of School Psychologists, “Preventing Youth Suicide: Tips for Parents and Educators.”