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Greg Fritz, MD (Host1): Recently, times have been tough for most of us and even harder for some of us. And as the pandemic drags on, a light at the end of the tunnel becomes harder and harder to see, but this will end, we've got to believe, at least, eventually. And while physical health is important, many of the measures being taken to protect physical health have had a negative impact on mental health, especially for our kids. Social isolation, virtual school, wearing a mask all the time, loneliness and many more changes have an impact on the kids. Now more than ever, parents are finding themselves ill-equipped to support their kids in this struggle. That's why supporting parents is one of the most important things we can do. So they in turn, can support their children with real confidence that they're doing it well and effectively. So, today we're here with Dr. Karyn Horowitz, Chief Medical Officer at Bradley Hospital. She has talked extensively on the topic of supporting parents and caregivers since the pandemic began. And she has insight on the topic of how to support your child's mental health during COVID-19.

This is Mind Cast, Healthy Mind, Healthy Child, a podcast from the mental health experts at Bradley Hospital, leaders in mental health care for children. I'm Dr. Greg Fritz with my colleague, Dr. Anne Walters.

Anne Walters, PhD (Host2): Karen, thanks for being here today to talk about parents and how we can best support them to in turn support their children's mental health during COVID-19. As Greg mentioned earlier, one of the ways we can support children is to equip parents and caregivers with the tools and strategies that can help support their children as we all navigate these challenging times together. But first, some questions for you. How do I know if my child is suffering, perhaps even silently?

Karyn Horowitz, MD (Guest): Well, I always like to tell parents that they know their child better than anybody else. There's a lot of people that interface with their children. There could be school teachers. There could be pediatricians, there's their friends, but really ultimately parents are the experts on their children. So, I just always remind parents that if you have any concern that your child seems different than usual, then you should pay attention to that.

Host1: So, let's say that happens, they notice something and you wonder, is my child depressed or is it anxiety? What's the difference and how can we distinguish between those?

Dr. Horowitz: Well, I think that, I'm really glad that you asked me about depression and anxiety in particular. You know, unfortunately what we know is that both depression and anxiety are incredibly common in children and adolescents. In fact, about one in five girls have depression and approximately one in 15 boys, currently have depression, whereas anxiety is even more common. It's about two in five girls and one in four boys. So, it's incredibly common. And during COVID, we know it's actually even more, that there's even more children that are suffering with depression and anxiety. So, I think your question is how do we know? How do we know? Because what we do know is that it's really normal for kids to feel sad and it's really normal for kids to worry, especially right now. There's a lot of things to feel sad and worried about. But sometimes that sadness and that worry gets to the point that it really starts to impact their ability to function. And so at that point is when we really need parents to take note and to get help.

Host2: So, in thinking a little bit about what a bigger problem would look like maybe particularly with teens, what might be some clues and warning signs that parents can pay attention to?

Dr. Horowitz: So, the things that parents can pay attention to, would be just to look at the way that your child functions throughout the day. So, pay attention to their sleep. Are they having a harder time than usual falling asleep? Are they having a harder time than usual staying asleep? Are they waking up too early? Are they sleeping throughout the day? Are they taking really long naps? So, pay attention to their sleep. How are they doing with their eating? Are they eating more than usual, less than usual? Are they gaining weight? Are they losing weight? Are they losing significantly more weight? So, just paying attention to that, then you can say how's their energy? Is their energy typical for them, more than typical, less than typical? And, the other thing that you can take note of is how they're interacting with other people. So, are they more irritable than usual? Are they isolating more than usual? And I think that the reason that I hesitate right there is that during COVID it was hard because we were sort of asking kids to isolate. So, what does isolation look like during COVID? I think that the electronics afforded our children a little less isolation on the one hand.

And on the other hand, it really, set them up to be vulnerable to having too much electronics time. But I think that if you notice that in their interactions with you, that they were more irritable than usual, or even that they weren't trying to interact with their friends at all. And certainly now that the world has opened up a little bit more and hopefully kids are back to school, are they finding ways to interact with their friends? Are they meeting up with them outside? Are there things that were interests of theirs that they've been able to re-engage in or do they not seem to be interested in things that they used to be engaged in? So, I think they just need to pay attention to who is their child and do they seem different than they normally seem like for you.

Host1: So, we hear a lot about self-care and it's on everybody's list of things to do and pay attention to. But what does that mean for teenagers and how about for oneself?

Dr. Horowitz: I'm a really strong proponent of sleep. I think that everyone needs to sleep and everyone needs a good night's sleep and everyone needs to protect their sleep. So, I think self-care is about protecting your child's sleep and protecting your sleep. I definitely recommend to families that electronic devices are parked somewhere about an hour before bedtime, not in children's rooms. We know that for each device that's in a child's room, you decrease the total amount of sleep that they get each night.

So, we really recommend electronics, not being in bedrooms and really protecting sleep. Reasonable bedtime, we know teenagers are going to tend to go to sleep a little bit later just because that's the way their clocks work. But you know, really shooting for eight to 10 hours of sleep a night for your child would be very important. So, that's the top of the list for self-care.

Same goes for adults, park your phones, park your electronic devices, keep them out of your bedrooms. Other things that people could do in terms of their self-care would be to think about exercise. I think it's really good to be active and everyone can be active in the way that is comfortable to them. At a minimum, I like to recommend that kids and their parents are outside for about 20 minutes a day. That vitamin D that they get from the sun is very important and it can be very important for their health. I know that initially at least, in the pandemic, people were inside quite a bit and on their electronics quite a bit and just stepping outside it can be really helpful. And I think some of those tendencies may be a little bit more hardwired right now. So, fresh air is important.

Host1: The glow from the computer doesn't supplant the sun?

Dr. Horowitz: Unfortunately it does not. And then I think other things for self-care are really engaging in activities that bring you joy and pleasure, things that make you feel good about yourself. Something that you can do each day, that you can complete and feel okay about. And it doesn't need to be big. It could be small.

Host2: You know, I think during the pandemic, routines became so skewed for children and for families, because all of the things that kind of mark our days were changed and we've really noticed so much of an impact of those changes on sleep. Just, slowly sleep times get later and later and you figure, well, you don't have to get up, so it's not as big a deal, but it really does impact kids' mood substantially.

Dr. Horowitz: Absolutely. And I know that in, in my family, one of the things that happened from slowing down is that we were actually able to make one change in a positive direction, which was reinstituting family meals. And, I think if you can also create some structure, if possible, I know this isn't possible for all families, but sometime each day that you're all sitting down together and sort of checking in in a neutral territory, food can be good and a healthy place to do that. That's another positive thing that you can do to create some structure.

Host2: So, you mentioned, more time online and putting in some safeguards to make sure that, that doesn't interfere with some of the self-care suggestions; but with prolonged time online, online bullying and cyber bullying has certainly become more prominent. What should parents be on the lookout for there?

Dr. Horowitz: This is a really important question. And unfortunately, over time, with increased access to electronics, you know, like I said, there are certainly some upsides. I think that we can see how people were able to remain connected with other people through their phones, through Zoom, through texting, through all kinds of social media, during the pandemic. And I think that was really important. I can't imagine what it would have been like before we had access. However, we also know that more time on these devices has led to really a worsening of some of the pressures that kids can feel from social media. And, we as adults know that what people post on their social media is often curated.

People use filters, people only show the best of themselves or make it look like things are going even better than they are for themselves. But for the people on the other end, it can really enhance that fear of missing out or what kids call FOMO and it can be really painful for kids. In addition, during COVID, eating disorders are on the rise. So, we know that some of what's put out there on Instagram or other social media areas can actually lead kids to having worse mental health. Not just the fear of missing out, but sort of even, encouraging them to engage in unhealthy behaviors with the idea that they may end up feeling better because they'll look better.

But in fact, they end up feeling worse and being more ill. So, cyber bullying is quite common. About a quarter of all kids in middle school and about 15% in school age kids end up experiencing some kind of bullying. It can happen via social media, video games, the chats on video games, it can happen through video sharing and it can be very challenging for parents and adults to monitor what's going on on social media.

I think that what parents should do is be sure to talk to their children about it and what's happening on their social media whenever possible. And if it does come to their attention that their child is being bullied, that they need to think about how to support their child in helping to get it to stop.

So, sometimes that can mean supporting your child to have a difficult conversation with an important adult at a school. Sometimes it means supporting your child to go to the police about the issue. Something important that you can do is be sure that you have screenshots and have retained any evidence if you believe that your child has been bullied in some way electronically. And you don't want to make your child feel that you're invading their privacy, on the one hand. And on the other hand, you really want to work with them to help them feel safe and socially protected.

Host1: So, in addition to disordered eating and things like that, what about other forms of self-injurious behavior? I know parents are worried about that. But what are your thoughts there and advice for parents?

Dr. Horowitz: One thing that kids will talk about and is unfortunately something that we're seeing a rise in is in self-harm, kids engaging in different kinds of self-injury. This can be cutting for example, or other forms of injuring your body in some way. And the important thing that I want parents to know about that or other adults to know is that it is something for them to pay attention to. That when their child is engaging in self-harm or self-injury, it is a way that they are communicating that there is something that is distressing to them, that they are unable to manage in a more effective way. That their ability to cope is not as great as the stress that they're experiencing. So, I just always want parents to know that if their child is engaging in that kind of activity to take it seriously. It's a form of communication. It's a way that they're asking for help in the best way that they're capable of at this time.

Host2: So, once parents recognize some of the things that you've been talking about, especially around distress and perhaps have opened up these channels of communication, but are still pretty concerned and think that the family needs some assistance, where should they go for help?

Dr. Horowitz: I'm glad that you're asking about that because the thing about anxiety and depression is, a little bit of worries, some depression can be common, but when it starts to impact your child's ability to function in life, their grades are slipping. They're not as social. They're really irritable. They can't sleep. All of these things start to happen. Sometimes they can feel incredibly hopeless and we'll even start to have kids expressing suicidal thoughts, engaging in suicidal behaviors. And, we would really like to catch it before it gets to that point.

So, what I want parents to know that anxiety and depression are medical conditions. And just like diabetes or high blood pressure, there are treatments for them. And so if your child is experiencing this kind of anxiety and depression, and it seems to be getting worse, there is treatment available. They can get help. I typically will recommend a great place to start is with your pediatrician. The pediatrician is someone that has, in many cases, known your family and your child for many, many years. And they often will know of mental health resources in the area where you live. They can also help you to sort out what might be typical behavior for your child's age, and what may be beyond what's typical. So, they can also help you to sort out whether something is at the stage of getting additional support.

What I want parents to know that there are things that they can do to protect their kids from suicidal behavior. In addition, to getting help from your pediatrician or another mental health professional, you could do a few things at home and I call it suicide proofing your home. So, what I would like for people to consider doing, is locking up any medications that you do not use regularly, or that could be dangerous to your child, even if you do use them regularly. Another thing that you could do, is if you have a gun in your home, to be sure that the gun is locked and that ammunition is stored separately from the gun. Lastly, you don't realize how important just listening to your child can be. So, if you can just take the time to talk with your child and listen to them and provide support, that can provide a huge amount of protection to your child and their mental health.

Host1: Karyn thank you. Very helpful. I think some people say that there are two pandemics happening right now, with children's mental health being the other pandemic that we're witnessing. In many ways, this is just the tip of the iceberg. As we continue to navigate the fallout on the different ways our kids have been impacted. What you've outlined here are some very effective tools to support parents as the first line of defense and keeping their kids safe. As I think you've said, at other times, if you see something, say something and parents can do so much just by being right on top it.

So thanks very much for your time. And if you listeners found this podcast helpful, please share it on your social channels and check out our entire podcast library at bradleyhospital.org/ podcast for topics of interest to you. This is Mind Cast, Healthy Mind, Healthy Child, a podcast from the experts at Bradley Hospital, Dr. Gregory Fritz with Dr. Anne Walters. Thanks for listening.