Mental health concerns have been on the rise in children, even before the pandemic. Today, Robert Althoff, MD, Ph.D., and Erica Gibson, MD, discuss the kind of effect the pandemic has had on pediatric mental health.
Pediatric Mental Health During the Pandemic
Transcription:
Host: According to the Centers for Disease Control and Prevention, mental health concerns like depression and anxiety were on the rise in children ages six to 17 even before the pandemic. Now, more than a year into the crisis, research leaves little doubt that ongoing social isolation and loneliness during COVID-19 among other factors has impacted the mental health of children and teens across the country, and our region is no exception.
We're going to explore this topic today with two pediatric experts. Dr. Robert Althoff is Division Director of Psychiatry at University of Vermont Health Network, Champlain Valley Physicians Hospital. He's also Vice Chair for Clinical Affairs at the University of Vermont Department of Psychiatry. Welcome, Dr. Althoff.
Dr Robert Althoff: Thank you. Nice to be here.
Host: And with us as well, Dr. Erica Gibson. She's Division Chief of Adolescent Medicine at the UVM Children's Hospital and Associate Professor of Pediatrics at the Larner College of Medicine at UVM. Thank you for coming as well.
Dr Erica Gibson: Thanks so much for having me.
Host: So I want to start with asking you both just what you're seeing in your own work. How dramatic an increase in mental health problems are we talking about among children? And Dr. Althoff, can you start.
Dr Robert Althoff: If you believe the numbers, we're having an increase of about 25% to 30% of children who are presenting for some psychiatric reason. That's a little different now than it was in the beginning of the pandemic. In the beginning of the pandemic, we actually saw a decrease in referrals, but I think some of that was related to changes in the just overall community, like people weren't going out. But now at this point, I think we're seeing about a 25% to 30% increase.
Host: Does that line up with what you're seeing, Dr. Gibson?
Dr Erica Gibson: Yeah, I would agree. We have definitely seen an increase in the mental health challenges amongst young people and their families since onset of the pandemic. And it's been discussed quite a bit in the press as you started out with, and also amongst healthcare providers locally and nationally. So the general pediatricians and other pediatric, primary care providers that we've been talking to are reporting that they're seeing a lot more distress, so depressed mood, anxious mood, and some increased thoughts of self-harm and suicide in some patients.
And it's interesting, we know overall the proportion of visits, not only to our clinics, but also to ERs and even admissions to pediatric hospital wards for psychological distress have really increased. And then in fact visits for infectious illnesses and injuries have actually gone down in the last year due to all our increased hygiene precautions and activity restriction. So this is a larger part of the work at this time, I would say, for a lot of general practitioners.
Host: Right. Well, we clearly have a problem on our hands. So let's talk about this in a little bit of detail. For parents, caregivers listening, what should they be on the lookout for? What are some troubling signs to pick up on, Dr. Gibson?
Dr Erica Gibson: So parents and guardians might note outright expressions of sadness or anxiety or anger. But sometimes psychological distress can manifest as physical complaints like we see in our more general pediatric clinics, things like more frequent abdominal pain or headaches. Young people might be sleeping more often, have changes in sleep patterns, maybe even have insomnia, may have changes in appetite. and sometimes you can see more significant behavior changes like becoming more withdrawn or, in fact, people might even act out a little more, especially if they're having trouble articulating emotional struggles.
Some parents are just reporting that young people aren't themselves, but they can't quite put their finger on what's going on. And also people might notice that folks are just interacting with the world in general a little bit of a different way. So their relationship with like substances or food or exercise or with other people might be shifting a little bit. And certainly, in terms of adolescents during times of stress, I think it's important for everyone to be alert to substance use amongst young people increasing whether it's tobacco or marijuana or alcohol or other drug use.
Host: Sure. So Dr. Althoff, how do you know when it's "serious enough" that people should start thinking about getting some professional help?
Dr Robert Althoff: The time for referral or time to talk to your primary care provider first is in those situations where it's really started to affect the child's functioning and the functioning of the family. So when you notice that a child has sort of drifted off their developmental trajectory in a way that they are starting to have trouble with function, like for example, school function. And it's a little bit difficult, I will say, just in the pandemic time, because school has been so sort of discombobulated anyway. But typically, if a good student and started to drift off and their function is impaired, say their grades have started to be impaired or their functioning with regard to maintenance of weight gain have started to change, all these things basically are indicators that this might not be a little blip. It might be something more significant. So we really concentrate on that functioning piece if they changed the way that they're managing in the world.
Host: Dr. Gibson, do you want to add anything?
Dr Erica Gibson: It's a very normal part of human experience to feel sad or anxious or angry at times. And certainly, these feelings can worsen periodically. But I would expect everyone in the world in this last year have felt these emotions to some degree and even had worsening of them. And just paying close attention to whether they're really interrupting a functioning or if more sort of dangerous behaviors or concerns are developing, is the thing to keep an eye out for.
Host: So staying with you for a second, Dr. Gibson, you'd mentioned before that some people, you know, have difficulty expressing themselves and their feelings and describing what's going on. So what are some tips for parents and guardians on how to talk to children about their feelings and draw some of this out?
Dr Erica Gibson: Once again, I think it's really important to normalize emotions and discuss them openly and acknowledge them. It's not so helpful sometimes to tell people, "Don't cry" or "Don't worry." It can be more helpful just to be available to listen and support and express understanding and also letting young people know that you've felt the same way can be very helpful too. And then working with them to help figure out in their own way what they might need to feel better is really important.
We can be so quick to rush in with words and action steps when people are in distress and sometimes that's really necessary, but it can also be okay to just sit in silence and listen. Also, helping folks with distraction can be helpful sometimes. Taking walks, playing games, helping folks to do things they love or things that soothe them or bring them at least a small amount of joy is really important.
Host: That's definitely a good list to start with. Dr. Althoff, I'm wondering if you can talk a little bit about how this is showing up differently in different age groups. You're obviously not going to see tobacco use increase as Dr. Gibson mentioned in 6-year-olds, but you're probably seeing that in 16-year-olds.
Dr Robert Althoff: It's totally true. I think, every time we think about stressors, we think about stressors in the context of the developmental timeframe we're talking about. So in the younger kids, the younger kids have actually weathered most of this better than the older kids, of course, because they typically fall back on their parents to help regulate them.
But you can see stress in the younger age groups by a change in what used to be a developmental milestone that they met, that they might fall back on. So a child who previously had been dry at night, might be wet at night; a child who previously was managing a lot of things without parents help, might be more clingy or more dependent on the parent. Whereas in the middle school and the high school age groups, you're going to see stress in the more typical ways that we would anticipate seeing it, increases in substance use, increases in withdrawn behavior. So it is slightly different because you're looking at this through the lens of different development. And as I say, the younger kids actually might weather it slightly better.
And the other thing to consider is some kids weather this really well. There's been a small percentage of kids who actually, with the lockdown and more remote school, have actually done better than the rest of the population. Because the stressors from school and the stressors of social interchange at school have been so difficult for them pre-pandemic, the time during pandemic has actually been generally bit easier. The problem with that is now as we move towards re-integration, those kids are going to have a harder time. And so now, we have to pay special attention to the kids who weathered the pandemic exceptionally well.
Host: Not an easy time to be a parent, that's for sure. Dr. Gibson, I want to tap into some of your specialty interests, which includes eating disorders. And I know there's been a lot of press coverage about how there's been a really big spike in that problem area. What can you tell us about what's happening in that arena in our region over the last year?
Dr Erica Gibson: We've also had a spike and it became pretty apparent to us about three to four weeks into the pandemic when we began to get a lot of calls from health care providers and families with concerns about eating disorders in the young people they care for.
So we have an adolescent eating disorder consult clinic here at the University of Vermont Children's Hospital. And what has played out for us is that many young people have presented with stress, frustration, depression, anxiety, that is played out in the form of restrictive eating and over-exercising, either of which or in combination can lead to dangerous amounts of weight loss.
And it's a common misconception that restrictive eating disorders in particular like anorexia are just due to a person really wanting to be thin, but we know it's much more complicated than that. These young people often have a genetic predisposition to developing these restrictive eating behaviors. And there's often a stressful environmental trigger of some sort that actually leads to the development of these behaviors. And that is basically what has happened during this pandemic.
We have had one of the largest environmental stressors of our time lead to this epidemic emergence of these restrictive eating disorders. And it's very hard to summarize restrictive eating disorders and all their complexity during just a brief conversation. But I think what's happened for these young people is that there's been an extreme loss of control and they have in turn sought increased control through either food or exercise potentially. And for many, that has just gone too far in terms of not eating enough to support a healthy body and potentially exercising too much to support a healthy body.
And if you think about it, we are in our bodies all the time, so to a certain degree, that's one of the easiest things for us to control in our lives. Likewise food is usually around most people all the time, unless they're struggling with food insecurity, and it's something else people can more easily control when other parts of their world are just crashing down around them.
Referrals for these kinds of concerns are really skyrocketing, and their referrals to clinics and even admissions to hospitals and residential treatment programs, unfortunately. And we're really scrambling to provide adequate care for these young people, because there aren't enough of us to go around to provide this care at this time.
Host: Well, right. There's already a shortage nationally of psychiatric resources, but this is a very particular kind of specialty as you're referring to. Speaking of specialty interests, Dr. Althoff, you have a research program going on to develop novel assessments for suicide risk. And I wonder if you could address an uptick as well that is being seen in suicides and suicidality among children during the pandemic.
Dr Robert Althoff: I think we are unfortunately at the leading edge of the uptick that we'll see with suicidality. We certainly see an increase in suicidal ideation. Again, we didn't see an uptick early in the pandemic. We saw a sort of a decrease, especially if you look at the European data, a decrease in death by suicide and a decrease in overall admissions for suicidality. But part of that was, again, people just weren't leaving their homes.
And because suicide is so intimately related to stressors and economic stress, I think what we're seeing is in part a companion to the economic stress that people have experienced, families have experienced in the pandemic. And that's led to stress in the parents, stress in the child. You throw into that mix a decrease in the ability to access services and a decrease in social interaction for some youth who really need that type of social interaction. And we're starting to see the beginnings of the uptick in suicidal ideation and, death by suicide.
So we are certainly seeing more young people showing up in emergency departments where suicidal ideation is part of the presentation and, in a system already taxed prior to the pandemic, there's just not enough secure beds and secure places to help people work through their suicidality, help the youth work through their suicidality. So, I think this is a problem and I suspect, unfortunately, a problem that we're going to be dealing with for a bit of time here as we sort through the effects.
Host: Right. Well, listen, as we wrap up, I want to look ahead a little bit. We've got a vaccine campaign well underway, and there's a lot of talk about things getting back to a more normal footing. So I'm wondering what your advice is to parents and guardians about managing this transition. And particularly what I have in mind is kind of managing expectations for, you know, not creating this idea that everything's going to be free and fancy-free this summer, but maybe figuring out how to calibrate that so kids don't end up being disappointed. Dr. Gibson?
Dr Erica Gibson: It's important again to acknowledge thoughts and emotions about what's happening in our world at this time. Some young people are feeling relieved and joyful at things opening up, others might be more apprehensive. And we're really leading into what we would call a new normal, right? Our learning curve with this virus and this pandemic has had to be really consistently readjusted and we continue to have new information coming out daily, weekly regarding next steps.
So I think we want to continue to focus on being more safe than sorry. Following all the recommendations from are absolutely phenomenal health department leaders here who have collaborated with pediatric providers every step of the way during this battle we've all been fighting.
I know the state is very much looking forward to pouring some resources into supporting youth this summer, because they've missed out on so much. So I think there will be some great opportunities for folks. And we should all take the time to enjoy the small amount of relief that we've been lucky enough to feel here in the state and in this country.
Unfortunately, we have to remember that this virus continues to rage through other parts of the world. And it's really extremely important to remain cautious and vigilant at the same time while we allow ourselves the joy of things getting a little bit better.
Host: Dr. Althoff, what would you add to that?
Dr Robert Althoff: I think Dr. Gibson summed it up very well. I think we talk with parents and with the kids about enjoying the parts of life that we can. I mean, we're going to be living with the virus for a while. And as Dr. Gibson says, I mean, certainly worldwide, we're still going to be dealing with it. We'll still be dealing with it here, but still living. And I think that's part of the key for both the parents and the child, is still enjoying the things that we can do, enjoying them to their fullest and trying to appreciate the times when we can get back that sense of what was, but also say, there's no reason to not enjoy the current moment in the way that it looks right now today and then to look forward to the future. I think we try to instill a sense of hope, but cautious hope, as you say, we don't want to say everything is going to be hunky-dory because it doesn't look like we're going to get to hunky-dory anytime soon.
Host: Well, that's good and realistic advice to end on. We're going to have to leave it there, but I want to thank you both very much for your time and advice today, Dr. Robert Althoff and Dr. Erica Gibson. For more information about pediatric health, you can visit childrens.uvmhealth.org. And for more information about staying healthy during COVID, you can visit uvmhealth.org/coronavirus/stayinghealthy. Thanks for listening.
Host: According to the Centers for Disease Control and Prevention, mental health concerns like depression and anxiety were on the rise in children ages six to 17 even before the pandemic. Now, more than a year into the crisis, research leaves little doubt that ongoing social isolation and loneliness during COVID-19 among other factors has impacted the mental health of children and teens across the country, and our region is no exception.
We're going to explore this topic today with two pediatric experts. Dr. Robert Althoff is Division Director of Psychiatry at University of Vermont Health Network, Champlain Valley Physicians Hospital. He's also Vice Chair for Clinical Affairs at the University of Vermont Department of Psychiatry. Welcome, Dr. Althoff.
Dr Robert Althoff: Thank you. Nice to be here.
Host: And with us as well, Dr. Erica Gibson. She's Division Chief of Adolescent Medicine at the UVM Children's Hospital and Associate Professor of Pediatrics at the Larner College of Medicine at UVM. Thank you for coming as well.
Dr Erica Gibson: Thanks so much for having me.
Host: So I want to start with asking you both just what you're seeing in your own work. How dramatic an increase in mental health problems are we talking about among children? And Dr. Althoff, can you start.
Dr Robert Althoff: If you believe the numbers, we're having an increase of about 25% to 30% of children who are presenting for some psychiatric reason. That's a little different now than it was in the beginning of the pandemic. In the beginning of the pandemic, we actually saw a decrease in referrals, but I think some of that was related to changes in the just overall community, like people weren't going out. But now at this point, I think we're seeing about a 25% to 30% increase.
Host: Does that line up with what you're seeing, Dr. Gibson?
Dr Erica Gibson: Yeah, I would agree. We have definitely seen an increase in the mental health challenges amongst young people and their families since onset of the pandemic. And it's been discussed quite a bit in the press as you started out with, and also amongst healthcare providers locally and nationally. So the general pediatricians and other pediatric, primary care providers that we've been talking to are reporting that they're seeing a lot more distress, so depressed mood, anxious mood, and some increased thoughts of self-harm and suicide in some patients.
And it's interesting, we know overall the proportion of visits, not only to our clinics, but also to ERs and even admissions to pediatric hospital wards for psychological distress have really increased. And then in fact visits for infectious illnesses and injuries have actually gone down in the last year due to all our increased hygiene precautions and activity restriction. So this is a larger part of the work at this time, I would say, for a lot of general practitioners.
Host: Right. Well, we clearly have a problem on our hands. So let's talk about this in a little bit of detail. For parents, caregivers listening, what should they be on the lookout for? What are some troubling signs to pick up on, Dr. Gibson?
Dr Erica Gibson: So parents and guardians might note outright expressions of sadness or anxiety or anger. But sometimes psychological distress can manifest as physical complaints like we see in our more general pediatric clinics, things like more frequent abdominal pain or headaches. Young people might be sleeping more often, have changes in sleep patterns, maybe even have insomnia, may have changes in appetite. and sometimes you can see more significant behavior changes like becoming more withdrawn or, in fact, people might even act out a little more, especially if they're having trouble articulating emotional struggles.
Some parents are just reporting that young people aren't themselves, but they can't quite put their finger on what's going on. And also people might notice that folks are just interacting with the world in general a little bit of a different way. So their relationship with like substances or food or exercise or with other people might be shifting a little bit. And certainly, in terms of adolescents during times of stress, I think it's important for everyone to be alert to substance use amongst young people increasing whether it's tobacco or marijuana or alcohol or other drug use.
Host: Sure. So Dr. Althoff, how do you know when it's "serious enough" that people should start thinking about getting some professional help?
Dr Robert Althoff: The time for referral or time to talk to your primary care provider first is in those situations where it's really started to affect the child's functioning and the functioning of the family. So when you notice that a child has sort of drifted off their developmental trajectory in a way that they are starting to have trouble with function, like for example, school function. And it's a little bit difficult, I will say, just in the pandemic time, because school has been so sort of discombobulated anyway. But typically, if a good student and started to drift off and their function is impaired, say their grades have started to be impaired or their functioning with regard to maintenance of weight gain have started to change, all these things basically are indicators that this might not be a little blip. It might be something more significant. So we really concentrate on that functioning piece if they changed the way that they're managing in the world.
Host: Dr. Gibson, do you want to add anything?
Dr Erica Gibson: It's a very normal part of human experience to feel sad or anxious or angry at times. And certainly, these feelings can worsen periodically. But I would expect everyone in the world in this last year have felt these emotions to some degree and even had worsening of them. And just paying close attention to whether they're really interrupting a functioning or if more sort of dangerous behaviors or concerns are developing, is the thing to keep an eye out for.
Host: So staying with you for a second, Dr. Gibson, you'd mentioned before that some people, you know, have difficulty expressing themselves and their feelings and describing what's going on. So what are some tips for parents and guardians on how to talk to children about their feelings and draw some of this out?
Dr Erica Gibson: Once again, I think it's really important to normalize emotions and discuss them openly and acknowledge them. It's not so helpful sometimes to tell people, "Don't cry" or "Don't worry." It can be more helpful just to be available to listen and support and express understanding and also letting young people know that you've felt the same way can be very helpful too. And then working with them to help figure out in their own way what they might need to feel better is really important.
We can be so quick to rush in with words and action steps when people are in distress and sometimes that's really necessary, but it can also be okay to just sit in silence and listen. Also, helping folks with distraction can be helpful sometimes. Taking walks, playing games, helping folks to do things they love or things that soothe them or bring them at least a small amount of joy is really important.
Host: That's definitely a good list to start with. Dr. Althoff, I'm wondering if you can talk a little bit about how this is showing up differently in different age groups. You're obviously not going to see tobacco use increase as Dr. Gibson mentioned in 6-year-olds, but you're probably seeing that in 16-year-olds.
Dr Robert Althoff: It's totally true. I think, every time we think about stressors, we think about stressors in the context of the developmental timeframe we're talking about. So in the younger kids, the younger kids have actually weathered most of this better than the older kids, of course, because they typically fall back on their parents to help regulate them.
But you can see stress in the younger age groups by a change in what used to be a developmental milestone that they met, that they might fall back on. So a child who previously had been dry at night, might be wet at night; a child who previously was managing a lot of things without parents help, might be more clingy or more dependent on the parent. Whereas in the middle school and the high school age groups, you're going to see stress in the more typical ways that we would anticipate seeing it, increases in substance use, increases in withdrawn behavior. So it is slightly different because you're looking at this through the lens of different development. And as I say, the younger kids actually might weather it slightly better.
And the other thing to consider is some kids weather this really well. There's been a small percentage of kids who actually, with the lockdown and more remote school, have actually done better than the rest of the population. Because the stressors from school and the stressors of social interchange at school have been so difficult for them pre-pandemic, the time during pandemic has actually been generally bit easier. The problem with that is now as we move towards re-integration, those kids are going to have a harder time. And so now, we have to pay special attention to the kids who weathered the pandemic exceptionally well.
Host: Not an easy time to be a parent, that's for sure. Dr. Gibson, I want to tap into some of your specialty interests, which includes eating disorders. And I know there's been a lot of press coverage about how there's been a really big spike in that problem area. What can you tell us about what's happening in that arena in our region over the last year?
Dr Erica Gibson: We've also had a spike and it became pretty apparent to us about three to four weeks into the pandemic when we began to get a lot of calls from health care providers and families with concerns about eating disorders in the young people they care for.
So we have an adolescent eating disorder consult clinic here at the University of Vermont Children's Hospital. And what has played out for us is that many young people have presented with stress, frustration, depression, anxiety, that is played out in the form of restrictive eating and over-exercising, either of which or in combination can lead to dangerous amounts of weight loss.
And it's a common misconception that restrictive eating disorders in particular like anorexia are just due to a person really wanting to be thin, but we know it's much more complicated than that. These young people often have a genetic predisposition to developing these restrictive eating behaviors. And there's often a stressful environmental trigger of some sort that actually leads to the development of these behaviors. And that is basically what has happened during this pandemic.
We have had one of the largest environmental stressors of our time lead to this epidemic emergence of these restrictive eating disorders. And it's very hard to summarize restrictive eating disorders and all their complexity during just a brief conversation. But I think what's happened for these young people is that there's been an extreme loss of control and they have in turn sought increased control through either food or exercise potentially. And for many, that has just gone too far in terms of not eating enough to support a healthy body and potentially exercising too much to support a healthy body.
And if you think about it, we are in our bodies all the time, so to a certain degree, that's one of the easiest things for us to control in our lives. Likewise food is usually around most people all the time, unless they're struggling with food insecurity, and it's something else people can more easily control when other parts of their world are just crashing down around them.
Referrals for these kinds of concerns are really skyrocketing, and their referrals to clinics and even admissions to hospitals and residential treatment programs, unfortunately. And we're really scrambling to provide adequate care for these young people, because there aren't enough of us to go around to provide this care at this time.
Host: Well, right. There's already a shortage nationally of psychiatric resources, but this is a very particular kind of specialty as you're referring to. Speaking of specialty interests, Dr. Althoff, you have a research program going on to develop novel assessments for suicide risk. And I wonder if you could address an uptick as well that is being seen in suicides and suicidality among children during the pandemic.
Dr Robert Althoff: I think we are unfortunately at the leading edge of the uptick that we'll see with suicidality. We certainly see an increase in suicidal ideation. Again, we didn't see an uptick early in the pandemic. We saw a sort of a decrease, especially if you look at the European data, a decrease in death by suicide and a decrease in overall admissions for suicidality. But part of that was, again, people just weren't leaving their homes.
And because suicide is so intimately related to stressors and economic stress, I think what we're seeing is in part a companion to the economic stress that people have experienced, families have experienced in the pandemic. And that's led to stress in the parents, stress in the child. You throw into that mix a decrease in the ability to access services and a decrease in social interaction for some youth who really need that type of social interaction. And we're starting to see the beginnings of the uptick in suicidal ideation and, death by suicide.
So we are certainly seeing more young people showing up in emergency departments where suicidal ideation is part of the presentation and, in a system already taxed prior to the pandemic, there's just not enough secure beds and secure places to help people work through their suicidality, help the youth work through their suicidality. So, I think this is a problem and I suspect, unfortunately, a problem that we're going to be dealing with for a bit of time here as we sort through the effects.
Host: Right. Well, listen, as we wrap up, I want to look ahead a little bit. We've got a vaccine campaign well underway, and there's a lot of talk about things getting back to a more normal footing. So I'm wondering what your advice is to parents and guardians about managing this transition. And particularly what I have in mind is kind of managing expectations for, you know, not creating this idea that everything's going to be free and fancy-free this summer, but maybe figuring out how to calibrate that so kids don't end up being disappointed. Dr. Gibson?
Dr Erica Gibson: It's important again to acknowledge thoughts and emotions about what's happening in our world at this time. Some young people are feeling relieved and joyful at things opening up, others might be more apprehensive. And we're really leading into what we would call a new normal, right? Our learning curve with this virus and this pandemic has had to be really consistently readjusted and we continue to have new information coming out daily, weekly regarding next steps.
So I think we want to continue to focus on being more safe than sorry. Following all the recommendations from are absolutely phenomenal health department leaders here who have collaborated with pediatric providers every step of the way during this battle we've all been fighting.
I know the state is very much looking forward to pouring some resources into supporting youth this summer, because they've missed out on so much. So I think there will be some great opportunities for folks. And we should all take the time to enjoy the small amount of relief that we've been lucky enough to feel here in the state and in this country.
Unfortunately, we have to remember that this virus continues to rage through other parts of the world. And it's really extremely important to remain cautious and vigilant at the same time while we allow ourselves the joy of things getting a little bit better.
Host: Dr. Althoff, what would you add to that?
Dr Robert Althoff: I think Dr. Gibson summed it up very well. I think we talk with parents and with the kids about enjoying the parts of life that we can. I mean, we're going to be living with the virus for a while. And as Dr. Gibson says, I mean, certainly worldwide, we're still going to be dealing with it. We'll still be dealing with it here, but still living. And I think that's part of the key for both the parents and the child, is still enjoying the things that we can do, enjoying them to their fullest and trying to appreciate the times when we can get back that sense of what was, but also say, there's no reason to not enjoy the current moment in the way that it looks right now today and then to look forward to the future. I think we try to instill a sense of hope, but cautious hope, as you say, we don't want to say everything is going to be hunky-dory because it doesn't look like we're going to get to hunky-dory anytime soon.
Host: Well, that's good and realistic advice to end on. We're going to have to leave it there, but I want to thank you both very much for your time and advice today, Dr. Robert Althoff and Dr. Erica Gibson. For more information about pediatric health, you can visit childrens.uvmhealth.org. And for more information about staying healthy during COVID, you can visit uvmhealth.org/coronavirus/stayinghealthy. Thanks for listening.