MENTAL CARE IN A HELPLESSNESS SITUATION CORONAVIRUS SARS-COV-2 CHILDREN AND ADOLESCENTS

Μental care in a helplessness situation

Coronavirus SARS-Cov-2

Children and Adolescents

Theodora Skali

Psychologist, MSc, PhD, Psychotherapist, ECP, GCP, Laboratory Teaching Staff in Psychology, Medical School, National and Kapodistrian University of Athens

Abstract

In times of crisis and prolonged adversity, children and adolescents are the most vulnerable population based on emotion handling, due to their developmental stage. The COVID-19 pandemic, as a sudden, unexpected, as well as ongoing, situation with no a visible end, has affected our lives in many ways, and has made us consider the impact especially on children and adolescents, in terms of mental illness prevention. So, we need to keep this emotional vulnerability of children and adolescents in mind, as well as the particular way in which they express their feelings. In this context, the way in which their behavior will be interpreted and reflected is very crucial, and family’s role in mediating this is very important.

Key-words : virus, quarantine, children and adolescents, family, mental health, behaviors, risk factors, resilience

**Introduction **

The event itself

The SARS-CoV-2 virus belongs to the coronavirus family, that infect humans and animals. This strain is new. It causes respiratory infection. Ιf this virus reaches the lungs then it causes very serious problems that require hospitalization. Even if that happens, the infection is usually mild. The virus is more harmful for the elderly or/and people with chronic diseases. Breathing problems, such as shortness of breath, are the main “signal” for the onset of pneumonia. But even in this case, where hospitalization is required, most people make a full recovery. In most patients, the symptoms were mild (about 85%). Only 15% needed hospitalization, and only 5% of these cases had to be admitted to the Intensive Care Unit (Peppou, Economou, Skali, Papageorgiou, 2020). The scientific community is making a superhuman effort to control and disperse cases over time, so that people with any severe symptoms can be treated, when and if needed. There is no health system in the world that can treat that many people simultaneously, no matter how well prepared it is. Thus far Greece has achieved a slow spread of cases. The concern, however, is great. In this context, the Greek government imposed a six week quarantine in order to stop the spread of the virus, from mid-March 2020 to May 4, 2020. And the story is not over yet ...

To our Youth!
Our youngest are back at school and we are all happy about that.
But I would like to talk about our young ones.
Those who are still waiting, still longing.
I would like to say to our young ones that you are not forgotten!
Our goal is to have them back at school before summer.

Many thanks have been given during this period of lockdown.
It is about time we thank our young ones.
They have sacrificed a lot.

Many adults have been in despair these weeks.
Some of them have been frustrated because they could not stay at their cabin.
Others have been frustrated about working from home.
I understand the frustration!
But your cabin is still there – it is waiting patiently for you to arrive.
And your job is pretty much the same when you return.
That is not the case when you are young.

The spring you turn 14 is not patiently waiting for you to arrive.
It is not possible to return to the summer when you are 17.
Celebrating graduation cannot be played on repeat.

We who are adults talk about next summer.
But next summer is for middle-aged men who buy minced meat and toilet paper on sale.
Next summer does not exist when you are young.

When you are young, you care about today and tomorrow.
You dream of the summer ahead and this spring.

You dream of the football cup where you will score a goal like no one has done before.
You dream of the field trip where you finally have the courage to flirt with the cutest boy in class.
**You dream of the school formal where your will dance the night away in the way too expensive dress **
that you had to nag about for a year.
You dream of celebrating graduation with your friends.
Then came the virus that killed dreams.
There is no football cup, no field trip.
There is no formal and no graduation.

**In addition, it is completely impossible to concentrate during home-school since your parents are **
talking too loudly during their Skype-meetings with the office.
**There is nothing more I would like to say to our young ones that everything will be the same as **
before.
But I cannot.

This spring will be different.
This summer will be different,
This year will be different.

You are the young ones who must do things different.
You have put your lives on hold for others to save their lives.

I hope you will dance even without a school formal.
I hope you will score fantastic goals even without a football cup.
I hope you will flirt with cute girls and boys even without a field trip.
I hope you will have a great time celebrating graduation even though it will be different.

These are different days – I still hope they can be nice.

Thank you to all Norwegian young ones.
Thank you to the graduating classes of 2020

We are proud of you!

By Minister of Health and Care services Bent Høie
(Speech held on the Corona Press Conference 27th April)
(Σκαλή, Πάλλη, 2020)

** _  March - April 2020_ **

So, we stay at home, limiting our activities to the absolutely necessary, thus, contributing to the scientific community’s effort to control the spread of the SARS-Cov-2 coronavirus. We all have to face this unprecedented condition and to discover and make use of our strength resources, individually and/or collectively, and to support ourselves and others around us.

This, although absolutely necessary, means that many important relationships with family, friends etc. will lose their spontaneity and the immediacy of coming together: father, mother, child, grandfather, grandmother, grandchild, boyfriend, girlfriend, classmate, cousin, nephew, niece, godfather, godmother, teacher… the list is endless...

It is something that happened abruptly, that required quick compliance, and we did not have time to process the relevant psychological repercussions. Repercussions that exist to this day, and have left their mark on our psyche, as a consequence of the temporary loss of people and daily habits, as a consequence of all these big ongoing changes in the way we connect and communicate. And of course this is something that has “spread” to all age groups, the most vulnerable of which are children and adolescents as well as the elderly (Bryant et al., 2020; Kousky, C., 2016; Steptoe et al., 2013; Tomaka et. al., 2006).

So, our everyday life was suddenly and necessarily gone, and with it significant people and daily habits. Thus, we lost for a while – I hope – the everyday meeting with the significant other, who reflects us, and who feeds and builds the meaning of relating inside of us, who functions as a continuation of our sense of self and identity. The loss of normal daily life has given rise to tremendous anxieties and uncertainties inside us, especially for children and the elderly, due to their developmental stage. And the danger that lurks here is, that as each person expresses these anxieties in his own way and this is often not properly interpreted (with everybody being lost in their own anxieties and fears), a suitable psychological modifying approach will not be utilized (Campbell, 2020).

Recent research suggests that incidents of neglect, abuse, and dysfunctional family relationships that occur before the age of 18 are predictors of mental health issues and are likely to worsen in a crisis such as the COVID-19 pandemic. Moreover, the challenge is even greater for children and adolescents from low-income and low-educational level families. It is therefore necessary, in addition to healthcare and public health, to effectively address adverse childhood experiences and prevent their short-term or/and long-term consequences beyond the current public health crisis (PsycInfo Database Record, 2020 APA).

Some children will remember this COVID-19 crisis as “those days, when mom and dad were home, we were eating together, completing jigsaw puzzles together, playing board games together and seeing our friends in online classrooms, e.tc.” . But for other children, this pandemic situation may have heightened the risk for adverse childhood experiences. Furthermore, it may be a traumatic adversity that is added to a variety of pre-existing family problems, a destabilizing situation which is going to affect them and their behavior, in manners that are not always distinguishable for the parents or others adults, and are not always handled in the best possible manner for the child’s and adolescent’s mental health.

Mental care for children and adolescents in crisis situations

Recent evidence regarding the perception of mental health, treatment, and mental care connect the concept of quality of life to the physical, mental and social well-being as a whole, as well as to the prevention of health problems to “ the person’s subjective perception of his place in life, within the context of the value system and cultural traits of the society he lives in, as well as in conjunction to his personal goals, expectations, standards and concerns ” (Prapas, Mavreas, 2015).

Therefore, in terms of Developmental Psychology, pre-school age, school age and adolescence are developmental stages that include critical periods for specific psycho-emotional achievements, related to the development of mental health and well-being that should reach a satisfactory level of emotional and behavioral adjustment and function. These developmental stages are considered crucial for the consolidation of mental qualities associated with the development of a person's ability - through a variety of paths - to enjoy life and to balance between the various aspects of life and mental resilience. According to the World Health Organization (WHO), mental health includes, among other things, _“subjective sense of well-being, perceived self-efficacy, autonomy, ability, intergenerational dependence, self-appreciation _ ο f a person’s mental and emotional potential”. The definition of Health contained in the preface of the WHO Statue states that “Health is a state of absolute physical, mental and social well-being and not just the absence of disease or disability” (International Health Conference, New York, 1946/in force since 1948).

Having these age distinctive characteristics in mind, in a situation like the COVID-19 pandemic, we know that we are having a hard time because we are searching for a way to help children and adolescents, when we probably do not know how to even help ourselves. We wonder about children and adolescents “do they understand?”, “what do they understand?”, “how do they feel”, “do they care?”, “what will the consequences of this situation be?”, “will it have consequences?”, "what should we tell them?", “how should we tell them?" etc. And what makes it even more difficult are the particular ways in which they express their emotions, fears, worries anxieties etc., due to age, as well as their inability to recognize and process all these at a more deep and mature level.

As professionals we know from research evidence, as well as from our experience, that any sudden situation may destabilize children’s psyches, to a lesser or greater extent, especially when its repercussions affect the adults in their environment, and even professionals as well as every wider system. The aftermath of such an event - like that of the COVID-19 pandemic - and its impact on every aspect of everyday life, can have a long-lasting effect on the child and adolescent and can be a triggering factor for consequences such as a higher risk of depression, anxiety, bipolar disorder, post-traumatic stress disorder, obesity, behavioral problems, and broader health problems such as heart disease. Research shows that about 80% of people who were abused as children met the criteria for at least one psychiatric disorder by the age of 21 (National Association of School Psychologists, 2017).

A troubled childhood can also lead a person to alcohol and drug use to relieve pain or as a way to feel the emotions. Studies estimate that up to two-thirds of patients receiving treatment for substance abuse have a childhood history of sexual, emotional, or physical abuse. In a troubled childhood there are many difficulties that need to be overcome. However, if there is a deep understanding and a facilitation of the child to process these difficulties, healing can be achieved (Viana, et al., 2017; Matsa, 2012).

A traumatic situation in childhood and adolescence as a potential risk factor in adulthood. Why?

The main reasons that hard life events during childhood and/or adolescence can have a destabilizing function on mental health and are difficult to deal with, even later, during adulthood, are the following (Sack, 2015; Umberson, 2010):

Children and adolescents do not have the capacity to focus on the source of their anxieties . Children have no frame of reference when traumatic experiences occur, and as a result they tend to consider reality as normal, especially if their parents are involved as a source of anxiety. Often, much later, under other life circumstances, they may realize the burden that their psyche suffered during their childhood. In the meantime, however, every adjustment mechanism they have, has been programmed into this “reality” (Skali, Moroyannis, 2020).

**Other comorbid conditions may occur, and the main problem is likely to be obscured. ** It is well known, from the area of substance and alcohol abuse, that it is very common for the addiction to be identified as the main problem, and thus treatment to only target that, instead of seeing it as a symptom of trauma. This way, the hidden trauma and the subsequent emotions and behaviors remain unresolved, with detrimental consequences on the individual’s mental and physical health. As a result the patient is constantly in and out of substance abuse.  Other times belonging in a group of substance users creates a psychological bond that will substitute family relations’ functions, especially when such relations were missing in an individual’s life (Matsa, 2012).

Traumatic events at a young age affect the biology of the brain . From the field of Neurobiology and Group Psychotherapy, research data clearly indicate that childhood trauma can change the structure of the brain and the way certain genes are manifested. Relevant studies suggest that childhood trauma, such as abuse or loss of a parent, has been found to alter the gene programming responsible for stress regulation, thus reducing the response threshold and increasing the risk of developing anxiety disorders. Also, other research data highlight the individual's reduced ability to mitigate negative impulses. Exposure to traumatic conditions in childhood can also affect the neurotransmitters in the brain, enhancing surrogate “pleasure” sources, making any addiction more likely. And when these brain structures are established, they shape the adult brain and manifest themselves through consequent behaviors. These relevant research data underline the difficulties of dealing with child trauma, and remind us to be vigilant regarding issues of prevention and treatment (Skali, Moroyannis, 2020).

**The fact is now a thing of the past. But what about the recollection? ** At a later date, in adulthood, some people experience the idea of ​​digging into the past as painful and thus reject it. Others do it without believing that anything from this mess of old and painful experiences can be resolved. Often, people grow up and grow old in a mist of "anxiety essence" emotions of unspecified etiology or definition, emotions that cannot have a clear reference, and which they have no desire or motivation to deal with (Skali, Moroyannis, 2020).

Repairing important past relationships may not be possible . Many times, even if an adult reaches the source of his childhood stress, through a therapeutic process, there are no available and/or willing persons, conditions, etc. for the repair of psychological bonds and relationships. Thus, the individual is left with the sense of incompleteness or the sense of a “missed” opportunity.

**Sometimes people are trapped into roles. ** People often try to find in present relationships what was missing in their life, in an effort to keep the past alive or to make up for the past. Thus, instead of focusing on themselves and their strengths, they waste huge amount of energy trying to become worthy in the eyes of others. This usually gets people involved in further traumatic experiences and reinforces the existing trauma. 

**Children and adolescents can easily isolate their emotions and make them “numb”. ** Their cognitive immaturity helps them in this. This way, they not only fail to develop qualities that would help them build healthy relationships, but they are also led to further complicated grief and trauma.

Finally, children and adolescents cannot block the internalized voices of important others . They adopt the image of themselves that others describe. Due to the lack of the ability of cognitive processing and reality control on an abstract level, they cannot distance themselves from condescending, dismissive and humiliating descriptions.

All the above are difficulties presented during childhood and adolescence, as well as difficulties that may be manifested in subsequent developmental stages. Despite the highly traumatic nature of many difficulties, it is already known that any healing process can, to a lesser or greater extent, improve our quality of life and the relationship with ourselves and others. As our understanding of the impact of childhood traumatic experiences on our brain structure, mind, and physiology grows the easier it gets for us to deal with situations like these. In addition, research on mental resilience highlight the relation between negative traumatic experiences and resilience as a result of finding use for them.

Above all, however, mental illness prevention is the basis of dealing with any adverse, sudden, uncertain and prolonged life event such as the present COVID-19 pandemic.

Crucial issues we need to keep in mind - as experts and parents - in this COVID-19 destabilizing situation

**Do children understand? ** Children and adolescents understand more than we think they do. Their daily life has already changed and this change has now shifted from the initial impression of the new reality resembling a game, to an anxiety inducing daily life experience. In addition to changes in their own realities, they also notice real changes in the life of the family (close and extended alike) and they experience the emotional conditions of the situation in general. Of course, factors such as age, intelligence, mental and emotional developmental stages, personality traits, environmental characteristics, previous experiences of changes, loss, and/or crisis events, affect their understanding, and their capacity to process the situation.

**How do they experience these changes? ** Are they upset? Are they scared? Do they feel guilty, etc.? Children and adolescents experience many emotions but they express them in a different manner than adults. Both, the content and the intensity of the emotions, also differ from that of adults. Therefore, children and adolescents experience the changes:

• Little by little . Children and adolescents cannot stand painful emotions for a long time, so they mourn in small doses, in a repetitive way and their mood can swing from laughter to mourning and then all over again. This does not mean that they are indifferent, that they have overcome it, that “they do not care”, “that they are insensitive”, etc.
• Through time and through their developmental process . There is no set time limit. Grief is rekindled in later developmental stages: Developmental changes bring feelings associated with past losses to the surface, thus allowing the child to process over and over again the meaning of things that have happened, when it has reached stages of greater cognitive competence.
• **They express difficult feelings by acting out instead of verbalizing. ** They express their feelings through behaviors and actions - through play, drawings, changes in behavior (sleep, food, changes in the way they speak) and more rarely in words.

They do not seek support . Children or/and adolescents do no ask for help either because all the family members experience similar feelings of sadness, fear, uncertainty, anxiety, or because their cognitive competence is low. They also do not want to differ – which is especially true for teenagers. Last but not least, parents often convey the message that “everything is fine”! “We are safe”, “we are here!” and children, as we know, follow the family’s messages (Skali, Palli, 2020).

How do children express their feelings in conditions such as these? Some children’s/adolescents’ common and absolutely normal ways of expressing feelings in such destabilizing conditions are:

• Sadness, bad mood
• Fits of anger or tears for no apparent reason
• Complaints for older “injustices”
• Fears (fear of separation, fear for the dark, etc.)
• Habit changes (sleep, food, etc.)
• Changes in behavior (isolation, introversion, aggression, decreased interest, etc.)
• Regression to previous developmental stages behaviors (pacifier, bed-wetting, night terrors, bad dreams, dependency behaviors, etc.)
• Persistent pursuit of the impossible (to go to grandparents, to go to friends, to go to school, to go out, etc.)
• Guilt for past behaviors (for example, he/she remembers that he/she made his grandmother feel tired or made fun of her, that he quarreled with his friends, classmates, etc.)
• Physical symptoms (headaches, stomach problems, respiratory problems, allergic reactions, etc.)
• Aggression (mainly in teenagers)
• Self-destructive behaviors
• Internet addiction and internet online gaming addiction

What do children and adolescents need in such conditions of ongoing changes and upheaval?

• To understand exactly what is happening and why.
• To understand exactly on what to cooperate and why.
• To be facilitated to express their emotions.
• To remain connected to significant others (technology proved to be very useful in this area).
• To feel that they can continue - and that it is required by the parents/state, etc. – in pursuing their interests and activities, within the imposed restrictions, and having implemented all necessary modifications.
• To be supported in many ways by the adults around them.
• To maintain as much certainties and habits as possible regarding their daily life.

How do we support a child or/and an adolescent?

• By informing him/her in a timely and reliable manner and in simple words.

• By encouraging him to express thoughts and feelings, whatever they may be.

• By facilitating contact and communication with people who he/she cannot see temporarily and/or with old habits that can be implemented.

• By enhancing their participation in what the family as a whole experiences

• Attention: “As much as necessary”: We do not overexpose children to information or other material, which exceeds their cognitive processing ability, nor do we leave them on the sidelines thinking they “cannot”, “do not understand” or in order to protect them from being scared, sad, etc.

• We ensure continuity and stability in their daily life (this presupposes we do the same, as parents, in our life).

• We are constantly present for any kind of support.

How do we inform a child, an adolescent?

• We do not hide information . Silence and/or deception make them feel alone, they give their own explanations, which are often more frightening than reality.
• We inform immediately after any event . Delay causes confusion and misinterpretation. Explain clearly and honestly exactly what is happening. ** Adjust the vocabulary you use to the child's level of understanding and need at the moment. **
• We use the words accurately . We say, “coronavirus”. We even paint or draw it, if necessary. We explain the symptoms, the damage it causes. We describe what we need to do to protect ourselves and others. We use the words “pandemic”, “quarantine”, we explain the purpose of quarantine (protection of self and others), etc. We explain what will probably happen if someone from the family gets sick, etc.
• We do not embellish reality . We want children and adolescents to cooperate with us in this reality.
• We listen carefully and give answers to what they ask . Do not bombard them with information. Let them express their emotions. If you do not know something they are asking, tell them “I do not know”. Do not give them information they did not ask for. They will come back for questions. Stop when they say “ok, I understand”, they have reached their limits for the time being.
• We inform the child, the adolescent about what will happen from now on . Children and adolescents want to know what is next: what will happen with family relationships, vacations, school schedules, friends, etc. They are worried about their future. Is it going to end? When? Let them know about the changes and modifications but also about the habits that will remain.
• We repeat the information and explain as many times as needed . They will repeatedly ask about the circumstances of the virus, they will find “guilty people” to blame, they will get angry, they will have questions, they will make fun of COVID-19, they will underestimate it, etc., in their attempt to make sense of it. We check what they have understood, using simple questions.
• We describe to them time and time again their obligations and the family plans for the future, when order has been restored, and we plan the future with them .

How do we encourage the expression of emotions?

• We «give» them time, space and ways to express them . We wait for them. Even if they choose not to share what they feel for the time being.
• We listen to what they say they feel. We do not censor them or tell them how they have to feel or think. Listen carefully to feelings of anger or negative thoughts they may have (if you rush to answer them, then you are limiting the expression and subsequent understanding of their emotions).
• Share your own feelings keeping in mind that you are the parent and he/she the child. Remember that you are an adult having many resources, while the child has none other except your answers and your attitude in this condition.
• Recognize your own feelings . Give yourself space and time to understand and express your own feelings. How will you help a child if you are not aware of how you yourself feel, what you need, how and where you will seek help from?
• Confirm – as many times necessary - that you love him/her Talk about beloved members of the extended family, those you cannot see and miss. Help the child write letters, keep notes, make cards, drawings, etc. for those he/she cannot see, so that he/she can give them to them when they reunite.

How do we promote the stability of family life?

• Maintain the rules of discipline and behavior that applied before.

• Keep the environment and daily habits stable - as much as possible.

• Support the child on a constant basis.

• Encourage the child and adolescent to continue any activity that is possible (reading, playing music, exercising, etc.)

When to worry?

• Ιf there is absence of any expression of sadness, anxiety, distress, etc. or if you notice withdrawal or aggressive behavior.
• If a child constantly blames or accuses his/her self (“it's my fault that grandmother now…").
• If you notice prolonged eating or sleeping disorders, nightmares, etc.
• In case of intense and persistent physical discomfort and symptoms.

Which children are the most vulnerable?

• Children with pre-existing mental or emotional problems or behavioral problems.

• Children who have previous experienced losses or any other unpredictable changes

• Attention : Of course, the way that the new crisis situation affect the child depends on the degree to which the previous one has been processed.

• Children in whose family someone is being treated, hospitalized, has just got sick or has died in the present pandemic.

**Afterword **

Keep in mind that the crucial point here is, above all, not so much to give the correct answer, but to understand why a child asks and what a child asks for. What is a child looking for, through a question? Try to be present in the communication in order to understand this.

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