While the physical health of our elderly dominates COVID-19 headlines as the population with the highest hospitalization and death rate, the mental health impact on all our family members, particularly the youngest, is often overlooked. Older individuals without the disease experience a far greater degree of social separation than ever before due to the practice of social distancing, with fewer multi-generational households, the elimination of elder programs, the closing of senior centers and the barring of family members from nursing homes. Nonetheless, we must remember that the younger generations are not immune to the pandemic’s effects. Children and teenagers are enduring closed schools, swimming pools and playgrounds. Concurrently, we are becoming aware of the physical dangers presented by Pediatric Multisystem Inflammatory Syndrome.
For most healthy young people, however, the most significant challenge remains the mental and emotional stresses of an uncertain short-term and long-term future, which has the potential to cause depression. This is something we, as medical students, should pay careful attention to in the young people in our lives. Our younger family members are not only the responsibility of their parents; we must strive to nurture and protect them as well. After all, as future physicians, our goal is not only to address the disease, but also to address the person as a whole. When it comes to our younger family members, this means acknowledging their social as well as functional and emotional needs. With this in mind, we should consider three key principles as we focus on the mental health of our younger family members.
First, we should help younger family members understand the reasons for our current practice of social distancing and help them process the changes it has brought to their lives. Childhood development is often filled with impulsiveness and piecemeal logic that confounds outsiders but makes perfect sense from the child’s perspective. As children, we may have climbed bookshelves, used our crayons on walls or eaten things we found outdoors. As teens, we may have consumed age-inappropriate media, snuck grown-up beverages or hung out with peers from the “wrong crowd.” Of course, our younger family members now face a double hazard: they espouse the same proclivities and endure the same temptations that we grew up with, along with the added burden of new social distancing rules. Children might not understand why they can’t run up to other children in public places. Teens might question why they can’t visit friends or why they must don unfashionable facemasks.
As student doctors, we have a unique opportunity to serve as a friendly adult family member with specialized knowledge, so we can facilitate a frank but understanding conversation about the importance of social distancing. We should explain to them that even if they don’t feel sick, they may have germs that can affect others and the best way to keep others safe is to stay away from them. Social distancing does not mean that we are abstaining from socializing; rather, we are socializing in different ways for safety’s sake. For children who miss playing with their friends, we can set up home activities or aid them in supervised video calls with their buddies. If teens worry about losing contact with their peers, we can remind them that phoning, chatting and sharing on social media can keep their connections with friends open.
Second, we should help our younger family members establish and maintain routines and healthy habits. Before the pandemic, they could keep a schedule in a relatively straightforward manner because school provided a fundamental structure for their lives. They would wake up, eat breakfast, go to school, engage in afterschool activities, followed by dinner and homework before bed. With the transition from traditional classrooms to remote learning (and with some K-12 teaching barely happening at all), many youths lost an anchoring landmark in their school building and the subsequent sense of normalcy they drew from traditional classroom work.
As medical students, we learned to create schedules meeting the unpredictable demands of our schooling, then remade our schedules in response to the COVID-induced curriculum changes. Armed with this experience, we can guide our younger family members towards home routines that will give them a greater sense of stability. We can encourage them to keep as close to a normal school schedule as possible. This means a good wake up and bedtime routine, as well as routines centered around the online classroom experience. If there are shortened educational hours, lessons can be supplemented with extra reading and writing time, along with time with family that integrates them into common household activities such as cooking. Immediate family gatherings provide structure as well; scheduled meals and quality time with the family can play a major role in helping everyone adjust to healthy daily habits.
Third, we must encourage our family members to talk about and address the understandable feelings of sadness and confusion they are experiencing. Sadness is a very reasonable and healthy response to the pandemic given the current situation. Many are missing important rites of passage, with canceled recitals, postponed landmark birthday celebrations and online-only graduations. For those who had hoped to flee the nest, summer programs have shut down, universities have moved to distance learning models,\ and even simple road trip plans have been dashed given the domestic travel bans mandated by various states.
Keep in mind that depression is distinct from sadness. As medical students, we learn that a diagnosis of major depressive disorder (MDD) must include at least five symptoms that interfere with daily living, daily for two weeks or more. However, we must be careful: pediatric MDD can also present with a number of somatic symptoms, most commonly headaches, abdominal pain, nausea and vomiting. There are also notable social symptoms, such as withdrawal from family life and reduced academic interest. When we are on the wards, we not only acquire clinical skills and knowledge but also function as the eyes and ears of the residents and attendings. We can use those observational abilities as a line of protection for family members’ mental health.
One day during my psychiatry clerkship, I met a patient who steadfastly refused to talk to the much older attendings. After a brief conversation, the 17-year-old young man warmed to conversations with me. The same is true of my nieces and nephews; at this stage of life, my younger family members feel that I am more approachable due to our closeness in age. This is why as medical students, we hold a unique voice within our families and communities, and we can use it to help the more impressionable generations in our lives. Keeping an open dialogue with our younger family members and a close watch on their mental health will go a long way in helping our families survive this pandemic.