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CLINICAL PERSPECTIVES
Protecting Youth Mental Health During the COVID-19
Pandemic: A Challenging Engagement and Learning
Process
C
ecile Rousseau, MD, Diana Miconi, PhD
lobally, the COVID-19 pandemic is causing
extensive morbidity and mortality and is fueling
psychological distress across populations. Early
evidence has shown an increase in anxiety, depression and
sleep problems in the general population.
1,2
Although
pandemics shatter the functioning of communities and
families globally, there is a paucity of studies targeting the
effects of pandemics on youth mental health.
As mental health professionals, our fields have become
aware of how the COVID-19 outbreak represents an
extraordinarily stressful experience for youths, including how
necessary public health measures may also threaten personal
and collective meaning-making, and disrupt family dynamics
and youths’usual social environment. Because of the
COVID-19related school closures and social distancing
measures, millions of children have been confined at home.
Although families, communities, and schools have attempted
to adapt, at times successfully, many children and youth have
been deprived of structured support, trapped in dysfunctional
family settings, and are relying largely on peer relations
through the unsupervised use of social media.
3
In the absence of much needed evidence, clinical
experience and available evidence on stress-related disorders
in emergency settings is provisionally informing clinical
practice and defining the role of child mental health services
during a pandemic. Although it is impossible and premature
to address all aspects of pediatric mental health during the
COVID-19 pandemic, it is important to begin conceptu-
alizing what this pandemic has meant for our practice and
where and how we can promote pediatric mental health
during a global emergency that is not currently remitting.
INDIVIDUAL YOUTH MENTAL HEALTH DURING
THE PANDEMIC
The mental health consequences of the COVID-19
pandemic in youth have been diverse, ranging from the
onset of stress-related disorders to the exacerbation of pre-
existing disorders, including a flare-up in cyber depen-
dence, and also, in rare cases, the alleviation of disorders (eg,
school phobia for some).
4-6
During the pandemic, a primary role for mental health
expertise is distinguishing normative responses to pandemic
adversities, that are not associated with severe psychological
distress or with significant impairment, from pathological
responses that require a specialized intervention.
Nevertheless, the fear of illness and death and the many
stressors of the pandemic can result in symptoms that corre-
spond to adjustment disorders and to posttraumatic stress
disorder (PTSD),
7,8
diagnoses that can be made during
ongoing dangers (such as pandemics, wars, domestic violence).
Some populations may be especially vulnerable, such as
those for whom the stresses reactivate personal or trans-
generational traumas. This reactivation may be associated
with the severity of the exposure, such as if youth or their
loved ones have become sick or family members or friends
have died.
7
In addition, children of essential workers,
homeless children, children with uncertain immigration
status, and children whose supports (particularly intensive
psychiatric and psychosocial supports) have suddenly
diminished or disappeared may be at increased risk for
developing mental health difficulties.
9,10
As the death toll rises, numerous children are grieving a
loved one in a context that is often highly traumatic because
of frightening aspects of the death—witnessing shortness of
breath, ambulances, videos of intubated relatives—as well as
associated helplessness, not being permitted to say goodbye,
and guilt associated with the impression of having aban-
doned the deceased. The confinement rules also interfere
with culturally accepted mourning processes, which may
further aggravate unresolved and complicated grief.
11
Adopting a developmentally informed trauma perspec-
tive that acknowledges individual and family capacity in the
G
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Volume 59 / Number 11 / November 2020
face of adversity may assist in assessing and, to some extent,
addressing traumatic consequences of a pandemic for youth.
As one example, some refugee families told us that they used
the stories about the ways in which they survived war,
deprivation, and a cholera epidemic to reassure their chil-
dren, conveying the idea that they had the collective
strengths to overcome this new challenge.
A key challenge has been how to safely provide mental
health services to individuals and families during an infec-
tious disease pandemic. Available evidence suggests that
telepsychiatry has been a promising tool with children and
adolescents in emergency situations. Indeed, telepsychiatry
has rapidly become a vital component in the efforts to
reduce safety risks related to coronavirus exposure.
12
However, its applicability to each case needs to be care-
fully evaluated, and, though it provides a measure of safety
during an infectious pandemic for all involved, its risks and
inadequacies must be further understood.
13
The availability
of the technology, the quality of Internet connections, the
level of computer skills required, the security of the tech-
nology, and the level of confidentiality possible at home
during the assessment and therapy sessions, as well as the
risks of eliciting disclosure of violence or abuse in an unsafe
environment, are potential drawbacks to telepsychiatry.
9,14
Crucially, it has been essential to recognize how the
pandemic changes our treatment courses.
Lucia is a 10-year-old girl presenting to the emergency
room with an exacerbation of her obsessive-compulsive disorder
(OCD) symptoms and suicidal ideation. Her pre-existing
hand-washing rituals had become pervasive. She reported
having the impression that the only way to escape death was to
commit suicide by jumping off her apartment building. Sur-
prisingly, she minimized the pandemic, stating “I don’t care.”
However, her mother reported that Lucia had recently become
terrified at the idea that her budgies could be killed by a virus,
and added that the cognitive behavioral therapy (CBT) that
they were receiving was not working well in the present context.
To increase Lucia’s sense of control and agency, the clinician
asked Lucia to help to keep her grandparents safe by Skyping
with them every day and reading them a story. Lucia and her
mother stated that they felt better after the assessment.
Lucia’s case illustrates how the pandemic can fuel
feelings of helplessness in children with pre-existing anxiety
and depressive disorders. Together with OCD symptoms
around contamination fears, which can be frequently
observed, Lucia’s suicidal ideation and attempt represent a
desperate bid to regain a sense of control. The clinician
proposed a shift from a CBT approach, with which the
family was already familiar, to an Acceptance and
Commitment Therapy (ACT) approach, which could better
meet Lucia’s need to accept the helplessness that she was
experiencing and to inform her on possible ways to become
meaningfully engaged with the situation.
WORKING WITH THE FAMILY DURING A
PANDEMIC
Recognizing the extent to which family mental health affects
youth mental health, we have to acknowledge the cross-
generational stress caused by the pandemic. Parents’fear of
infection during a pandemic is associated with the transmission
of the same fear to their children, which in turn is associated
with children’sanxiety.
15
Confinement and isolation measures
have a negative impact on caregivers’functioning, their ca-
pacity to support their families, and their own mental health,
and this can increasingly disrupt family dynamics. A recent
systematic review highlighted an increase in PTSD symptoms,
confusion, and anger in adults who underwent quarantine.
16
For families, confinement-associated stressors such as un-
certainty about the pandemic’s duration, frustration and
boredom, lack of in-person contact with peers, reduced phys-
ical activity, irregular sleep patterns, and financial strains un-
dermine family functioning and ultimately youth mental
health.
17
Mental health is more likely to deteriorate in families
in vulnerable situations, for example, in those who experience
financial difficulties affecting the availability of food and access
to healthcare, those who live in overcrowded housing, as well as
families with a history of child abuse or neglect, a history of
domestic violence, or who have special needs (eg, children with
a disability, parent with mental health problems).
9,10
Assessing the relative safety of a child at home is one of
the major challenges posed to mental health professionals
during a pandemic. Fueled by parental stress and in the
absence of the benevolent gaze of the school or daycare, the
risk of maltreatment is increasing as the rate of cases re-
ported to youth protection is decreasing.
18
A key intervention for mental health professionals is family
support through education. Parents and caretakers can be
educated about age-appropriate communication around what
is happening, how to access social support, and how to re-
establish of a sense of safety and normalcy via routines (eg,
regular schedule, sleep patterns, eating habits), symbolic play,
physical exercise, and learning. Reactions to quarantine and
confinement measures vary according to age group and may be
particularly challenging during adolescence because such
measures interfere with typical individuationseparation pro-
cesses (eg, interactions with peers, rules imposed by adults).
9,19
Adults should be encouraged to listen to children’scon-
cerns and to engage them in proactive ways, speaking about
the pandemic in ways appropriate to the child’s age and
developmental level. Multiple age-appropriate guidelines on
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Volume 59 / Number 11 / November 2020
ROUSSEAU AND MICONI
how to do this are available and can be recommended to
parents.
9,19
However, vulnerable families and parents over-
whelmed with anxiety will need guidance and support to
understand and to implement these guidelines in a reassuring
manner. Through psychoeducation, there is an opportunity
for clinicians to make parents aware, in a nonjudgmental way,
of the effects of their own anxiety and stress on their children.
Nathan, a 7-year-old boy with nonverbal autism spectrum
disorder, was brought to a hospital emergency room because of
an increase in severe aggression toward himself, his mother, and
his siblings (eg, biting, hitting). Nathan’s school had been closed
the week before. Initially, his mother was overwhelmed, and
terrified by the virus as well as by the prospect of spending
several weeks at home with her son in a very small apartment.
From our interview, we came to understand that Nathan was
reacting both to his mother’s anxiety and to substantial changes
in his routine. The extended family was mobilized to facilitate
the planning of a short- and medium-term respite for the
mother. At the end of the interview, the clinician explained to
Nathan why his mother was afraid. He listened carefully before
establishing a brief but intense eye contact with her.
Nathan’s story illustrates the frequent consequences of a
disruption of routine and lack of developmentally appro-
priate explanations about what is happening for children
with ASD. Such children can become disorganized and
unmanageable, further undermining the family system,
which can result in them experiencing terrifying feelings of
rejection. The clinician modeled in front of the mother a
way to help Nathan make some sense of the situation,
involved the extended family to offer support in a systemic
resilience-based approach, and proposed parental support
through virtual communication.
ADDRESSING YOUTH MENTAL HEALTH NEEDS
ACROSS SOCIETY
During natural or social disasters, children and youth are
exposed to frightening information from the media, from
peers, and from the adults around them. A great deal of this
information is incorrect, misinterpreted, or taken out of
context.
3
Mitigating the exposure to frightening informa-
tion and supporting a developmentally adaptive under-
standing of the pandemic is key in the prevention of youth
mental health difficulties.
Pandemics have been associated with an increase in stig-
matization of specific minority groups, fueled by dramatic
headlines and political provocations in the traditional and social
media.
20,21
For example, during the COVID-19 pandemic
there has been a flare-up of conspiracy theories targeting the
Jewish and the Chinese communities, among others.
22,23
Furthermore, the extent to which marginalized and minority
communities are disproportionately affected by the pandemic,
both in terms of mortality and morbidity,
24,25
has been well
documented, in addition to the cumulative disadvantages of
social precarity,
26
such as educational disparities in youth.
27
Luke is a 14-year-old boy with attention-deficit/
hyperactivity disorder and oppositional defiant disorder who
is living in a group home placement. He was brought to the
emergency department because of an escalation in acting-out
TABLE 1 Take-Home Messages for Professionals Working in Child Mental Health Units During a Pandemic
The mental health consequences of a pandemic on youth are associated with communication around the pandemic, as well as with
individual, family, and community dynamics.
The pandemic may trigger anxiety symptoms but also externalizing behaviors (eg, acting out), and increase suicide risk and
substance abuse, in particular among adolescents.
Supporting parents and communities by providing guidance can help reduce stress-related symptoms in children and adolescents.
Pre-existing mental health disorders in children and adolescents may be exacerbated by the social and family contexts during the
pandemic.
Assessment of risks of suicide and aggressive behaviors and development of strategies for risk reduction and safety planning in the
context of state and national stay-at-home policies are important components in the role of child and adolescent psychiatrists and
other mental health professionals in providing care to individual children and adolescents during this crisis.
The pandemic has led to an expanded role for telepsychiatry in current efforts to reduce safety risks associated with COVID-19
exposure for patients of all ages and healthcare workers.
The disruption of standard services and health professionals’security concerns call for a systemic and resilience-oriented approach
that relies largely on family and community resources.
The elevated stress is likely to cause tensions within institutions and teams. Acknowledging and validating clinicians’legitimate fears
and mobilizing courage and hope among them is essential.
Journal of the American Academy of Child & Adolescent Psychiatry www.jaacap.org 1205
Volume 59 / Number 11 / November 2020
CLINICAL PERSPECTIVES
behaviors (eg, fights, defiance of safety measures that limited
contact with his family). The clinician realized that he had
become fixated on online pandemic conspiracy theories pro-
moting an anti-Semitic rhetoric. He projected the anger and
distress prompted by the confinement onto these external en-
emies that he wished to fight. Some problem-solving discussion
led to the identification of a mentor in the group home staff to
begin regular jogging and who would support him in his online
activities, thus responding to some of his attachment needs while
promoting critical thinking.
The pandemic is further disrupting the already fragile
attachment balance established by children and adolescents
in foster care. Young people like Luke, feeling hurt, rejected
and attacked, will use splitting and will project their aggres-
sion onto an external aggressor through blaming, attacking,
and rejecting. Intervention in such cases can focus on
addressing the attachment issues at the core of the problem
and understanding how the behavior represents acting out as
an attempt to regain control on the anticipated rejection.
Child mental health professionals must continue to
advocate to ensure that families and children get the mental
health support that they need to support resilience, to
decrease family conflict and child maltreatment, and to
decrease risk-taking, unsafe, and dangerous behaviors.
6
The COVID-19 pandemic challenged our preparedness
to deal with a global health emergency. The pandemic has
highlighted how we need to be able to adapt our skills to
emergency environments to creatively use available re-
sources to meet the needs of youth and families.
The high levels of distress observed among mental
health staff, ranging from emergency departments to out-
patient departments, reflect our real fears as well as our
uncertainty in facing a crisis which is shattering our world
and challenging individual, familial, and collective notions
of safety and security, while exposing individual, familial,
and social vulnerabilities. In the present context, the
governmental and institutional responses to mental health
professionals’legitimate concerns about their own safety as
well as that of their loved ones is based on the reiteration of
security measures, although data on casualties among
healthcare staff demonstrate that these measures only
partially protect against the risk.
28
Indeed, the danger of
contagion for ourselves and our families is real, and our
capacity to confront it without being paralyzed requires
acknowledging the risk and nonjudgementally sharing our
fears within our teams, while collectively assuming our re-
sponsibilities as mental health professionals in the midst of
adversity. Support and solidarity within mental health teams
is an essential first step to support courage and hope in an
emergency context. Some preliminary take-home messages
for professionals working in child mental health units are
reported in Table 1.
As we look forward, we need to consider how we must
rethink educational, community, and family support in a
pandemic that is not going away. For example, what com-
munity systems can we put into place to support vulnerable
children during school closures? What can we do to protect
children in their homes, when their homes may not be safe,
while youth protection agencies are in total disarray? What
are the strengths and limitations of a virtual clinical approach?
Answering these questions is crucial in order to develop
effective strategies in response to youth mental health needs
during a major health crisis such as this one.
Accepted August 21, 2020.
Prof. Rousseau and Dr. Miconi are with the Faculty of Medicine, McGill Uni-
versity, Montréal, Quebec, Canada.
The authors have reported no funding for this work.
Author Contributions
Conceptualization: Rousseau
Investigation: Miconi
Resources: Rousseau, Miconi
Writing eoriginal draft: Rousseau
Writing ereview and editing: Miconi
ORCID
C
ecile Rousseau, MD: https://orcid.org/0000-0002-6533-6774
Diana Miconi, PhD: https://orcid.org/0000-0002-7088-1646
Disclosure: Prof. Rousseau and Dr. Miconi have reported no biomedical
financial interests or potential conflicts of interest.
Correspondence to C
ecile Rousseau, MD, Professor Division of Social and
Cultural Psychiatry, McGill University, Scientific Director eSHERPA Research
Center CIUSSS Centre-Ouest-de-l’I
ˇ
le-de-Montr
eal, CSSS de la Montagne (Parc
Extension), 7085 Hutchison, Suite 204.2, Montreal (Qc), H3N 1Y9; e-mail: cecile.
rousseau@mcgill.ca
0890-8567/$36.00/ª2020 American Academy of Child and Adolescent
Psychiatry
https://doi.org/10.1016/j.jaac.2020.08.007
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All statements expressed in this column are those of the authors and do not
reflect the opinions of the Journal of the American Academy of Child and
Adolescent Psychiatry. See the Instructions for Authors for information about
the preparation and submission of Translations.
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Volume 59 / Number 11 / November 2020
CLINICAL PERSPECTIVES
