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Project TEACH/NYS AAP October 2020 Newsletter

Project TEACH E-Newsletter

Schooling in the Time of COVID, Part 1

Project TEACH has been working with pediatric practices in New York State since 2010. The project, funded by the New York State Office of Mental Health, has supported and strengthened the critical role that New York State pediatric primary care providers (PCP’s) can play in the early identification and treatment of mild-to-moderate mental health concerns for children ranging in age from 0 to 21.

One component of the Project TEACH /NYS American Academy of Pediatrics partnership in 2021 is a series of monthly newsletters touching on topics of concern to pediatricians and to parents.

And now to our topic of this Project TEACH Pediatric Newsletter: "Schooling in the Time of COVID, Part 1”

By:

Introduction
As November approaches, we are already several months into the academic year. We are starting to learn what works and what doesn’t. We are also preparing ourselves for the possibility that everything will change again as colder temperatures and flu season approach. Most likely, we have become well versed in what does not work when it comes to schooling, whether it be entirely remote, through hybrid learning or a return to in-person classes with a whole host of new rules. As we navigate these challenging times, there is no shortage of articles, news stories and videos covering the topic and offering advice. To help sort through all of this information, we find it helpful to break up tips into three categories and then within those categories consider different options to choose from that may work for your family. The categories: routine and predictability, facilitating open discussion, and encouraging self-care.

Keep in mind as you consider these categories and specific ideas that while the details may differ depending on the age of the child you are focusing on, the underlying principles apply throughout childhood and adolescence, and, indeed, across the lifespan. It also may be helpful to consider that while the goal of school is primarily centered around academic outcomes, it has grown to serve so much more than that in the lives and development of youth. While learning facts and how to be a good test taker are helpful in navigating today’s society as an adult, the best way to foster a child’s happiness and self-actualization is to use this time to teach resilience and psychological flexibility.9

Routine and Predictability
When faced with times of such uncertainty and chaotic nature, it is best to take a breath and focus on the basics. This is where structure and routine play a major role. When we find ourselves spiraling (as adults, children or adolescents), being able to rely on even the smallest routines can provide predictability, and even comfort. Keeping home life as predictable as possible will provide the entire family with the structure needed to navigate times that are completely unpredictable otherwise. In tackling this, we recommend starting small:

  • Pick out some basic and essential routines that will be the same regardless of remote or in-person learning. An example would be a morning routine – no matter the time that the child wakes up, have them go through the same schedule: get out of bed, brush their teeth, change out of pajamas, have breakfast (or whatever variation of this your household may have).5 It may be as short as 5 or 10 minutes but starting out the day with even that small amount of predictability can alleviate a great deal of anxiety that a child might otherwise have if they are laying in bed trying to figure out what the day holds for them.
  • Another basic way to tackle routine and predictability is with a physical and/or digital calendar.5 This can be useful for mapping out in-person vs remote learning days, how they match up with the adult schedules in the home and especially marking down fun and enjoyable activities – such as family game nights, virtual play-dates or a physically distanced family outing.

A reliable physical environment can be quite important to establish a sense of predictability. This does not mean the child needs a full home office. Something visual that clearly marks a consistent space where they are expected to complete their schoolwork is important in helping to orient them and facilitate transitions between “school time” and “home time”.5

  • This can be as simple as a specifically colored placemat at the table. When in households with multiple children, physical dividers may be helpful to limit distractions if each child is struggling to focus.5 In that space, it is important to set expectations as clearly as possible for what work will need to be completed. This can be done by writing a to-do list, or laying out only the work that will need to be completed in the space. Sometimes having timers or clocks around to help divide up the child’s time in completing these tasks can assist with breaking up the day more.
  • Speaking of timers and timing, setting limits on screen time and social media can be incredibly helpful in maintaining your child’s mental health.5 The transition away from screens and social media tends to be one of the more difficult times of day. Visual timers can be helpful for this, especially with younger children or children with developmental delays. If you are not sure exactly how much time will be needed (if say, an adult is on a work call), you can use a timer such as numbers (5,4,3,2,1) written on post-it notes one of which the adult removes every so often in a way that allows for the end of the time to correlate with a time that functions within the whole family’s need but still does so in a predictable way.5

While all of these structures and routines are helpful for predictability, for some they can take away a sense of control from a child in a very uncontrollable time, which runs the risk of increasing anxiety and frustration. To address this, it is helpful to increase a sense of control in your child by offering choices when appropriate.5

  • If you work a family board game or outdoor activity into your routine, letting the child choose the game or the outdoor activity (or the route of the outdoor activity if it is a walk, bike or drive) can increase the child’s sense of control in their environment.
  • Another example could be allowing the child to have design choice of calendars or to-do lists so that they are associated with a fun crafting activity in lieu of an added stressor or school assignment.
  • Lastly, with routine and predictability, make it work with your whole family’s schedule. Each family is navigating their own school, work and childcare requirements. Identify and acknowledge the challenges and barriers you face, and then communicate with your child’s school and teachers so that they can provide you with support in overcoming them.7,8

Discussion and Checking in
As difficult as this time is for you and your child, this is a true opportunity for socioemotional learning and facilitating a stronger and more open connection between your child and the rest of the family.1 This is a chance to explore where some of the big emotions that are coming up now fit into your child’s development. If it hasn’t already become clear, one thing that children are fantastic at is picking up on household and adult anxiety. They tend to be aware when something is off. This is a very important time to be honest with your child, while also being reassuring. So much is unknown, which can be unsettling for adults and children both. By clearly acknowledging things you don’t know (will school ever open up, will school close again, etc), while also emphasizing the reassuring things you do know (we live in a safe home environment, I am and will continue to be here with you, we will update and support you through whatever happens), you are conveying and role modeling an approach to confronting uncertainty in life.

  • When providing explanations or updates to children, it is helpful to do so in a developmentally appropriate way – sharing information that is clear and understandable will be essential to addressing their anxieties. Visual aids may be especially helpful, particularly when discussing day to day routines, handwashing expectations, mask wearing expectations and physical distancing.1
  • Speaking of mask wearing, that is certainly a new task that children are taking to at varying levels. Some tips to keep in mind include: making it fun with colors, characters or themes, ensuring that it is as comfortable as possible with headbands or ear savers, giving choices in what type or which mask to wear, modeling wearing a mask during fun or enjoyable activities, explaining why it is important to wear a mask, involving the child’s favorite toy in wearing a mask, graded exposure (look at the mask, touch the mask with your hands, touch the mask to your face without putting it on, putting the mask on for gradually longer periods of time) and then when you do go out, utilizing rules, breaks and rewards to incentivize proper mask wearing.10

Another important piece of open discussion is knowing what your child is exposed to through social media, the news or peers. This can help you be informed as to some of the worries or anxieties that your child may have. It is important to keep in mind the following basic themes: productive vs unproductive worries, maintaining reasonable expectations and knowing your resources.

  • Regarding worries, children, adolescents and adults will have many worries around this time. It is helpful to determine which are productive and should therefore be addressed and which are unproductive and should therefore be encouraged to be discarded.6 It is important to do this in a validating way that shows appreciation for the worry, while reassuring the child that focusing on this worry will not serve to change or decrease the worry.
  • Feelings associated with any type of worry may translate to periods of increased distress and dysregulation and while those shouldn’t be ignored and safety is most important to consider, they should also be taken with the expectation that it is appropriate to have big reactions (to a degree) during this time.7,8 Lastly, know your resources. It is important to be familiar with what supports you can call on, whether they be family, friends, community supports, school supports, physical health professionals or mental health professionals.

Self-care
Even before COVID hit, self-care was a hot topic. Similar to the opportunity to facilitate deeper connection and open discussion with your child, this is a fantastic opportunity for building resilience through focusing on the importance of caring for themselves during difficult times. Though this may not fall under one’s traditional idea of “self-care”, a huge piece of this is fostering growth in your child’s socioemotional learning.1 This should be worked into part of their every day routine and can be done in a variety of ways.

  • One of these ways is an emotional “temperature check” at the beginning, middle or end of the day during which the child tells you how they are feeling through a chart, feeling word or number demonstrating the intensity of their feeling.1
  • It is then helpful to discuss the physical sensations that pair with the emotion being experienced to help facilitate a stronger mind-body connection. Another way to foster socioemotional learning includes promoting journaling or group discussion with peers or siblings, which can give your child opportunities to process their emotional reactions and receive validation and normalization of their experience.

Humans are social beings and attending deliberately to social interactions is an important part of self care. The time of COVID has led to an increased sense of isolation from others, which has continued into the school year whether the child is attending school in person or remotely.1 It will be important to foster human connection even more during this year. This can be done through facilitating group discussion in school, virtual or physically distanced hangouts with peers outside of school, sending letters to friends, studying or completing assignments together virtually or in a physically distanced way or other creative ways (such as making a joint playlist together).

In addressing caring for themselves when they are alone, this is a time to encourage new skills such as mindfulness or grounding techniques. For younger children, mindfulness often resembles playing, especially playing make-believe, as it engages their imagination but in a way that focuses on the moment and their “right now” experience.3 In talking about play, it is important to stress the need for active engagement. While spending so much time inside and with the limit of extracurricular activities, it is important to facilitate hands-on activities when families can.1 This can be done with outdoor activities such as walking or biking or with indoor activities such as board games, crafting, drawing or painting, cooking or having family dinners.

Lastly, and most importantly of this entire article is the importance of role-modeling self care and fostering self-compassion.6 This is one of the most difficult times that your family may go through, and everyone is going through it at the same time. Everyone will have their periods when they are experiencing big emotions and big reactions.7,8 It is important to have compassion for yourself and for your children. It is also important to encourage them to have compassion for themselves as this is arguably more important for them to learn during this time than any academic syllabus.

Sources

  1. Berman, G., & Dubinski, A. (n.d.). Supporting Students’ Mental Health During COVID. Child Mind Institute. Retrieved October 5, 2020, from https://childmind.org/article/supporting-students-mental-health/?utm_source=newsletter&utm_medium=email&utm_content=Supporting%20Students%E2%80%99%20Mental%20Health%20During%20COVID&utm_campaign=Public-Ed-Newsletter
  2. Brown, R. (2020, September 25). URMC partners with schools to help parents navigate remote learning. WHEC News10NBC. https://www.whec.com/back-to-school-rochester/urmc-partners-with-schools-to-help-parents-navigate-remote-learning/5874369/
  3. Fairyington, S. (2020, September 18). How to adapt meditation for little kids? It looks a lot like play. Washington Post. https://www.washingtonpost.com/gdpr-consent/?next_url=https%3a%2f%2fwww.washingtonpost.com%2flifestyle%2f2020%2f09%2f18%2fchild-mindfulness-meditation-pandemic%2f
  4. Gleeson, S. (2020, August 4). The revised meaning of self-care in the wake of COVID-19. Counseling Today. https://ct.counseling.org/2020/08/the-revised-meaning-of-self-care-in-the-wake-of-covid-19/?utm_source=counselinginsider&utm_medium=email&utm_campaign=ct_online&utm_term=article&utm_content=selfcare
  5. Hume, K., Waters, V., Sam, A., Steinbrenner, J., Perkins, Y., Dees, B., Tomaszewski, B., Rentschler, L., Szendrey, S., McIntyre, N., White, M., Nowell, S., & Odom, S. (2020). Supporting Individuals with Autism through Uncertain Times. Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill. https://afirm.fpg.unc.edu/sites/afirm.fpg.unc.edu/files/covid-resources/Supporting%20Individuals%20with%20Autism%20through%20Uncertian%20Times%20Full%20Packet.pdf
  6. Mental Health America B4Stage4. (2020). Back to School 2020 – Coping During COVID – Outreach Toolkit. Mental Health America. https://mhanational.org/sites/default/files/Full%202020%20Back%20to%20School%20Toolkit%20-%20Images%20Separate_08.28.20.pdf
  7. SPCC, Whole Child Connection, & UR Medicine, Golisano Children’s Hospital. (2020a). Returning to Middle and High School Education during the COVID-19 Pandemic. The Society for the Protection and Care of Children.
  8. SPCC, Whole Child Connection, & UR Medicine, Golisano Children’s Hospital. (2020b). Returning to Pre-K and Elementary Education during the COVID-19 Pandemic. The Society for the Protection and Care of Children.
  9. Strauss, V. (2020, October 5). How much learning is really “lost” when children aren’t in school buildings? Washington Post. https://www.washingtonpost.com/gdpr-consent/?next_url=https%3a%2f%2fwww.washingtonpost.com%2feducation%2f2020%2f10%2f05%2fhow-much-learning-is-really-lost-when-children-arent-school-buildings%2f
  10. Strong Center for Developmental Disabilities in the Division of Developmental and Behavioral Pediatrics. (2020, August). A toolkit for helping your child wear a mask during COVID-19. University of Rochester Medical Center. https://www.urmc.rochester.edu/MediaLibraries/URMCMedia/strong-center-developmental-disabilities/documents/Mask-Wearing-Toolkit.pdf

Overview of Project TEACH Services

Current initiatives in Medicaid and Commercial insurance and the NYS PCMH incentive project, all create an environment that encourages pediatric practices to work toward integrating children’s behavioral healthcare into pediatric primary care. Behavioral health integration has the potential to enhance the value proposition for most practices.

Project TEACH Child and Adolescent Psychiatrists are available through the Project TEACH warm lines to provide guidance on assessment of a children’s and adolescents’ mental health symptoms and evidence-based treatment following traumatic events. You can also find the Child PTSD Symptom Scale (CPSS) on the Project TEACH website: https://projectteachny.org/rating-scales/

Project TEACH can help with a variety of behavioral health concerns presented by COVID-19, including school re-entry and self-care: https://projectteachny.org/covid/

Project TEACH direct services to pediatricians include:

Accessing the educational and supportive services of Project TEACH can help your practice contract for higher payments, while also supporting you and your team in providing more comprehensive higher quality care to your patients with mild-to-moderate mental health concerns.

Funded by a grant from the New York State Office of Mental Health’s Project TEACH.

New York State American Academy of Pediatrics (NYS AAP)

A Coalition of AAP NY Chapters 1, 2, & 3

Elie Ward, MSW | Dir. of Policy, Advocacy & External Relations | eward@aap.net

About The Authors

Michael Scharf, MD

Project TEACH Child and Adolescent Psychiatrist, Region 1
Chief of the Division of Child and Adolescent Psychiatry, Golisano Children’s Hospital

Annalyn M. Gibson, M.D.

Child and Adolescent Psychiatry Fellow, University of Rochester

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