With Americans being vaccinated at a rate of more than two million shots per day, attention has begun to turn to life after the pandemic. But public-health officials are increasingly concerned that more than half a million deaths in this country alone and a year of isolation, closed schools, and lost jobs have had traumatic effects on many Americans, especially children. To talk about what those effects might be, and how to insure that people get the care and support they need, I recently spoke by phone with Dr. Archana Basu, a clinical psychologist at Massachusetts General Hospital and a research scientist at the Harvard T. H. Chan School of Public Health. During our conversation, which has been edited for length and clarity, we discussed how children and adults deal with trauma, the distinct challenges facing young adults, and how lessons from the pandemic can be used to improve mental-health care going forward.
When it became clear that a pandemic was going to change our lives, what were you most concerned about, in terms of mental health?
As was the case for a majority of Americans, I don’t think I expected what the horizon for the pandemic would be. I doubt that most of my colleagues really anticipated it would last as long as it has. We absolutely expected that there would be an increase in mental-health concerns and some level of distress, because that would be a very typical reaction to an extreme pervasive stressor or trauma, like a pandemic. And we’ve seen this in the past with other mass disasters. There is an increase in mental-health concerns and distress, and then once safety is reëstablished and a sense of routine is reëstablished, we see a decline and a return to baseline for the overwhelming majority of people, including children. What that’s really saying is we are very adaptable, certainly as humans, and as kids. It is with the prolonged period, such as the one we are experiencing now, that we start to worry about more long-term and more pervasive effects.
What effects, specifically?
We are hearing about an increase in rates of severe anxiety and depression-related concerns. We also know that this may have been even more challenging for people who were already struggling with mental-health concerns. There is emerging data to show that rates of self-injuring behaviors have increased as well. The fact is that is what we would expect, and we are seeing a really broad spectrum of mental-health and behavioral concerns. However, I do want to point out that I don’t think this is going to be limited to mental-health concerns. I think there are other parts of our children’s lives where we’re going to see those effects. Some of that might be physical health. Pediatricians have been very concerned about the amount of exercise that children are getting. And there is emerging data to show that sleep- and weight-related issues might be other examples of physical-health concerns.
You focus especially on kids. How might the mental-health challenges facing kids after something like this be different or similar for adults, broadly speaking?
Fundamentally, I think children of all ages—and this is certainly truer for younger children, but really even teens—need a supportive, responsive adult, at least one responsive caregiver, to really help them understand what’s happening, to cope with it in terms of thinking about what they’re feeling, what they’re experiencing. An adult’s capacity to cope with the level of unpredictability and isolation is just more varied relative to a child’s. One of the biggest things that is different for children is that they are not going to get as much out of digital tools, because they’re just much more likely to need the in-person interaction. This is especially true for younger kids. And we know from decades of research that a supportive caregiving environment is one of the strongest buffers for children. And I think that is different for kids than it is for adults. Adults need social support and social connections, but I think their capacity in terms of figuring out a way to access it and to perhaps go longer periods without it is greater than it is for children.
The second thing is the idea of stability. We all benefit from routines and structure, but children are developing their sense of routine and structure, and when there is a stressor or trauma like a pandemic, all elements of their lives are affected. They need an adult to help them develop those routines and structures in this adapted format. And having that sense of stability and predictability—it’s true for all ages, but kids really benefit from that.
If children do not get these things that you’re saying they need, what are the long-term effects of that?
So, for younger kids, that might look like what we think about as difficulty in regulating themselves, whether it’s sleep, whether it’s a bigger emotional response to even the smallest kind of challenge that they might otherwise be able to cope with. It may be more irritability or anger, but also somatic symptoms around eating and sleeping. It’s a range of symptoms, but broadly in more extreme versions what we think about as anxiety, depression, lack of motivation for school, or lack of desire to connect with other people. In younger kids that might be less willingness to play, or their emotional regulation is going to look different, so more crying, more irritability.
What should the government have done at the state and local and federal level to prepare for this, starting a year ago? And what did they do?
A couple of things have come out of this pandemic period that have been very valuable and that I hope will define future policy. There’s always been a shortage of mental-health-care resources, even pre-pandemic, and certainly if you move out of major cities and metropolitan areas, that was definitely true, even more so for children. We were already looking at a system that was really close to capacity or at capacity when the pandemic came along.
And so at this stage, the emerging mental-health landscape really speaks to the need for not only increasing our capacity but fundamentally rethinking the ways in which we are delivering mental-health care. An example of that would be that pre-pandemic, in the state of Massachusetts, where I practice, some insurance companies would reimburse remote tele-mental-health care, and other insurances did not. One of the things that happened in the pandemic across the United States really was that there were emergency orders issued to make this remote tele-mental health reimbursable by insurance companies, and in the state of Massachusetts that includes both video and phone sessions. Recently, in the state of Massachusetts, this has now been made permanent. And this is actually important because, while it makes mental-health care hopefully more accessible to a broader group of people, it also just reduces the burden in terms of commute. But we also know that a video visit requires a stable Internet connection, which is not always possible and not available to every family, and so I think the fact that it also includes phone sessions is important. To me, that is one very concrete example of how policy related to mental-health care can be a game changer.
That being said, I think there are at least a couple of other areas for us to consider. Fundamentally, our health-care system, including our mental-health-care system, is a tertiary health-care system. By the time we see children in an outpatient clinic, they have a diagnosable mental-health condition that they have really been struggling with for a while. In fact, the criteria to diagnose someone and bill their insurance requires that the mental-health condition be actively impairing their lives, whether it’s in terms of their school or their relationships. So, fundamentally, we are working in a system that prioritizes tertiary care. And this is a big problem, because we really know that we can work with people, and children in particular, in a preventive manner. There are emerging models of care that have actually been used across the country—I won’t say uniformly certainly—but there’s been successful implementation of this in different health-care settings across the country, and I think they are becoming more common, which I think is important and promising. Basically, these are integrated models of care where mental-health assessments and interventions are integrated as part of routine care visits, whether it is pediatrics or internal medicine.
The other thing that is emerging is the use of digital tools. There is emerging data to show that, for certain types of mental-health concerns, at low to moderate severity, certain types of digital tools, like those the V.A. uses, are a very effective adjunct to working with a therapist. So that traditional model of weekly hour-long sessions or fifty-minute sessions—we can build on that, and digital tools can really help with that process. There are very effective interventions for anxiety or sleep aid.
What do you compare the pandemic to, or what events do you look to, when trying to make sense of it?
Prior mass disasters such as Hurricane Katrina are one example that we might extrapolate from and learn from. But we know that it’s a best-case estimate, because the pandemic has upended every element of our lives, and it has really fundamentally changed how we live, how we work, how we attend school. It’s not geographically circumscribed, and it’s been prolonged. And it seems like perhaps there’s a horizon now, but, as you said, there’s still a ways to go. So I think there are ways in which we can learn from prior mass disasters, but also recognize that this is a pretty unique stressor that we haven’t experienced before.
Obviously, different kids are going to deal with this in different ways, and, of course, different groups have been hit harder and less hard by the pandemic. So I don’t want to make it seem like everyone’s had the same experience, but, broadly speaking, does the universality change how to treat it, how to talk about it, how to think about it, how people respond to it? At the very least, people are looking around and seeing other people with similar challenges.
