Commentary: The pandemic will haunt today's children forever, but we can help them now
Summary: As much as the early public health response to the pandemic has been criticized, we should ultimately judge the response to the pandemic on the strength of the support and compassion we give to those who survive it, especially our children.
Unlike adults, children seem to be less vulnerable to the effects of the coronavirus, with few needing hospitalization or ventilator support. But many children are and will be profoundly affected across the United States and worldwide.
There won't be a diagnostic test to tell us which children have been affected, the way a nasal swab might yield a positive result for the coronavirus. However, we will see consequences across all ages and stages of life, both because of the things they will experience and because they will see their parents struggling with other challenges. Moods might change or favorite games might not be fun anymore. The more lasting consequences can include mental and physical illness. Some children will experience strong emotional reactions simply by being aware of the existential threat of covid-19, the disease caused by the coronavirus. And others still may not even be aware of the events playing out around them but will nevertheless be affected by them.
Older children can, of course, be shaken up by stressful events unfolding around them. Puberty is a particularly crucial time for growth and development in key parts of the brain that control emotion regulation and cognitive function. Stress during this vulnerable period can be especially damaging to children who already have accumulated trauma in their lives and further increases the chance a child will develop anxiety, depression or even schizophrenia. Exposed adolescents are at higher risk for risk-seeking behaviors, setting the stage for violence and drug abuse.
There's also ample research to show that a parent's well-being can affect that of their children. Psychological stress during pregnancy increases the likelihood that a baby will be born prematurely and the chance that a child will need breathing and feeding support in the neonatal intensive care unit. Stress can be an endocrine disrupter, in the same way that synthetic chemicals disrupt hormonal functions that shape the development of the brain and other body systems. We don't routinely check cortisol levels in infants, but if we did, we would see higher levels of this stress hormone, because mothers can transmit stress or depression to their infants. Children who suffered the ill effects of toxic stress during pregnancy also have reduced lung function at school age. Stress can increase unhealthy diet and physical activity behaviors in school-age kids, showing up as weight gain that increases the risk of later heart disease.
The effects of stress from the coronavirus pandemic may propagate for generations to come. The Dutch Hunger Winter in 1944-45 showed us how environmental stressors in pregnancy can have effects that reverberate all the way to the grandchildren. Stresses like these change how our genes are imprinted, turning genes on or off without changing the underlying genetic code. These imprints can modify how genes are expressed, not just in those who are exposed, but after they are passed on to the next generation, programming a ticking time bomb of disease that appears as much as 70 years later.
The parallels to the Dutch Hunger Winter are surprisingly relevant for the children living in the poorest households, even in a country where food is plentiful. In our experience working at Bellevue Hospital in New York, these families rely on the public school system for meals for their children. Now, they are reluctant to open their doors, let alone go to community centers for meals delivered there by the city government. When they go out for food, they may resort to the closest and cheapest options rather than the healthiest. Coronavirus-related job and income losses may magnify extant household stressors.
Research on the aftermath of the Sept. 11, 2001, terrorist attacks and other disasters can give us some insight on how to treat and, more importantly, prevent harm. Children of first responders were particularly affected, suggesting that we should focus on families of those who are grappling directly with the crisis, including health-care personnel, who are likely to be at higher risk. Direct experience, such as witnessing the fall of the twin towers in 2001 or thinking a loved one might be hurt, predicted post-traumatic stress symptoms six to seven years after 9/11. People who previously reported re-experiencing the trauma of the disaster were nine times as likely to report re-experiencing the disaster after Hurricane Sandy, indicating that those affected by previous disasters are uniquely vulnerable to the effects of the pandemic.
The stress induced by the coronavirus outbreak will require additional medical care. In primary care, pediatricians have designed interventions to build parenting skills and confidence in low-income families most likely to be affected by the pandemic. These interventions use video recordings and developmentally appropriate toys, books and resources to improve parent-child interactions and strengthen early development in infants, toddlers and preschoolers.
Programs have been built for school-age children to help them adapt and enhance their innate resiliency. We need a trauma-informed approach to care that cuts across all aspects of child and family care, as well as ages and stages of development. Just as we have spun pediatric wards into adult intensive care units on a dime, we need to adapt our health-care settings and schools to provide routine psychological screening to children after we return to normal.
Families can help, even while they are staying at home. Remember that children will observe adult behaviors and emotions for cues on managing their own emotions. Remind children that they can control much of what happens in their lives by practicing good hygiene and self-care, including getting plenty of quality sleep. Parents should also keep an open dialogue with their children about what they are seeing and hearing from peers, websites, apps and games.
As much as the early public health response to the pandemic has been criticized, we should ultimately judge the response to the pandemic on the strength of the support and compassion we give to those who survive it, especially our children. The capacity of the next generation to manage other disasters depends very much on our children rising from the challenges we face now and not simply surviving, but thriving and developing into their fullest potential.
Leonardo Trasande is a professor of pediatrics at NYU Grossman School of Medicine, where he directs the NYU Center for the Investigation of Environmental Hazards.
Benard Dreyer is a professor of pediatrics at NYU Grossman School of Medicine, where he directs the Division of Developmental and Behavioral Pediatrics. He previously was president of the American Academy of Pediatrics.