Child Mental Health in the COVID-19 Context
Last Updated: July 29, 2020
Now more than ever it is important for your patients to look after their health and receive care from you as their healthcare provider. It’s essential that patients continue to seek out care that they need.
This tool has has been developed to support primary care providers in navigating and providing patient care in a world where COVID-19 is the ‘new normal’. While how care is delivered has changed, efforts should be made to ensure that the quality has not. As always, when treating your patients, continue to use your clinical judgement and follow standards of care, best practices, evidence and guidelines.
Click on the sections below to get started:
How to talk to children about COVID-19
Parents and caregivers should ensure children receive honest and accurate information during the COVID-19 pandemic (SickKids, March 31, 2020).
- Share ‘need to know’ information with children, using age appropriate language.
- Answer questions directly and honestly, and do not make false promises.
- It’s okay if you don’t know all the answers. Focus on the short-term plan for the whole family.
- If children are distressed, let them know that it is ok and understandable to have these feelings.
- Model healthy coping skills and attend to your own physical and mental health.
- Consider seeking out additional resources and supports for children with special needs or who are having trouble coping. For a list of local mental health services for families, children and youth, see Local Services > Mental health services.
Answering children’s questions about COVID-19
“We wipe things down to keep them clean.”
You don’t need to explain more than this—young children don’t understand germs or infection transmission yet.
“Sometimes people wear masks to decrease sickness from spreading, when they aren’t feeling well or to help keep them safe from getting sick.”
“Everybody gets sick sometimes. If you get sick, your parents will take care of you until you are all better. I will help you, too.”
“Your child care/school is closed right now. Your teacher and your friends are home too, just like you. When child care is open again, you can go back and see your friends.”
Avoid going into details about illness so toddlers don’t develop fears about attending child care.
“Right now, there is a rule that families need to stay home for a little while and be together. That helps you and your friends stay healthy. I know it can be sad when you can’t see and play with friends, but there are lots of fun things you can do at home!”
Given the Pfizer vaccine has been approved for use in children age 12 and older, children and their parents may have questions regarding COVID-19 vaccination in children. See COVID-19 Vaccines for Ontario Youth (Kids Health First, 2021) for answers to frequently asked questions, as well as other resources for parents, youth and providers.
Preparing children for reopening
Reopening is presenting kids with a different set of anxieties and challenges. Doing the following, parents and caregivers can help children adapt and prepare for the changes resulting from COVID-19:
Plan, but stress flexibility
Even if only a few weeks at a time, planning ahead will help give kids a sense of safety and security. Children should be included in planning and informed that these plans might have to be reassessed. This can lessen their anxiety over how they’ll be spending the next few months and help them prepare to handle changes.
Agree on ground rules
Establishing clear family rules for socializing will give kids a sense of control. Empathize with their fears, but encourage them to think of ways that your family will work together to help everyone stay safe and healthy.
Take it step-by-step
Emphasizing that reopening is a gradual process can help kids manage their behaviour and feel more confidence. Steps to start with might include maintaining physical distancing or wearing a mask while with friends, or limiting the number of friends your child can see. Discuss what other steps might come down the road so kids know you’re planning ahead even if they can’t do everything they want just yet.
Prepare children by coping ahead
Other families might follow different rules, which could result in uncomfortable moments for kids. Work with kids to anticipate unsafe situations they might encounter so they feel more comfortable and can make better decisions when the time comes.
When a child expresses worry or fear, helping them know their feelings are valid will help manage those feelings. Instead of telling them not to worry, try to find out what they are worried about and answer their questions to correct any misinformation.
Encourage kids to do various activities in their neighbourhood, such as go on a bike ride or play games outside, and ask them which one they think would be the easiest. Pair this with praise or even a reward for trying one of these activities.
Be alert to signs of something more serious
Look out for signs of mental health distress as discussed in following sections.
Recognizing the signs of mental health distress
Look out for:
- Changes in behaviour or emotions that seem out of proportion even with the current circumstances (e.g. angry outbursts, depressed mood, sense of panic).
- Problems sleeping; shifts in sleep patterns.
- Appetite changes; changes in weight.
- Headaches, stomach aches/nausea and fatigue.
- Infantile behaviours that aren’t common anymore for the child (bedwetting, thumb sucking, being afraid of the dark, wanting to be held).
- Loss of interest in activities they enjoy; reduced feelings of anticipation.
- Worry and/or fear of leaving the home.
- Increased rebellion and/or complaining about schoolwork or chores.
- Increased aggression towards others.
- More frequent outward expression of emotions.
- Harsh self-assessment.
If a child expresses thoughts of hurting themself or engages in suicidal behaviour, seek help from a mental health professional immediately. For a list of local mental health services for families, children and youth, see Local Services > Mental health services.
For age-specific signs, see Is my child or adolescent feeling stressed about COVID-19? (SickKids, April 14, 2020).
Circumstances of the pandemic can make the symptoms of depression worse.
See How to help youth tackle the blues during COVID-19 and #physicaldistancing (CPS, March 31, 2020) for information on how to:
- Validate feelings.
- Create a new routine.
- Challenge negative thoughts.
- Solve immediate and controllable problems.
- Stay connected to family and friends.
- Be kind.
- Reach out to a professional.
Managing stress and anxiety
Use the CARD System (Comfort, Ask, Relax, Distract) to help children cope
- Comfort: help the child accept negative thoughts and feelings.
- Ask: listen and talk to each other.
- Relax: model relaxation for the child.
- Distract: try to keep normal routines and limit the amount of time the child focuses on whatever is making them anxious.
General actions to help support children during the pandemic (WHO, 2020)
- Support children with at-home learning, and make sure time is set aside for play.
- Help children find positive ways to express feelings such as fear and sadness. Sometimes engaging in a creative activity, such as playing or drawing, can help with this process.
- Make sure children have time away from screens every day and spend time doing off-line activities together. Draw a picture, write a poem, build something, bake a cake, sing, dance, or play outside where safe to do so.
Actions to combat disconnectedness
- Create a photo album of the child’s favourite activities or memories.
- Make a playlist of favourite songs that remind the child of family and friends.
- Schedule time to connect with parents, siblings, extended family members, and friends through a phone or video call.
- For more creative ways to stay connected, see Coping with separation from family and friends during COVID-19 (SickKids, April 14, 2020).
When a family member is self-isolating
Emphasize that this will be temporary. Although we don’t know when, this will end.
Family member(s) who must self-isolate should offer the child choices, and together, plan how they will stay connected. This will support the child’s sense of control, as well as the emotional connection between the child and the family member(s).
For more information, see How to talk to your kids about COVID-19: Considerations for health care providers (CMA, March 23, 2020).
Children experiencing the death of someone close to them are particularly vulnerable (Canadian Virtual Hospice, 2019). They need time to process their thoughts and feelings and to ask questions. Willingness to discuss difficult topics teaches children that hard conversations can happen safely, and that they can talk with you about difficult things (Canadian Virtual Hospice, 2019).
Talking to a child about the loss of a loved one:
- Have the conversation in a safe, comfortable place where you won’t be interrupted.
- Get down to eye level.
- Tell them that you may be upset or cry while you talk because you’re feeling many emotions, and that this is natural and okay.
- Explain that they may have strong feelings too and it’s okay to express them.
- Start with what the child already knows and build from there.
- Give the information in a straightforward way, using words they can understand.
- Let them know their questions are welcome. Praise them for asking questions and sharing their thoughts and feelings.
- Be gentle and sensitive, giving the information they ask for and need.
- Watch for cues to guide you around pacing the conversation, signs that will help you gauge how much information to provide and when the child is ready to hear it.
- COVID-19 Fact Sheet: Talking to Children About the Pandemic (MOH, March 28, 2020).
- How to talk to your child about COVID-19 (SickKids, March 31, 2020).
- Talking To Kids About COVID-19 (Anxiety Canada, November 24, 2020).
- COVID-19 for 3-6 year olds (COVID-19 Health Literacy Project, 2020).
- COVID-19 for 6-12 year olds (COVID-19 Health Literacy Project, 2020).
- COVID-19 for 13-18 year olds (COVID-19 Health Literacy Project, 2020).
- My Quarantine Book.
- From Fear to Hope: A parent’s guide to supporting children’s mental health during the COVID-19 pandemic.
Coping with separation from family and friends
- Coping with separation from family and friends during COVID-19 (SickKids, April 14, 2020).
- How to talk to your kids about COVID-19: Considerations for health care providers (CMA, March 23, 2020).
For individuals with developmental disabilities
- How to stay safe, well and connected (Health Care Access Research and Developmental Disabilities, October, 2020).
- Supporting your child with a neurodevelopmental disorder through the COVID-19 crisis (SickKids, April 14, 2020).
- COVID-19 resources for health care providers and caregivers (Surrey Place, 2021)
Stress, anxiety and fear
- Is my child or adolescent feeling stressed about COVID-19? (SickKids, April 14, 2020)
- The CARD system for parents/caregivers.
- Supporting youth with anxiety disorders during the COVID-19 pandemic (CPS, April 3, 2020).
- Don’t Use the ‘D’ Word: Exploring Myths about Children and Death (Canadian Virtual Hospice, 2019).
- Talking with children and youth about death (Canadian Virtual Hospice, 2019).
- When to Tell the Children: Preparing Children for the Death of Someone Close to Them (Canadian Virtual Hospice, 2019).
- Helping Your Toddler Cope with Grief and Death (ZERO to THREE).
Acknowledgement and legal New
The COVID-19 Resource Centre was developed by the Centre for Effective Practice (CEP) in collaboration with the Department of Family Medicine at McMaster University, the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario using a rapidly modified version of the CEP’s integrated knowledge translation approach.
They are some of several clinical resources developed as part of the Knowledge Translation in Primary Care Initiative. Funded by the Ministry of Health and Long-Term Care, this initiative supports primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.
Clinical Working Group
A clinical working group was established and provides significant input and oversight into the development of this resource. Members include:
• Claudia Mariano, MSc, NP-PHC
• Darren Larsen, MD, CCFP, MPLc
• Derelie Mangin, MBChB (Otago), DPH (Otago), FRNZCGP (NZ)
• Dominik Nowak, MD MHSc, CCFP, CH
• Jennifer P. Young, MD, FCFP-EM
• Lee Donohue MD, CCFP, MHSc, MPLc
• Mira Backo-Shannon, MD, BSc, MHSc
• Paul Preston, MD, CCFP, CCPE, CHE
• Rob Annis, MD, CCFP
• Soreya Dhanji, MD, CCFP
In addition to our clinical working group the CEP also obtained feedback from others, including:
• Arun Radhakrishnan, MSC, MD, CM, CCFP
• David Price, BSC, MD, CCFP, FCFP
• Jose Silveira, BSC, MD, FRCPC, DIP, ABAM
• Michael Chang MD, FRCP(C)
• Payal Agarwal, MD, CCFP
• Robert Sauls MD, CCFP(PC), FCFP
• Tara Walton, MPH
Thank you to everyone who supported the development of this resource.
Conflict of interest
• Clinical Leads receive compensation for their role
• Clinical Working Group receive an honorarium for their participation
• Focus group and usability participants receive a small token of appreciation (e.g. gift certificate)
The Child Mental Health in the COVID-19 Context resource is a product of the Centre for Effective Practice. Permission to use, copy, and distribute this material for all non-commercial and research purposes is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of the Child Mental Health in the COVID-19 Context resource for commercial purposes or any modifications of the Tool are subject to charge and use must be negotiated with the Centre for Effective Practice (Email: firstname.lastname@example.org).
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