'You deserve to celebrate': A doctor's advice for teens and parents during the pandemic

The rites of passage that often define childhood — summer camp, prom, tossing a mortarboard into the air at graduation — will look very different this year, if they happen at all. And that can have a profound impact on the mental health of young people.

It's not just the loss of fun activities. They're missing out on experiences meant to “conclude one chapter in our life and start the next chapter,” said Dr. Joshua Stein.

Stein is a psychiatrist with PrairieCare, a mental health provider with locations in the Twin Cities and Rochester, Minn., and president of the Minnesota Society of Child and Adolescent Psychiatry. He joined MPR News host Tom Crann with advice for young people and their parents who are struggling in the present and looking ahead to an uncertain future.

Hear their conversation using the audio player above or read a transcript of it below. It has been lightly edited for clarity.

I want to start with teens, especially those who may be missing out on the end of their senior year or are trying to make decisions about their future in a very scary time. What advice do you have for them and their parents?

The uncertainty is making things more difficult, and especially for teenagers who commonly are at a period where it's very appropriate to rebel to test the limits. They're being brought back into the home and feeling very much like elementary school students. For teenagers, interactions with friends are the most important thing to them — their clubs, their sports. Many of those things have been taken away and that can be overwhelming.

I think what teens do have that older people or young children don't is the ability to really connect online, and I would say that allowing them to do this and encouraging them to do it in healthy ways is very important.

Milestones are so important from a cultural perspective for helping us conclude one chapter in our life and start the next chapter. I think figuring out how to make these significant events [even as we are social distancing] is very important. And parents may find that their teens have better ideas about how to do this than they do.

Is there the potential for lasting impacts when it comes to, for example, post-traumatic stress disorder?

Unfortunately, based on what we're seeing out of initial reports from China, in the Journal of the American Medical Association, is that about 20 percent of kids are displaying trauma-related symptoms [such as] depression and anxiety.

It's uncertain right now how long those symptoms will last and, if they're adequately treated, how quickly kids will respond. But I think there is concern that as we go through flu seasons in the future, as we see people wearing masks in the future, that it may trigger fear and this helplessness that many children are struggling with right now.

I think as we move through this, helping them remain focused on their future, even if the timing is uncertain, can help protect against those lasting symptoms.

At what point should parents seek help, and what help is available?

In some ways, resources are more available than they've ever been. The opportunity to connect with a physician, nurse practitioner, or therapist through a computer may feel very comfortable to a teenager in a way that may not feel comfortable to older adults.

In my practice and in my colleagues’ practice, teens actually seem to let their hair down, relax and engage in a strikingly different and more authentic way. They have in some way it's practiced for this, whether on Snapchat or other apps, and so they may feel more prepared for it.

The first part of your question: When do we think it's time to ask for help? [That can] feel confusing. I think a lot of teenagers are going to be more irritable, they're going to be pushing back more, they're going to perhaps have more difficulty with day-to-day routines, as many of the structures have dissipated. Teenagers love to sleep and may be sleeping more.

But I think when it feels like things have changed significantly — when your teenager is not making it to family dinner a few days a week, when they’re rebelling to the point that you're concerned about their safety or stability — I think that would be a point to reach out for help.

One additional point, we know that teenagers and children from homes where there are adverse childhood events, such as neglect or abuse, they really benefit from the structure of positive childhood events — those connections to sports teams, to churches, synagogues and mosques. Right now, we're seeing that many kids presenting to our clinics and our hospitals are showing that the loss of the structure from beforehand is really a risk factor. If in the past they've needed this structure to be successful, it may be worthwhile reaching out to get some more support.

What would you say to the class of 2020 right now?

To the class of 2020: You have a very bright future. The world may be more moldable and more flexible than it's ever been when we come out of this. You should be excited for it. You will make major changes.

You will be able to vote in your first presidential election this year. You have an opportunity to speak and make major change.

Though [ceremonies and events] being canceled, [the milestones] are still happening. You are still graduating and you deserve to celebrate. Find a way to celebrate them with your family, with your loved ones. And at some point, you will celebrate them with your peers.

Remain focused on your future. It is going to happen and it's going to be wonderful. We're just waiting to figure out when. You have an opportunity to make a marked change in this world, and we're excited to see what you do.

What about younger kids?

We are seeing some significant changes there, as well. And I think with younger kids, the warning signs can be a little bit harder.

Some kids are struggling to even know how to talk about their feelings. In elementary schools, there's a lot of emotional learning that takes place. And for toddlers and those who don't speak or have limited words, it's really hard to understand where they are at.

One things parents can look for is an increase in irritability and an increase in somatic concerns like upset stomach, having more trouble bathrooming, changes in their appetites and major changes in their sleep-wake schedule.

It's an opportunity for parents to start the conversation that these children may not know how to have. And truthfully, it's a chance to share your own emotions. Children learn a lot from mirroring their parents and seeing what their parents do, and by talking about your own emotions and what is hard for you, it may give your children the words and the language to talk about how, in fact, they are doing.

What changes are you seeing in in your patients or your workload at PrairieCare?

Initially, we saw a dip in the amount of patients. Now we're seeing quite the opposite, and this does mimic what is being seen in New York and in California.

Currently, we are seeing significantly more kids [saying] the pandemic and their subsequent quarantine is the reason that they need admission to the hospital or they need admission to an intensive day program. They are reporting that the isolation and loss of structure are incredibly hard on them.

Parents are reaching out for more support, more help and more crisis stabilization resources as parents are required to wear more hats within their family, being a teacher, a therapist, a chef. There's increased conflict, and so it's getting harder.

And we are seeing a large shift in these adjustment-related concerns triggering genetic illnesses that hadn't been triggered in the past.

Stressors related to the pandemic are triggering genetic illnesses?

We know that for many illnesses, whether schizophrenia, bipolar disorder, depression or anxiety, there is this genetic predisposition.

Often there is an environmental cue that can lead to the condition presenting itself. This level of stress, with the loss of many of the supports that are so helpful, whether it be religious or a good coach, can really be overwhelming and lead to that kind of presentation.

An example would be in children with a predisposition to depression. The loss of structure, the loss of supports, the isolation and loneliness can rapidly present as a neuro-vegetative state where things really slow down. They're sleeping excessively. They're eating too much or not eating very much at all. And they're losing interest in things.

What about parents? How can they take care of themselves during this time?

The first step is to remember that it is not valuable to be stoic right now. You do not have to be utterly strong. It may be helpful to show your children your emotions and how you're feeling. This may, in fact, help them express themselves in a healthier manner.

The other part is, it's OK to go easy on yourself. No one is expecting you to be the perfect teacher and the perfect parent and make sure your child is getting the right amount of outdoor time. Medical professionals understand that this is a unique time. The American Academy of Pediatrics has recommended less than two hours of screen time. That is not the case right now [and] you do not need to feel guilty about that.

For some parents, though, this may be reaching a point where it is too much for them. They are finding that they are tearful every day. There are lots and lots of supports through telehealth that can help parents when they are having a hard time. If you are starting to have thoughts of not wanting to get up or feeling like you're inadequate or you can't take care of your children anymore, this is a chance to get some support and help. But it is OK to [let go of] our desire for being perfect and be more flexible at this time.

More advice from Dr. Stein:

The following is adapted from the American Academy of Child and Adolescent Psychiatry.

• Try to establish a regular routine and schedule at home. Kids are reassured by structure and predictability.

• Give kids choices, where there are choices. You may not be able to visit friends or go to the movies, but you can pick which game to play or program to watch.

• Help kids keep in touch with friends and family members by phone, e-mail, FaceTime, Zoom, Skype, etc.

• If kids have questions about COVID-19 or about why you’re sheltering in place, answer them honestly, using words and concepts they can understand.

• Help children find accurate and up to date information. Print out Fact Sheets from the Centers for Disease Control and Prevention, World Health Organization or your local health authority.

• Don’t let children watch too much television with frightening images. The repetition of such scenes can be disturbing and confusing.

• Encourage kids to choose something new to learn about. It could be a game, a craft or a challenging book

• Make sure kids stay physically active. If you’re in a rural area, take a walk outside (observing social distancing guidelines). If you’re in a more urban setting, help your child develop and maintain a regular in-home exercise routine.

• Let kids participate in menu planning and meal preparation. Try and cook or bake something new.

• Be flexible … and patient. Sheltering in place may seem fun for the first few days, but the novelty quickly wears off. Your kids may not always feel like talking or doing what you’re doing.

• Be honest. Acknowledge that this is a difficult time for everyone. It's normal to feel tense and anxious under such trying and unusual circumstances.

• Give kids space. Everyone needs some private “down time”.

• Let little things go. Try not to overreact when things break, take too long or don't go quite as expected.

• Make future plans. Talk about and research things to do and places to go after the pandemic ends.

This reporting is part of Call To Mind, our MPR initiative to foster new conversations about mental health.

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