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| PERSPECTIVE/VIEWPOINT |
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| Year : 2021 | Volume
: 3
| Issue : 2 | Page : 73-76 |
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Perspectives on the Pediatric Syndemic: Losses and Opportunities
Margaret Weiss1, Anthony Rostain2, Nicholas Carson3, Sarah Gander4
1 Director of Research for Child Psychiatry, Cambridge Health Alliance, Cambridge MA, USA
2 Chair, Psychiatry and Behavioral Health, Professor, Psychiatry and Pediatrics, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA
3 Medical Director for child and adolescent outpatient services, Cambridge Health Alliance, Assistant Professor in Psychiatry Harvard Medical School, Cambridge MA, USA
4 Clinical Department Head of Pediatrics, Assistant Professor Dalhousie University and Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| Date of Submission | 08-May-2021 |
| Date of Acceptance | 07-Jun-2021 |
| Date of Web Publication | 31-Aug-2021 |
Correspondence Address:
Dr. Margaret Weiss
Cambridge Health Alliance, 1493 Cambridge St, Cambridge, Massachusetts
USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wsp.wsp_18_21
How to cite this article:
Weiss M, Rostain A, Carson N, Gander S. Perspectives on the Pediatric Syndemic: Losses and Opportunities. World Soc Psychiatry 2021;3:73-6 |
| The Syndemic | |  |
A syndemic[1],[2] is a set of linked health problems involving two or more afflictions, interacting synergistically, and contributing to excess burden of disease in a population. Syndemics occur when health-related problems cluster synergistically with contextual or social factors creating an adverse disease interaction to contribute to excess burden of disease in a population. An effective response to a syndemic requires that we respond not just to each affliction but also to the forces that tie those conditions together.
The components of our current global syndemic include the disease state of COVID-19, the social and emotional consequences of the lock-down response to the virus, and the economic devastation selectively impacting disadvantaged people because of closures and unemployment. For children and youth, the syndemic includes additional vulnerabilities. Special needs children lost access to care and services. Children have been asked to be on a computer for a good part of the day to learn-we discovered Zoom fatigue. They have been isolated from peers and the social play that is the essence of childhood. Children have been confined in many cases to their families and exposed to increased parental distress, conflict, abuse, and domestic violence. This is a perfect storm. This paper attempts to describe the pediatric syndemic, and the ways in which we can mitigate syndemic interactions. In many parts of the world, the syndemic is at its peak. As some countries establish vaccination, they are emerging into a postsyndemic world where we will need to better understand the syndemic interactions to address the enduring morbidity we face when the acute COVID-19 crisis abates.
| Parents, Teachers, Clinicians | | |
Parents face unemployment or have been trying to work from home, while also supervising online learning. The usual rules of parenting: limits on screens, or regular bedtime have taken second place to trying to survive caring for children with limited resources. Families have been isolated, sometimes with the awareness of grandparents or other family members who are at risk and need care.
Teachers have had to do heroes work running both an in person and an online curriculum. As students return to school, teachers need to assess and adapt the educational program to be appropriate for both those students who have kept up and those who have fallen behind.
Clinicians have worked over the last year within the constraints and opportunities of telehealth. Clinicians, and health-care systems, are now catching up in identifying the physical ailments and mental illness which was lost to follow up during the acute crisis. In addition, clinical services must now figure out how to create a hybrid system of telehealth and in person care, that optimizes the best of both. Some patients do not want to take time off work, keep their children out of school, endure a long commute, and pay for parking, for routine follow up visits which they have now discovered can be done remotely.
| The Social Context of the Child Mental Health Pandemic | | |
All this is occurring in the social context of awareness that the pandemic has selectively impacted people of color and those living in poverty.[3] This is true for employment, housing, wages, education, parenting and health. Much has been written about each of these challenges. The focus of this commentary is to gain a social perspective on the impact this is having on child mental health. We have yet to discover the full impact of what has been conceptualized as a child mental health pandemic.
It takes a village to raise a child: That village has been disrupted and divided. Children who were out of school lost their access to play, peers, administration of medication, and structure. They lost access to school breakfasts and lunches, counseling, and for those with special needs who could not engage virtually– access to learning. The uncertainty associated with the pandemic, the angst experienced both on a personal and a social level, has for some children been an adverse childhood experience (ACE).[4],[5] At time goes on for countries emerging from the pandemic, we will begin to see the visible and invisible scars the syndemic has been left behind.
| Postsyndemic: Youth and Young Adults | | |
Older adolescents and young adults may feel “cheated” of lost time and lost opportunity to build their own lives.[6] Many college students have had to move back home, a return to the nest that breeds conflict on many fronts. Youth and young adults typically carry a protective veneer of healthy narcissism, perceiving themselves to be invulnerable. The pandemic punctured a hole in the healthy optimism of youth. Even those youth who are resilient, and who have remained silent, have suffered.
| Children with Special Needs | | |
These pandemic pains are exacerbated for children with special needs. Families with children with autism have had to provide 24/7 care for children who lost all in person services.[7] The loss of access to partial hospital programs, in home treatment, and observational assessment has had a major impact on special needs children with serious mental illness.[8] During this period in which we saw a marked increase in psychiatric emergences[9] and in suicidal behaviour,[10] we also saw an increase in wait times in the emergency department and a shortage of beds. The developmental regression and psychiatric decompensation experienced by many youths with special needs in the last year, is going to take time to repair. It is easier to stay well, than to get well. For children who have experienced complex trauma, the syndemic has been an additional ACE that triggers the past wounds associated with complex trauma.[11]
Children who were already in treatment prior to the syndemic for mental health challenges were even more vulnerable during the syndemic. These are the children we are aware of, and yet even some of these children have been lost to follow up because of lack of access to Wi-Fi or for other barriers to care. We know this is only the tip of the iceberg. Information on the impact of the syndemic on emotional well-being at the population level indicates significant unmet distress and need.[12]
| Parents Now | | |
Some parents feel they “survived,” but at what cost? Parents may feel a silver lining that they had this opportunity to get closer to their children. They may also feel they failed their child in one or another respect. In the last year many parents had to act as parent, teacher, guidance counselor, support worker– all while working from home.[13] Many of these parents have themselves had to cope with having COVID, supporting other family with COVID, or losing close friends and family to COVID. The crisis did not leave them with time or the emotional resources to grieve.[14] All this is occurring while many parents are either still working from home or adjusting to a return to work. The financial repercussions of the syndemic will endure for years.
In many families the reopening of schools has created new challenges for children. Children who liked being at home because they had been bullied at school or because they have social challenges may not want to go back to school. Children who spent the last year keeping themselves occupied on screens, are resistant to returning to a daily schedule that involves getting up in the morning and doing nonpreferred activities. Parents who had to create spreadsheets to adapt to the ever complex and changing schedules of hybrid learning, now once again must arrange for permanent childcare. In many settings, this will be the first time we have seen a population of children to return to school after being out for more than a year: We thought September was difficult!
Parents who went into the pandemic with a sprint, now find themselves in a marathon. Resilient parents who were able to escape an acute stress reaction, may now find themselves in a postsyndemic period of yet another adjustment. Ironically, it can be as challenging to stop wearing a mask as it is to start wearing a mask. Parents carry the burden of their own psychological strain, while they are trying to support their children's emotional needs and set up new skills and family routines. This is even more true for single parents or families in which children go between households, routines which may have altered during the pandemic. All these challenges are magnified for parents who have themselves had COVID and now have residual impairment.
| Recovery: Families | | |
The skills we teach in parent training are the same skills that allow a family to function in the syndemic.[15] Setting up daily routines, special time, limiting exposure to stress inducing media, maintaining a healthy diet and sleep schedule, relaxation techniques and even “mindful” parenting: Taking pleasure in the moment for some of the opportunity to be with their children.[16] While we promote all these targets of healthy living, we need to also be aware that there are many things in the current situation which make the usual recommendations of parenting more difficult.[17] How do you help children adjust to school after a year at home? How do you get a child back on an early to bed, early to rise sleep routine? How will your child adjust to a return to activities, and to being with other children?
It is inspiring to see how some of the families we work with have pulled together in the face of adversity.[18] Some families who struggled with organizing in the past, have now successfully set up a schedule. Families thrown upon each other may have engaged with each other in new ways that have strengthened relationships. Working parents who have been home with their children during the past year may have started to engage with their children in new and joyful ways. Families who never ate meals together because of so many extra-curricular activities, may now have a dinner routine. Grandparents called in to help with childcare during the pandemic may have fostered closer relationships with their grandchildren which will endure. Where families have found shared resiliency with their children, this will build coping skills for those children in the future. Adversity can be a become a bonding experiences that fosters attachment and growth.
| Recovery: Clinicians | | |
Clinicians are the gatekeepers of care for children and families in distress, but clinicians have struggled with their own challenges. Digital stress affects all of us who have transitioned to the slightly eerie experience of spending a clinical day with a computer, rather than people. It is a long day trying to help patients connect virtually, struggling to assess a young child who won't stay on the screen, to assess a family when only one person is in the image at a time, or to do a phone consult when more is needed. Clinicians share the strains of the families they treat and offering virtual care may sometimes feel just like too little, too late.
Clinicians who treat children learn to communicate in play: Screens are not a play friendly medium. We are experts in sensing subtle changes in affect, or interpersonal reactions– telemental health makes this more difficult. For clinicians who are of necessity working from home, the boundary between work and home has blurred, and while working from home can be convenient it can also be lonely. The pandemic has been frightening and exhausting, on many levels.
Like their patients, however, clinicians have also found new opportunities grow out of necessity.[19] Telehealth has vastly increased access to follow up and decreased the burden on patients who need help but cannot easily come in.[9] Space which is often a rate limiting factor to hiring new staff may no longer be a constraint. Virtual care has given us a window into patient homes raising awareness of social determinants of health and family interactions we may have missed. Virtual care allows us to 'coach' in the moment as the temper tantrum is happening. Clinicians are warming to the opportunities presented by telehealth and gaining the skills to make this work effective. Telehealth as an opportunity is quite different to telehealth by necessity. New telehealth technologies have expanded the scope of practice, and as the pandemic eases those patients who need in person care will be able to access it.
Necessity has been the mother of invention throughout the syndemic. As we greet the postsyndemic world, virtual communication may open up new opportunities for care. The best of online learning, of being together as a family, of working from home, and of providing virtual care may endure. Out of adversity, comes growth.
| References | | |
| 1. | Singer M, Bulled N, Ostrach B. Whither syndemics? Trends in syndemics research, a review 2015-2019. Glob Public Health 2020;15:943-55.  |
| 2. | Singer M, Bulled N, Ostrach B, Mendenhall E. Syndemics and the biosocial conception of health. Lancet 2017;389:941-50. |
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| 11. | Segre G, Campi R, Scarpellini F, Clavenna A, Zanetti M, Cartabia M, et al. Interviewing children: The impact of the COVID-19 quarantine on children's perceived psychological distress and changes in routine. BMC Pediatr 2021;21:231. |
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| 13. | El-Osta A, Alaa A, Webber I, Riboli Sasco E, Bagkeris E, Millar H, et al. How is the COVID-19 lockdown impacting the mental health of parents of school-age children in the UK? A cross-sectional online survey. BMJ Open 2021;11:e043397. |
| 14. | Roos LE, Salisbury M, Penner-Goeke L, Cameron EE, Protudjer JL, Giuliano R, et al. Supporting families to protect child health: Parenting quality and household needs during the COVID-19 pandemic. PLoS One 2021;16:e0251720. |
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| 16. | Arnsten AF, Condon EM, Dettmer AM, Gee DG, Lee KS, Mayes LC, et al. The prefrontal cortex in a pandemic: Restoring functions with system-, family-, and individual-focused interventions. Am Psychol 2021;May 13. doi: 10.1037/amp0000823. Epub ahead of print. |
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