Students nationwide are returning to school after over a year of virtual or hybrid learning. Most youth across San Diego were prompted to smile with their eyes for their memorable first day of school photos. Masks, hand-sanitizers, and distanced drop-offs are new additions to the school routine. Regular first day of school jitters about new teachers, old friends and new friends, and classroom assignments will be accompanied by new concerns carried over from last year: “Will I get sick? Will my family or friends get sick? Will I be okay? Will school continue? Will I feel alone?” While it takes a village, pediatricians and primary care physicians are important resources for families as children head back to school. In this newsletter and others to follow, we will review common experiences and provide both resources and advice for pediatricians and family physicians so they can be optimally prepared to help their patients and their families.
— Vignette —
8-year old Olivia is a talented musician and ardent learner, but she struggled with virtual learning over the past year. She is nervous to start school, afraid that school will continue to be a challenge for her with in-person classes, stating “maybe I’m just stupid now.” She has been slow to start her morning routine, spending a lot of time in the bathroom with many prompts to come to the breakfast table. She does not want to enter the front gate when arriving at school and frequently complains of headaches, nausea, and stomachaches. During a visit to the school nurse, she makes a comment that one of her classmates was making fun of her for wearing a mask when walking to school.
In children and adolescents, anxiety and stress may manifest differently from how they do in adults. Moreover, anxiety and stress can present differently in each individual child. Somatic symptoms, such as headaches, nausea, upset stomach, and fatigue, are present in 50% to 95% of anxious children (Hale et al, 2017). These somatic complaints can be challenging for schools to navigate, especially in the context of the ongoing concerns about the COVID-19 Delta variant. Some children may begin to delay, avoid, and become quite angry and dysregulated when asked to go to or get ready for school. Others will isolate on the playground and have difficulties integrating socially.
Pediatricians can support children and families by inviting a dialogue about anxiety around the transition back to school and the COVID-19 pandemic and by noting that these have been and are still hard times for lots of people. Parents have concerns of their own about health, work, other children, extended families, finances, schedules, among countless other examples. Just like COVID-19, stress can be contagious and parental stress inevitably affects children. Pediatricians may assist by encouraging parents to stay calm themselves, to seek out emotional support from friends and peers, and to engage in other strategies to promote their own well-being. These actions can enable parents or caregivers to be better prepared to support their child.
Pediatricians can model conversations for parents during visits by asking children what it is like to go back to school, acknowledging that it has been an especially rough year and it might feel different and uneasy (Wykoff 2021). Pediatricians can also brainstorm strategies to creatively grow positive feelings about attending school; these may involve starting routines before/after school, discussing favorite parts of the day, and engaging in fun activities to increase feelings of mastery. Asking about bullying is critical, especially when exploring reluctance to attend school. In Olivia’s situation, a peer was bullying her for wearing a mask before entering the campus. There are increasing instances of bullying around masks (Brown 2021). Pediatricians can empower youth and families by giving a name to these sorts of behaviors, and acknowledging that many people—kids and grownups—are angry and scared. Reminding youth that when they are following the rules, they are helping to keep their school, themselves, their families and community safe and that youth should not feel that they have to answer to taunts or teasing. Practitioners should also stress that if situations become uncomfortable for a child, they and their friends can proudly and comfortably seek support from school staff.
Olivia visits her pediatrician for her persistent somatic complaints and they talk about her concerns. Olivia feels relieved and surprised that other peers are experiencing similar feelings. She agrees to talk with her teacher and her school counselor about what she is feeling and to take time each day to talk about school with her parents. She feels better after telling her pediatrician about the bullying, as her pediatrician reminded her that she is helping to keep her school and family safe. Olivia begins playing music again, settling into her new routine, and soon becomes more confident at school.
Transitions are rarely easy and during this continued uncertain time, reminders to check in, to listen, and to support our patients and families are more important than ever. Pediatricians are well poised to work with schools and parents/caregivers to encourage open dialogue and dispel myths as well as encourage youth to engage in activities they enjoy.
Suggestions for pediatricians and primary care practitioners:
- Incorporate formal or informal screening of all children (and their parents) for anxiety and depression at all primary care visits.
- Validate parental concerns, and encourage parental mental wellbeing.
- Suggest before and after school routines to promote a feeling of security in children.
- Talk with teachers/schools about creating inclusive classrooms and addressing mask bullying.