Even before the pandemic, Ana Groves was well aware that working full-time and raising three kids was challenging.
"I feel like I'm always just running around with my head cut off trying to do everything," Groves said.
With the pandemic came added responsibilities: monitoring her kids' remote learning and helping them adjust and feel safe. All of which triggered some difficult emotions.
"I had a lot of anxiety, a lot of stress, a lot of guilt," Groves said. "Just always thinking: 'Am I doing enough for them? My teenager, is he sleeping 'til noon? How is that going to affect him?' "
Navigating the pandemic with her 8-, 14- and 17-year-old children became increasingly overwhelming.
"I think the pandemic pushed me over the edge," Groves said. "I was already just hanging on by a string."
In March of 2020, as the virus began to take hold in the U.S., Groves' eldest son was placed in a therapeutic boarding school after years of being in and out of psychiatric hospitals to treat Tourette syndrome, obsessive-compulsive disorder and attention deficit hyperactivity disorder. Groves was used to the challenges that come with caring for a child with mental health issues.
She said there were periods of time over the last few years — usually about "a good six months," where she said her son would be fine living at home, but eventually, his mental state would decline.
"I think the pandemic pushed me over the edge. I was already just hanging on by a string."Ana Groves
"What that looks like with him is severe dysregulation, and that includes self-injurious behaviors," Groves explained. "He can get pretty aggressive, and that's not him at all. But he can get aggressive with others. He's destroyed furniture."
Pandemic-related restrictions prevented visits to her son's new school so it made it difficult for everyone to acclimate to his new placement. She wanted to see her son, and his siblings wanted to know that he was OK. Groves said trying to feel connected and keeping the kids feeling safe about COVID, while taking precautions, was a tough line to draw.
Talking To Kids About The 'Feelings Doctor'
Last fall — with no end of COVID in sight — Groves took a 12-week leave from her teaching job to help her and her children adjust. When she returned to work amid managing her suburban Foxborough household, she went to see her doctor. She felt overwhelmed.
"I ended up going to my primary care in February and said, 'I just, I am not handling anything,' " Groves said. "I broke down in her office."
The Centers for Disease Control and Prevention cites a 2021 study estimating that one in 14 children has a caregiver with poor mental health. Some recent surveys of parents suggest that as many as half of them reported that their mental health worsened during the pandemic. The most common issues are depression, anxiety and post-traumatic stress.
For Groves, her doctor prescribed medication. And Groves started seeing a therapist, or what her 8-year-old daughter, Kate, calls "a feelings doctor."
"It's a doctor you go to to talk about what you're feeling and thinking," Kate explained.
Because of their sibling, Groves said her kids already understood the importance of mental health, so she has been open with them about what she's going through. Kate said she might want to talk with a "feelings doctor," too. The isolation of the pandemic has made her sad, and she might like to talk more about what she's experienced.
"My friends," she explained. "Like, if their parents tell them they can't have a play date or something with other people, and they can't go out of the house."
Many children's mental health experts say what Groves is doing is exactly right: communicating about her own struggles and normalizing mental health issues.
"I think that's such a great way of explaining developmentally appropriately to an 8 year old ... a 'feelings doctor,' " said Dr. Chase Samsel, medical director of the Psychiatry Consultation Service at Boston Children's Hospital. He added that being forthcoming with kids increases the likelihood that they'll reach out to process difficult emotions.
"Families should come back together and say, 'Listen, we can talk about this,' and 'This happens,' and normalize emotions in difficult times and show that we can still move forward," Samsel said. "We can still be OK."
How Caregivers' Actions Affect Kids
How a caregivers mental health ripples down to a child largely depends on the family's response and circumstances. The greater the pandemic adversities — such as financial hardships, or the illness or death of a loved one — the greater the likelihood of mental health issues.
"There's some really profound consequences for kids who are constantly feeling that sense of threat and not getting the support that they need from caregivers who themselves are either absent or overwhelmed."Dr. Heather Forkey
In a large-scale crisis like a global health pandemic, many caregivers tend to focus on the wellbeing of kids. But many experts stress that when crisis strikes everyone, parents need to prioritize getting support for themselves. Dr. Lovern Moseley, a psychologist at Boston Medical Center and CEO of Empowerment Counseling in Stoughton, said doing that will help caregivers better gauge a child's health, help kids feel safe and model how to reach out for help.
"This has been a very abnormal event, and we can't apply the same coping strategies that we may have had in the past," Moseley said. "So that means that parents have to look at how to take care of themselves first, and that's going to be the thing that's going to help to benefit their child."
Several pediatricians said while children will typically experience the same mental health issues as adults in a crisis, the symptoms might be different — especially in younger kids. They advised watching how kids play to observe if they're behaving aggressively or having trouble with daily functions, like eating or sleeping. For older kids and teens, the symptoms usually resemble rebellion and anti-social behavior.
UMass Medical School pediatrics professor Dr. Heather Forkey said long-term exposure to stress affects the brain's physiology — especially for developing brains. Feeling safe is key, she said, because the body responds to threats by overstimulating the parts of the brain that seek safety, while turning off the parts that allow for higher-level thinking. Forkey said that could affect kids' ability to focus, organize information, and ultimately, impact their physical health.
"So there's some really profound consequences for kids who are constantly feeling that sense of threat and not getting the support that they need from caregivers who themselves are either absent or overwhelmed," Forkey said. "In a very primitive way, we're animals, and we're responding the way we were designed to respond.
"Recognizing what that physiology is," she added, "and working with it, instead of against it, would be to our advantage."
As director of the Child Protection Program and Foster Children Evaluation Service at UMass, Forkey also sees a lot of vulnerable families. She said the less children are supported by caregivers, the more adverse childhood experiences (ACE) they're likely to carry. Several studies have shown that children with a higher number of ACEs often have mental and physical health problems into adulthood.
Research from other large-scale disasters, such as hurricanes or 9-11, shows that close to half of children have some type of initial reaction, like depression or anxiety. But the effects of a more than year-long global pandemic are still unknown. Some researchers are looking for clues in studies on the effects of long-term trauma on the whole family; similar to what happens during some divorces.
Resiliency Can Be Built
Lili Lengua, a University of Washington professor partnering with Harvard researchers to study the mental health of children during COVID, estimates that the number of kids with behavioral and mental health problems will double because of the pandemic. What's more is that those with stressed caregivers are especially at risk.
"Adult's mental health — everyone's mental health — was more likely to worsen in the pandemic," Lengua said. "For youth, in some ways, we can think of it as a double jeopardy or a double whammy from the pandemic. Not only are they and their families experiencing stress, but if their parents have their emotional or mental health disrupted, that, in turn, probably disrupts their ability to support their children."
Lengua said much of the previous disaster research suggests that about a quarter of children affected by a disaster will have longstanding problems — and those can last for years. The kids most at risk are those who had behavioral health issues before COVID.
The good news, Lengua said, is that the research suggests that most kids are expected to bounce back.
"For most children, this will be something like a speed bump in their life, and most of them will be resilient to the effects of the pandemic," Lengua said.
The key to that resilience, according to many researchers, is the social support or buffering that is available to kids and caregivers. They also said while nearly everyone has experienced some degree of discomfort during COVID, that does not mean that every problem is a mental health issue.
"We've been through a difficult time, but difficulty doesn't mean that we all have a mental health disorder," said Melissa Brymer, director of terrorism and disaster programs at the UCLA-Duke National Center for Child Traumatic Stress. "So how do we make sure we acknowledge that there have been some struggles right now, that there are things that you can do to help yourself right now? And how do we normalize and educate on those issues?"
"We've been through a difficult time, but difficulty doesn't mean that we all have a mental health disorder."Melissa Brymer
Brymer said support can come in many forms — connecting with communities, establishing familiar routines and perhaps getting directly involved with projects that help others as society makes its way out of the pandemic. Support for some may involve trying to move on quickly while others may need more of a focus on acknowledging the loss of loved ones and livelihoods.
For Foxborough mom Ana Groves, "bouncing back" will be a process. She said she'll continue to work with a therapist, exercise regularly and be involved with parent support groups. But for her, the pandemic has left a permanent mark.
"I'm a happy, smiling person, and it's changed me for sure — still has," Groves said. "Still, I'm struggling on a daily basis to just find the good, you know?"
This project is funded in part by a grant from the NIHCM Foundation. Illustrations and animations in this series were created by Sophie Morse.