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Communicating With and Supporting Youth Diagnosed With COVID-19: A Trauma-Informed Care Approach

      Relaxing or removing COVID-19 pandemic-related restrictions (e.g., mask-wearing), increasingly transmissible variants, and lack of vaccination is facilitating SARS-CoV-2 transmission in youth [
      • Riley S.
      • Wang H.
      • Eales O.
      • et al.
      REACT-1 round 12 report: resurgence of SARS-CoV-2 infections in England associated with increased frequency of the Delta variant. medRxiv. Published online January 1, 2021:.
      ]. COVID-19 has also brought increased exposure to potentially traumatic events for adolescents such as a COVID-19 diagnosis, hospitalization or death of a close family member or friend, loss of important life events, economic challenges, and/or increased exposures to abuse or violence in their home or community. Mental health challenges (e.g., depression) for adolescents have increased since the start of the pandemic [
      • Chadi N.
      • Piano C.S.-D.
      • Osmanlliu E.
      • et al.
      Mental health-related emergency department visits in adolescents before and during the COVID-19 pandemic: A multicentric retrospective study.
      ].
      Importantly, adolescents have similar cognitive abilities to adults when it comes to reasoning about health risks and information [
      • Reyna V.F.
      • Farley F.
      Risk and rationality in adolescent decision making: Implications for theory, practice, and public policy.
      ], but uniquely they also have strong needs for autonomy and social connection [
      • Horesh D.
      • Brown A.D.
      Traumatic stress in the age of COVID-19: A call to close critical gaps and adapt to new realities.
      ], and exhibit notable developmental and individual differences in their neurobiological susceptibility for mental health problems when exposed to stress [
      • Malter Cohen M.
      • Tottenham N.
      • Casey B.J.
      Translational developmental studies of stress on brain and behavior: Implications for adolescent mental health and illness?.
      ]. Those youth who are diagnosed with COVID-19 may be at even higher risk for mental health challenges due to isolation and fears.
      Given the increase in mental health challenges and potentially traumatic events for many adolescents, we provide a trauma-informed approach for medical care that providers can use to support adolescents’ emotional health through a COVID-19 diagnosis. Primary goals of trauma-informed medical care include identifying youth and families who are struggling with trauma reactions/emotional health, connecting families to resources, and preventing further/retraumatization. See Table 1 for examples of trauma-informed messages that providers can use with youth diagnosed with COVID-19.
      Table 1Trauma-informed messaging for common questions and concerns among COVID-19+ adolescent patients
      Example questions from COVID-19+ adolescentKey message content from healthcare providers
      No symptoms, mild, or moderate symptoms
       How did I get sick? Is it my fault?Most of the time we can’t tell exactly when or where people get COVID19 because so many people have it and it’s very easy to spread from person to person. Wearing masks, giving people space, and washing hands are really important for reducing the risk of getting it, but they don’t reduce the risk to nothing. Despite this, it is still important to do these things because they work most of the time
       I’m going to be so bored. I don’t want to do this [isolate at home], I’ve already missed so much school/friends/activities.It’s fair to be angry and upset about these things. Let’s make a plan for how you can pass the time and still do things that you enjoy
      Providers can aim to come up with a concrete activity plan focused on self-care and practical activities that meet the teen’s needs. Listening and validating will be important so that teens are heard and their specific concerns are addressed.
       Why do I need to stay home if I feel fine?Being honest with yourself and others is a huge part of becoming more independent. The truth is that while it is still in your body, you can spread the virus to other people, people you care about and people you do not know. You can be the best friend possible by staying at home until the isolation period is over and your body has gotten rid of the virus
      Some teens will not perceive a need to isolate and not be amenable to this guidance. Fear-based messaging, especially around low probability events, is generally not conducive to behavior change. We recommend focusing on prosocial guidance such as being a good friend or finding other motivators (e.g., honesty, independence) that are salient and valued for the teen and their family.
       What if I fall behind at school?We can talk with your school to get you extra help or time for your work if you need it
       What kinds of treatments am I going to get?Most young people don’t even know they have the virus and do not need treatments. Some have fevers and feel unwell, just like with other viruses. We can give medicine to help lower temperature and ease aches and pains if you need them. If you get very sick, there are doctors and nurses at the hospital to take care of you
       What are people going to think if they find out that I have COVID?Right now, millions of people are getting COVID. It can be tough to deal with. There is a lot of misinformation around. Tell me more about what you are worried about
      Messages can encourage the teen to only take responsibility for themselves while asking other people to take responsibility for their feelings and emotions; providers can follow-up on teens’ specific concerns as appropriate.
       What if my family or friends are mad at me for getting COVID?Millions of people have gotten COVID. Lots of teens are struggling with the stress of COVID. We can get you some support if your family or friends are stressing you out about COVID
      Messages can encourage the teen to only take responsibility for themselves while asking other people to take responsibility for their feelings and emotions; providers can follow-up on teens’ specific concerns as appropriate.
      [action: offer referral for mental health intervention]
       What if I can’t do [insert activity, e.g., play soccer] as well after I get better?Most young people recover well and are able to get back into their activities quickly. If you have long-term symptoms, we will be here to help you figure out how to work through them
      Messages can encourage the teen to only take responsibility for themselves while asking other people to take responsibility for their feelings and emotions; providers can follow-up on teens’ specific concerns as appropriate.
      (action: review practice guidelines for return to activities [e.g., https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/])
       Is someone going to get sick because of me and die?The virus is no one’s fault. You and your family are going to follow precautions (for example, stay at home) to give your body time to heal and recover. Honesty is an important part of any relationship, so it’s important to be a good friend to others you care about by staying home. This way you are being honest with yourself and others about the risks, and taking ownership of what you need to do to manage these risks. If you need help with process at any point you can always talk to me, your parents, or I can put you in touch with a psychologist
      This can be a practical factual question or a sign of emerging stress, providers can consider screening and monitoring mental health, and referring as appropriate.
       My parents are worried about me. What can I do?Focus on taking care of yourself. I will help your parents if they need it
      This question should be viewed as indicator of the caregivers needing more support.
       Will I ever get better?Some young people that get COVID19 do not feel sick at all. Others feel unwell for a little while and need to rest, and then completely recover! Rest can help you feel better. You or your parents can call our office with any questions you have when you are not feeling well
       Am I going to die?It is very unlikely that will happen. Most young people with COVID19 have no symptoms or recover quickly
      Symptoms requiring hospitalization
       What kinds of treatments am I going to get?Some treatments in the hospital might include helping breathing, medicines to help with inflammation, and medicines to help your body’s immune system deal with the virus. Sometimes young people can feel unwell a few weeks or months after they got the virus. The teams in hospitals are very used to giving this kind of help. The doctors and nurses at the hospital will explain any treatment they think is needed and why
       What is going to happen to me in the hospital?While you are in the hospital you will get treatments to make you more comfortable and to help your body to do its work
       Will I ever get better?We expect almost all young people to get better from this virus. The treatment we give in hospitals helps your body get rid of the virus itself. Let’s give the treatment time to work
       Am I going to kill someone? What if I got someone else sick already and do not know?The virus is no one’s fault. When other people get COVID19, we will take care of them too
       Am I going to die?We expect almost all young people to get better from this virus. We are keeping you in the hospital so that we can keep a close eye on you and give you any help you need at the time you need it. If you have any worries about anything or any questions about how you are recovering just ask us at any time. We will come and chat with you and your family
      a Providers can aim to come up with a concrete activity plan focused on self-care and practical activities that meet the teen’s needs. Listening and validating will be important so that teens are heard and their specific concerns are addressed.
      b Some teens will not perceive a need to isolate and not be amenable to this guidance. Fear-based messaging, especially around low probability events, is generally not conducive to behavior change. We recommend focusing on prosocial guidance such as being a good friend or finding other motivators (e.g., honesty, independence) that are salient and valued for the teen and their family.
      c Messages can encourage the teen to only take responsibility for themselves while asking other people to take responsibility for their feelings and emotions; providers can follow-up on teens’ specific concerns as appropriate.
      d This can be a practical factual question or a sign of emerging stress, providers can consider screening and monitoring mental health, and referring as appropriate.
      e This question should be viewed as indicator of the caregivers needing more support.

      A Tiered Trauma-Informed Care Approach

      Providers can implement a tiered resource approach to care and communication for those adolescents diagnosed with COVID-19: universal supports for all youth (e.g., psychoeducation, education about likely medical care pathways, routine emotional health screenings for youth and parents); targeted interventions for youth with risk factors such as those presenting with some emotional health symptoms or family risk factors (e.g., monitor symptoms, brief mental health consultations); and clinical intervention for those who demonstrate significant mental health symptoms or whose mental health symptoms interfere with medical care (e.g., mental health treatment) [
      • Kazak A.E.
      Pediatric Psychosocial Preventative Health Model (PPPHM): Research, practice, and collaboration in pediatric family systems medicine.
      ].

      No Symptoms or Mild Symptoms

       Universal intervention

      As a first step, providers can ascertain what fears a young person has about COVID-19 keeping in mind that some may have concerns about dying or hurting others while others may have more practical concerns (e.g., When can I play sports?). For those who are worried, providers can focus messaging on how they will be cared for and how to seek help if they need it, taking care to avoid blaming language. Providers can share recommendations on managing disease transmission within the home, taking families’ unique circumstances (e.g., multigenerational households, culture) into account.

       Targeted intervention

      For adolescents experiencing anger, fear, confusion, or guilt about their diagnosis, providers may need to spend additional time addressing these emotions or refer adolescents for a brief mental health intervention. Some adolescents may self-blame, perceiving they have failed at prevention. Providers can emphasize positive messages of staying home to promote self-care by “building up the body” and capitalize on adolescents’ need for autonomy and friendship by reorientating them to focus on actions for the present and immediate future, that is, taking care of themselves and being a good friend to others by staying home. Troubleshooting barriers to isolation generates opportunities to develop tailored solutions (e.g., safe ways to stay connected with friends through video chats, online games).
      For youth who have impairing mental health symptoms either before or resulting from a COVID-19 diagnosis, providers can facilitate a referral to a mental health professional. Some adolescents, given their developmental need for autonomy and confidential healthcare, may be more willing to share their emotions with someone outside their family or peer group.

      Significant COVID-19 Symptoms

       Universal intervention

      Providers face the challenge of striking a balance between not providing false reassurance that young people will be fine, while not worrying them and their parents about the small percentage of cases who develop significant disease. Giving the family small bits of information about COVID-19 as applied to their situation can be helpful. If youth develop acute respiratory distress syndrome, Pediatric Multisystem Inflammatory Syndrome/Multisystem Inflammatory Syndrome in Children [
      • Irfan O.
      • Muttalib F.
      • Tang K.
      • et al.
      Clinical characteristics, treatment and outcomes of paediatric COVID-19: A systematic review and meta-analysis.
      ], or Long-COVID, providers can provide information about symptom management at each stage. Lack of face-to-face contact can be stressful for families and disrupt parent-patient-provider communication in instances where members of the family are advised to isolate or the patient is sedated. Proactively anticipating this disruption and agreeing on a communication plan at the point of care (e.g., scheduled phone calls, identifying a family point person) can help to minimize this problem. Providing education about common challenges that adolescents face with these conditions and when to seek help may ease some worries for teens and their families. Active surveillance for Long-COVID (currently under-recognized) in adolescents may help some families mitigate the psychological sequelae of young people feeling they are not believed or supported by providers [
      • Looker D.K.J.
      • Bell M.M.
      • Skerry R.
      • et al.
      Long COVID in children: A report summarising the views of young people, parents and doctors.
      ].

       Targeted intervention

      Targeted interventions for those with more severe symptoms may include reviewing medical information/next steps more frequently, identifying more supports that the teen can be connected to via technology, providing the teen with more consistent medical providers (e.g., a named nurse or doctor who conducts the majority of consultations), and/or mental health treatment. Depending on the level of clinical interventions needed to manage physical symptoms, these factors may be more pertinent during the postillness care and recovery period. Screening for known traumatic stress risk factors (e.g., trauma history, pre-existing mental health challenges) can help identify patients likely to need more support.
      In summary, a trauma-informed care framework can strengthen communication among adolescent patients, parents, and providers. This is a key component of high-quality adolescent healthcare [
      • Ford C.A.
      • Davenport A.F.
      • Meier A.
      • McRee A.-L.
      Partnerships between parents and health care professionals to improve adolescent health.
      ], and is an important strategy to use to minimize traumatic aspects of medical care and communication for youth diagnosed with COVID-19 [
      • Marsac M.L.
      • Kassam-Adams N.
      • Hildenbrand A.K.
      • et al.
      Implementing a trauma-informed approach in pediatric healthcare networks.
      ]. The purpose of using trauma-informed messaging is to alleviate mental health symptoms (e.g., anxiety related to COVID-19 diagnosis) and prevent further or retraumatization. Key principles and shared messaging for providers can be a useful way to get these important conversations started. Such conversations will become increasingly important and common as the number of adolescents infected with SARS-CoV increases worldwide.

      Acknowledgments

      Contributors Statement: Dr. Jessica Hafetz Mirman conceptualized, drafted, and critically revised the manuscript. Drs. Meghan Marsac and Rod Kelly contributed content, reviewed and critically revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

      References

        • Riley S.
        • Wang H.
        • Eales O.
        • et al.
        REACT-1 round 12 report: resurgence of SARS-CoV-2 infections in England associated with increased frequency of the Delta variant. medRxiv. Published online January 1, 2021:.
        (2021.06.17.21259103. doi:)
        • Chadi N.
        • Piano C.S.-D.
        • Osmanlliu E.
        • et al.
        Mental health-related emergency department visits in adolescents before and during the COVID-19 pandemic: A multicentric retrospective study.
        J Adolesc Health. 2021; 69: 847-850
        • Reyna V.F.
        • Farley F.
        Risk and rationality in adolescent decision making: Implications for theory, practice, and public policy.
        Psychol Sci Public Interest. 2006; 7: 1-44
        • Horesh D.
        • Brown A.D.
        Traumatic stress in the age of COVID-19: A call to close critical gaps and adapt to new realities.
        Psychol Trauma. 2020; 12: 331-335
        • Malter Cohen M.
        • Tottenham N.
        • Casey B.J.
        Translational developmental studies of stress on brain and behavior: Implications for adolescent mental health and illness?.
        Neuroscience. 2013; 249: 53-62
        • Kazak A.E.
        Pediatric Psychosocial Preventative Health Model (PPPHM): Research, practice, and collaboration in pediatric family systems medicine.
        Fam Syst Health. 2006; 24: 381-395
        • Irfan O.
        • Muttalib F.
        • Tang K.
        • et al.
        Clinical characteristics, treatment and outcomes of paediatric COVID-19: A systematic review and meta-analysis.
        Arch Dis Child. 2021; 106: 440-448
        • Looker D.K.J.
        • Bell M.M.
        • Skerry R.
        • et al.
        Long COVID in children: A report summarising the views of young people, parents and doctors.
        (Available at:)
        • Ford C.A.
        • Davenport A.F.
        • Meier A.
        • McRee A.-L.
        Partnerships between parents and health care professionals to improve adolescent health.
        J Adolesc Health. 2011; 49: 53-57
        • Marsac M.L.
        • Kassam-Adams N.
        • Hildenbrand A.K.
        • et al.
        Implementing a trauma-informed approach in pediatric healthcare networks.
        JAMA Pediatr. 2016; 170: 70-77