As a result, some experts say many children are behind in their social and emotional development. In the first and second grade, kids are struggling with basic skills they’d typically learn in preschool and kindergarten, like taking turns, working in groups, keeping their hands to themselves, sitting quietly for a period of time, standing in line or unpacking their backpack on their own.

“Since the pandemic, I've noticed a lot of regression in kids,” said Amy Arriaga, a pre-K teacher at Fort Worth Independent School District’s Mendoza Elementary. “They have regressed to like they are at 2 or 3 years old and not 4 and 5. I’ve noticed an increase in separation anxiety. Now that we’re starting to go back to normal somewhat and mom and dad say you have to go to school, kids are like, ‘but you’re not going to go with me?’ I’ve also noticed more aggressive behavior and not being able to keep their hands to themselves.”

There’s also been a loss in the mastery of fine motor skills, according to Arriaga. She said most kids used to start pre-K with some basic skills, like how to properly hold a crayon and recognition of some shapes, letters and numbers. That’s not the case this school year.

Teasha-lee Frattarelli, D.O., is a developmental behavioral pediatrician at Cook Children’s Child Study Center. She said what teachers are likely seeing is a lack of typical or normal progression of pre-K students due to fewer opportunities to experience and practice their pre-academic skills, social skills and emotional self-regulation skills with peers and teachers outside of their family.

“I don’t think the children are regressing with their skills,” Dr. Frattarelli said. “It is actually a lack of progression that teachers are reporting which is likely due to the unprecedented experience during the pandemic, particularly when isolated with their family without an opportunity to attend school or daycare in person.”

The early years of education are the ones where kids get hands-on experience with life lessons that shape their social skills. What might look like play and entertainment to the untrained eye, be it in the classroom or on the playground, is actually reinforcing behavioral expectations, healthy relationships and emotional regulation in a way that appeals to kids.

Playing together in centers teaches little ones how to share, work together and relate to each other. A game of Mother May I challenges kids to listen and follow directions. Storytime on the carpet helps busy little ones learn to sit quietly and process what they are hearing.

“Teachers teach those behavioral expectations,” said Kathleen Kyzar, Ph.D., associate professor of early childhood education at Texas Christian University’s College of Education. “What does it look like to stand in line? What does it not look like to stand in line? What does it look like to have to sit in our seat appropriately? What does it not look like? Now we’re going to practice that. We’re going to teach you explicitly what we expect of you when you’re in school.”

Mastering social and emotional skills is as important to a child’s foundation and future as reading, writing and arithmetic. There is research-based evidence that positive social skills promote positive academic skills, according to Kyzar.

But the pandemic disrupted all of that and now teachers and parents are playing catch up to help kids reach their social and emotional milestones.

“I would say the pandemic has definitely taken people off of their typical developmental trajectory,” said Casey Call, Ph.D., LPC, associate director of professional practice and associate director of education at TCU’s Karyn Purvis Institute of Child Development. “In intervening with children there are two big areas that we focus on. One is building healthy relationships and the other is practicing regulation. The students who haven’t been in a classroom consistently or had any early childhood education have the potential to really get off of their developmental trajectory in these two skills.”

Regulation is the ability of a child to adjust, manage and cope with their environment and situation. As babies, they solely rely on their parents to regulate their environment for them. Eventually, they’re able to point to a blanket if they’re cold and then rely on someone else to give it to them. That’s called co-regulation. In time, they can self-regulate and get up to get the blanket and cover themselves with it.

It’s the co-regulation and self-regulation pieces that some kids are lacking because those are the pieces that require teaching, mentoring and practice. But young children haven’t had consistent opportunities to practice those things outside of their homes and in situations with others where they must manage big emotions and big behaviors. Those immature relationships and regulation skills are evident in many early childhood and elementary classrooms today.

“Early childhood teachers are setting the stage for understanding one’s emotions and being able to regulate behavior,” Dr. Kyzar said. “So engaging in turn-taking so that we understand that it’s my turn now and then it’s going to be my friend’s turn and I need to wait. Those are skills that are setting them up for academic learning later on and being resilient, listening to each other, and learning to problem-solve.”

For kids, consistency is key. It plays a huge role in their feeling of security. Kids who feel safe and secure are less anxious, better able to focus and have more energy to spend on learning. Consistent classroom routines set the stage for learning. Preschool and kindergarten teachers usually spend the first half of the year just going over classroom routines. Once those routines are in place, learning can begin. But with so many stops and starts to the school year, teachers have had to start again, and again, and again in teaching routines and acceptable behavior just to get kids ready to learn.

That’s why it’s so important to reinforce these activities at home. Practicing, modeling and reinforcing social and emotional skills at home — taking turns, keeping emotions in check during conflict, listening well, following instructions, being patient — can help set kids up for success in school and in life.

The good news is that helping kids get back on their developmental track with these skills doesn’t have to be complicated. Kids engage, speak, process and learn through play. Fun is their universal language. When they’re playing and having fun, they’re also practicing important life skills. For example, a game like Simon Says reinforces regulation while players listen, wait and think about their response. And as you play with your child — or cook with them, take a walk with them or participate in any activity they enjoy — you’re modeling what a safe and nurturing relationship looks like.

“I think the stress that parents have been feeling has been really overwhelming,” Dr. Call said. “With everything they have on their to-do lists sometimes parents can spend all of their time on structure, things like setting and enforcing rules, correcting behavior, and making sure school work is complete, while the nurture, or the joy and play, gets pushed down to the bottom of their list. When stress is high, we need to make it a priority to balance nurture and structure.”

Parents, teachers and kids will inevitably play catch up on meeting these social and emotional milestones in the months and years ahead, and time will tell the depth and breadth of developmental and learning loss due to the pandemic. If your child is struggling with social skills and regulating their emotions, set aside a little time for some fun. If you feel they are particularly behind or struggling to cope, talk to their teacher or pediatrician for guidance and help.

All of it against the backdrop of COVID-19, which has killed almost 1 million Americans in the past two years, affecting families who have lost loved ones and upending the lives of everyone, especially children, who’ve changed the way they socially interact, attend school, or even celebrate milestones.

As the youth of today might say—they’ve had a lot to unpack since 2020.

Many parents, educators and mental health experts have expressed concerns about whether young people can unpack it all. And some wonder if this generation (born between 1997-2012 and known as Gen Z) can withstand the weight of historic events happening in real-time.

No one knows for sure. But leadership expert and author Tim Elmore, Ph.D., who conducted interviews and focus groups with people from five different generations, including those who endured World War II and the Great Depression, says he believes Gen Z can find hope and resilience during these trying times as long as adults lead with empathy.

“This pandemic has affected students in ways we adults could not have predicted,” says Elmore, author of The Pandemic Population: Eight Strategies to Help Rediscover Hope after Coronavirus. CEO and founder of Georgia-based Growing Leaders, Elmore also speaks to parent and educator groups across the country. “As a parent, I need to listen and validate, even if I don’t agree with their emotions.”

“What they need is an adult who cares and says, ‘I get it.’ That’s critical. As a parent, I tend to want to explain and have an answer—but it’s not always that easy,” he says.

Candles or Brushfires?

It’s clear the COVID-19 pandemic took a toll on the mental health of today’s youth.

In March 2021, Cook Children’s Medical Center reported record numbers of suicides and attempted suicides with patients as young as 7, and it marked the first time suicide became the leading cause of trauma death, surpassing child abuse and car wrecks. In response, the hospital system initiated the JOY campaign in April 2021—an ongoing series that addresses and educates readers on children’s rising mental health care needs and issues they may face.

As part of the JOY series, Cook Children’s launched its podcast “Raising JOY” this month in an effort to reach more audiences about mental health issues facing youth across the nation.

In its 2021 Children’s Mental Health Report, the non-profit organization Child Mind Institute (CMI) revealed: “about 70% of both children and adults reported some degree of mental discomfort, resulting in loneliness, irritability or fidgetiness.” In its study, which surveyed more than 5,600 people in areas hardest hit by COVID in the United States and the United Kingdom in April 2020, researchers found 55% of the children felt “more sad or unhappy” compared with 25% of the adults. (The child’s mental health three months before the pandemic seemed to play a factor.) “In other words, a child struggling with depression prior to the pandemic was more likely to be struggling during the pandemic than one who was not,” the report stated.

But, based on a growing body of research, it appeared the moods of many children and adults may be improving and possibly “the distress experienced early in the pandemic has evened out over time,” according to the CMI report.

“Most kids are naturally resilient,” the study concluded, “but others may require extra support from their parents, social networks, health care providers, and others in their orbit.”

Researching for his book, Elmore found the same to be true while interviewing members of past generations who lived through challenging times. He discovered that Post-Trauma Growth (PTG), a psychological term coined in the 1990s, often applied to those he interviewed instead of the more well-known Post-Traumatic Stress Disorder (PTSD).

“(PTG) wasn’t a term on my radar,” he says. “I was under the assumption that if you go through trauma, you’re probably going to have some level of PTSD, but it was quite the opposite. Most of the people, like over 80%, move to PTG, meaning they go through the trauma—it’s hard, it hurts—but through processing what happened, they’re able to make sense of it, and they end up feeling like they grew from that hard time.”

“PTG requires making sense of things. It requires a listener, often an adult for a child, who listens empathically and validates what they’re feeling…but then gets to the place wherein the discussion, they can say, ‘Who knows? You might be better for this,’” he says. “I know it sounds cliché, be we all know the real growth in our lives often comes from the hard times, not the easy times.”

But listening is more than saying, “Yeah, sweetheart, fine, fine, fine and then move on,” Elmore says. When adults listen, the goal is to make children “feel heard and valued” and empathizing helps them “feel understood and validated,” he says.

“And then (as an adult) when I try to guide them, I’ve earned the right with those first two steps to say, ‘Well, you know, maybe something good can happen from this,’” Elmore says.

Most of the strategies he suggests for parents and educators to encourage hope and build resilience among young people are intuitive, he says.

One of Elmore’s favorite approaches is using a metaphor to change the narrative of the situation. For example, when the pandemic first began, he was counseling a high school senior who was having a challenging time applying to colleges. Together they came up with the metaphor of a candle versus a brushfire.

“That became a picture in our heads that gave us a choice we had to make” when things were getting hard, he says. “Every time we started getting down on ourselves or down on life, we were either going to be a candle, which is a flame put out rather easily, or a brushfire that isn’t put out easily at all. In fact, it gets bigger with the harsh wind. As simple as this sounds, we would just say to each other, ‘You can be a candle or you can be a brushfire.’”

“When he went to college, he texted me and said, ‘Tim, I’m going into my school as a brush fire,’” Elmore says. “It helped him. It didn’t change his IQ or anything, but it changed his narrative.”

Elmore also suggests other strategies to boost hope and resilience among youth:

• Make a habit of discussing the silver linings. Listen. Empathize. Guide. Find some positives that might come from the problem. An example would be the development of vaccines during the pandemic. (Being cheesy about it defeats the approach, though, he says.)
• Break down hardships into digestible bites in their minds. Kids may get overwhelmed during this time. Cut up issues into small bites so they can process them.
• Identify cognitive distortions and confirmation bias in their narratives. An example would be if they say, “Nobody loves me!” Don’t correct them right away, but maybe later, at bedtime, discuss with them why that statement wasn’t true.
• Remind them of past personal successes.
• Help them practice psychological distancing. If parents see kids getting down about something, let some time pass, then ask them, “If your best friend was having this issue, what advice would you give him?” Help them take their own advice.
• Tell stories about those who turned a disadvantage into an advantage. Elmore uses Sir Isaac Newton as an example. Newton continued his studies in mathematics, figuring out calculus, laws of gravity and optics theories, among others while quarantining at home from Cambridge during the Great Plague of London, which killed as many as 100,000 people between 1665 and 1666.
• Express high beliefs coupled with high expectations. An example would be for parents to say to children, “I’m giving you this feedback because I have high expectations of you and I know you can reach these goals.”

Silver Linings Ahead?

According to the key conclusion in CMI’s 2021 Children’s Mental Health Report, there may be cause for optimism in this generation. The available data indicates “children and young adults are more resilient than we sometimes assume” but adds that “it’s crucial to devote resources to meeting their mental health needs.”

In the report, 42% of teens overall say the pandemic increased the number of conversations they’ve had about mental health. (This trend is particularly significant among Hispanic and Black teens.) And, researchers reported 53% of teens say they’re comfortable discussing their mental health with family members. The next most trusted individuals were friends (49%), then doctors (26%), according to the report.

CMI researchers concluded “we should take heart from the fact that even teens who said they were struggling right now felt positive about the future. This speaks volumes about innate human resilience, particularly that of young people, and it’s a hopeful sign that many children and teenagers will emerge from the pandemic without lasting harm.”

Texas Wesleyan University senior Angela Castillo, 22, an English/ Mass Communications major, doesn’t necessarily connect with the Gen Z label, but she does believe her peers will overcome the pandemic era and work to bring about a more positive future.

“I think we have what it takes to get through it. Look at us. We’ve already gotten through two years of it, and I think we’ll get through much more if needed,” she says. “Everybody just wants to go out there and do something. And even if they don’t, it’s interesting to see that openness in this generation—there’s value in that. Maybe it’s not resilience, maybe it’s just more of a mutual understanding of everyone’s situation and where they’re at today. I really appreciate that about my generation.”

In the earlier days of the pandemic, Castillo did struggle. She became anxious but wasn’t overly concerned. But in October 2020, after being diagnosed with COVID-19, her anxiety skyrocketed. She sought help from a therapist.

“I got COVID, and I was like, ‘It’s time for me to be completely OCD about it,’” she says, adding even after she recovered from it, “I remember feeling anxious, depressed. I was scared to leave my dorm.”

With therapy and medication (which she’s now tapering off), Castillo has worked through many of her anxieties. She can now leave her apartment, shop for groceries or socialize with friends “without coming out of my skin.”

She’s also excited about her upcoming graduation and is seeking an internship or job. One of the good outcomes of the pandemic has been employers’ willingness to become more flexible with schedules and work with remote employees, Castillo says.

Her generation’s “advocacy of self” is another powerful thing to come from the past two years, she says. Through the pandemic, her peers learned to cope by setting personal goals for themselves, even small ones, to keep from getting overwhelmed by it all, she says.

“That’s the thing that’s going to make this generation resilient—it’s that ‘This is my best today.’ I read a book. I read a chapter of a book. I read one word, and that’s enough for me today,” Castillo says. “And those varying levels, I think are important. To still applaud yourself and say, ‘You know what? I did that. It might not be much, but I did that.’”

Let’s imagine a scenario that no parent wants to think about.

Let’s say your child starts acting weird over the past few weeks. She seems tired. She’s sleeping more, and laying around all the time.

She starts to drink more water. It sure does seem like a lot of water – way more than on a hot day outside. She’s starting to pee more often. She’s waking up at night to refill her cup over and over.

She’s starting to lose weight. She’s complaining her vision is blurry. She started to vomit yesterday, and cries today that her stomach hurts. She’s acting exhausted.

You take her to the pediatrician, who checks her blood sugar. The number is so high, the monitor cannot read it. It only says “over 500”.

You rush her to the ER, where you get the diagnosis: diabetic ketoacidosis. Your child is a new diabetic, and you had no idea until this moment. DKA is life-threatening and requires ICU care, the ER physician says.

“The problem is…we don’t have any PICU beds available currently. The unit is completely full.”

In the spirit of our ongoing efforts to be real and transparent with you about the status of children with COVID in Tarrant and surrounding counties, allow me to share with you what my colleagues have shared with me. I asked them, “Are the high numbers of COVID patients in our hospital affecting your other patients?”

The following quotes are nearly word-for-word (though I took to liberty to make a few large medical terms more understandable, and keep patient details anonymous):

Dr. Scott Perry, Neurology: “I’ve got plenty. Several surgeries canceled. Surgeries that could potentially stop seizures in children where their condition is life-threatening. Several workups canceled while we wait for more room. Trying to manage people at home throughout the night so they don’t need the emergency room. I am so exhausted from this, from dealing with the pandemic and the risk of losing highly trained people as a result. The list goes on…”

Dr. Samson Cantu, Gastroenterology: “From the GI standpoint, we have had to second guess our decision to proceed with planning for gastrostomy tube (feeding tube) placement in our failure-to-thrive patients. All new feeding tube placements require hospital admission for 48 to 72 hours. Given the scarcity of inpatient beds, we are very limited in having a scheduled admission, despite a feeding tube being a true life-line for several patients.”

Dr. Charles Saadeh, ENT: “With airway surgery, we have to take into account worst-case-scenario hospital resources that necessitate PICU bed availability. I have had two patients so far that have had a delay in care. Cook has been so very diligent about accommodating patients that need to go when they are delayed, but it’s definitely a case-by-case discussion with each family. We wouldn’t be offering supraglottoplasty (a complicated surgery that allows children with airways disorders to breathe easier) if things weren’t relatively urgent to begin with, so this is certainly a difficult position for us.”

Dr. Teena Thomas, Endocrinology: “More than once last week, when I received a transport call for a new onset, I was not always sure that I would be able to admit a new onset in DKA to the PICU because of the lack of bed availability. On my last day of call, we had to divert a very young new onset to another hospital… I have never not been able to admit a new onset here. I checked on the child the next day and the hospital they went to did not actually have PICU availability either (they had to some shuffling to get the kid to the PICU). Last week, my diabetic patients also had to spend a lot more time in the ER because of lack of bed availability in the PICU or the endocrine floor.”

Dr. Michelle Marcincuk, ENT: “I had an entire day of surgeries cancel because there were no beds to admit the patients to post-op. These were kids with trachs, airway obstruction, swallowing dysfunction. I had a child with a mass on the face that needs a biopsy. Had a little one with a draining fistula on the neck. All had to be postponed. Two kids were hoping to get their trachs out. But had to cancel.”

(Imagine the day finally comes when your child gets the breathing tube taken out of their neck…and your day is yet again postponed, and sometimes for a YEAR. Keep reading.)

MM: “Since the hospital has been full, I can’t say whether we will get to do their surgery the next time they are scheduled. It’s just a complete guess as to whether or not there will be a bed available for them on the day we reschedule. And since we don’t decannulate (breathing tube taken out) kids in the winter, if we don’t get them done soon, they may miss their window of opportunity to get decannulated this year and may have to wait a whole year more for their next chance. That’s a whole additional year with a trach due to COVID. None of my patients have COVID. But their health is being affected by the COVID surge. 

The health of these kids is suffering because of this pandemic. Even though they themselves don’t have it. And their parents have done everything possible to keep them healthy. The parents have taken days off work preparing for this surgery. When the surgery is cancelled, they have to take even more days off for the new surgery date, putting their jobs at risk due to absences. And some patients drive 5-6 hours here for surgery, only to arrive and be told that they can’t have the surgery and have to drive back home because the hospital is full. Then you think of the wasted time the surgeon experiences when this happens. Basically, it’s a day that they can’t see patients because of the last minute, unexpected cancellations. We have a huge list of kids waiting to be seen in clinic, but most of the time these cases are cancelled last minute and it’s too late for new patients to be booked into clinic. So both the surgery patients and the new patient for clinic who are waiting for appointments are affected.”

Dr. John Honeycutt, Neurosurgery: “It is frustrating from several different levels. However, we are ONLY delaying non urgent or elective surgeries. Cases for brain tumors or other surgeries where delay could cause harm we are still full steam. But it is very frustrating to families that have planned, taken off work, mentally prepared and then have to delay. It’s extremely hard for them. Nobody’s outright angry or screaming, all seem to understand, which is so cool. We see all this in media about people screaming and yelling about selfish things, but they miss the vast majority of people that are just trying to get by in life and care for their community and others. They are frustrated, but make the sacrifice for the better of others. That is missed and it is refreshing to see that personally.

As a team, we are so used to being full steam, so for us to transition to a lull is a bit of a challenge (easier for younger docs, harder for me). But we understand too. We see the ICU, ER and hospitalists and nursing staff overworked and stressed. Sad to see.

Finally, our service line has not had our neuro PICU for a year and a half since it is now the COVID unit, and last week we lost our neurosciences floor to be the second COVID floor unit. So we are scrambling hard, being extra sure our patients get what they need since they are now scattered throughout the hospital. Exhausting for our team.

We are fine, just adapting to the new norm which I pray is short lived.

Dr Karthik Srinivasan, Pediatric Hospitalist: “As pediatric hospitalists, we care for children who require hospitalization. I recently took care of a cute infant who was not admitted for COVID and improved within a day. I was excited to discharge him home, as was his mother. We had a pleasant conversation, and the mother was very thankful. She seemed to trust Cook Children’s and all our staff. As I was leaving, I mentioned that her son was too young for the vaccine but wanted to know if family members had received it. “No. No. We’re not going to talk about that” was what I got, and the tone and mood took a 180. There was an awkward silence. The family was out the door within the next 20 minutes. 

As of about two months ago, we were fortunate to have ZERO COVID positive patients admitted to our service. Now, we are up to about 40% of our service as a whole. About 75% of these children are admitted directly because of COVID, not just incidentally being positive. This is very different than in months past.

Clearly, the delta variant has been a game changer that is much more easily transmitted. We recently set our service’s all-time record for the number of hospitalized children we are taking care of, which can be directly attributed to COVID. We started last year utilizing one floor as the typical “COVID unit.” This grew to two floors, and most recently we have started filling up a third floor, anticipating even more as I write this. 

We are seeing children in all age groups being admitted due to COVID. Although we are noting that obesity is a risk factor, we are admitting some children without any apparent predisposing factors. More recently, about 3-4% of older teenagers who are testing positive in the Cook Children’s system are being hospitalized. Beyond infancy, our highest rate of hospitalization and many of our sicker patients are older teenagers, the vast majority who are vaccine eligible but have not received the vaccine.

On a typical call shift, it is not unusual to be called on at least a couple of children who are admitted for COVID and are appearing sicker. And it is a process to see them. For staff member safety and our own protection, there is extensive protective equipment required to see them, and this needs to be worn anew upon entering and completely removed upon exiting the room. Additionally, for some of these sicker children, multiple specialists may be involved in their care, leading to several phone calls. This is all while the Emergency Department anxiously is paging for several additional patients needing to be admitted. Admittedly, in these times, it can be near impossible to return their calls in a timely manner.

As we are stretched thin, the medical care we provide may not be as efficient as you are accustomed to. We need your patience, understanding we are all in this together. If your child gets sick and needs to be hospitalized, we are here for you and your child. But the best weapons we have against this is preventing the illness in the first place. Go back to the basics that have been preached by Cook Children’s physicians for quite some time now. Mask up, socially distance, and get your vaccine if eligible. Even if your child cannot get the vaccine, have family members and friends get it if eligible. Please trust us on this as you do with the care of your child. To be clear, virtually all the physicians at Cook Children’s were vaccinated well before the word mandate was even thrown around. We preach what virtually every major physician organization has advocated for and what we have practiced ourselves. Do it for yourself. Do it for your child. Do it for your neighbors. Do it for us.

We strive to keep our “Promise” to you and your children, but we need your help.

Dr. Christine Ellis, Pediatric Hospitalist: “Page comes through as I barely walk through the doors of the hospital that another one of my patients is in respiratory distress. Seconds later, I hear the “Med Alert” overhead- of course, it’s my patient I was just paged about from the COVID unit. I skip making my morning coffee and checkout from the evening physician and run upstairs to the COVID unit.

I throw down my bag, quickly place on my PPE and walk into the crowded room to see my teenage patient breathing over 60 breaths a minute and oxygen saturations decreasing despite maximum support on a non-rebreather face mask. PICU team arrives shortly and my patient is whisked away to our pediatric ICU for higher level of care. I try to comfort the mother quickly as they start to roll to the elevator for transfer.

I take off my n95 mask, make my coffee and get the rest of my checkout from last night’s physician that stayed late to talk to me. I finally slump into my chair to start rounding on all my other children for the day and all the emotions flood over me. 

SADNESS for the patient and family as they go through this difficult time with a very sick patient.

FEAR for my patient’s respiratory status as I am afraid that he is on a long road that will require possible Bi-Pap or even intubation.

FRUSTRATION sinks in as this patient, like many of my other patients, was eligible for the COVID-19 vaccine and is not currently vaccinated. This child likely would not have these severe complications if he was vaccinated. They were completely healthy except for obesity (which significantly increases chances for complications as well). All of this could of been prevented.

As the day goes on, I go between our now two full non-ICU COVID units and see patient after patient similar to my first child of the day. Some children too young for the vaccine but when I talk to their parents, no one in the house is vaccinated either. I continue to march room to room. EXHAUSTION hits me. My face hurts from my n95 mask but I sign up as the COVID physician the next day.

As I drive home to my family I try to find HOPE. Hope that tomorrow will be a better day. Hope that tomorrow another sweet child does not go to the ICU for a now preventable disease. Hope that our community continues to step up and get vaccinated and wear their masks appropriately. Hope that vaccines are available for our younger children soon so my patients and my own children at home can be more protected.

❤️ Dr. Ellis

Dr. Laura Romano, Pediatric Hospitalist: “Our hospitals are full. Our ICUs are full. Due to the surge from the delta variant, we do not have any beds. This means that patients at outside hospitals or clinics who need specialized care cannot be transferred to our facilities. This means that there are children who have to wait longer for necessary and sometimes life-saving treatment.

I've seen a lot of people say that wearing a mask or getting vaccinated is a "personal choice" or "my body my choice." Your choice to not wear a mask and to not get vaccinated is putting our children and our patients in jeopardy. The time for personal responsibility is over. It has already failed our children and that failing has led to unprecedented COVID spread in a few weeks since schools have returned without mask mandates and without vaccine mandates. This spread will continue unchecked and we won’t have the beds or the space to help our patients. It's simple math at this time.

I've seen people posting that health care professionals need prayers because we are tired and overwhelmed. Yes, we are exhausted. We are tired. We are running on empty and are experiencing burn out that we have never felt before. Yes, we appreciate your thoughts and prayers. But what we need more is for YOU to get vaccinated.

The time for talk is over. You need to get vaccinated. You have to get vaccinated. It is the only way to end this.

If you don't care about your own health and wellbeing, please care about your children's health. Please care about my patients' health. Please care about your nieces and nephews. Please care about your neighbor's children. They need your help. We desperately need your help. 

And if that's too much to ask, if it's too much to ask you to care about a child, then wear a mask. It's literally the least that you can at this point.

The time for talk is over. We need action. We need it now. I know how some of you will react to seeing this: another COVID post. Some of you will say that this is a joke and a political hoax. Some of you will say that this is baseless fear mongering by the mainstream media to make you afraid of what will amount to a slight cold or a flu. Please know that none of those statements are true.

This is virus that spreads easily. This is a virus that is now causing severe and life threatening disease in children. Please, please, please listen to medical professionals who are quite literally begging you to get vaccinated. 

If you don’t want the vaccine for yourself, please get it for your kids, your nieces and nephews, your friends’ kids, or even for the children in your neighborhood since a lot of us don’t have the option to vaccinate our kids against a deadly and fatal virus. 

If you have any questions about the vaccine, please reach out to me or your family doctor. We would love to talk to you about it! You have entrusted your children to us throughout the entire lives. We need you to put your trust and faith in us again. Please get your vaccine. 

And if getting vaccinated is too much to consider, then please just wear a mask. Please. Children are literally dying from this and we have the ability to stop it.

Dr. Bianka Soria-Olmos, Pediatrician at Cook Children's Pediatrics Haslet:

"Se sabe que la variante delta es altamente transmisible, desafortunadamente ha causado que los casos de COVID pediátricos aumenten significativamente recientemente. Esto, a su vez, ha provocado un aumento de las hospitalizaciones por COVID en nuestro propio hospital.Ha habido varias partes diferentes del hospital que se han convertido en unidades dedicadas al tratamiento de niños con COVID-19.Esto significa que a medida que más niños requieren atención para su enfermedad COVID-19, hay menos camas disponibles y personal para cuidar a otros niños que pueden requerir pasar la noche en el hospital por una condición médica no relacionada con COVID-19. El aumento actual está provocando retrasos en los procedimientos que no son de emergencia o electivos, dado que algunos de esos niños requieren habitualmente de hospitalización, seguimiento posoperatorio o recuperación.

Como pediatras y especialistas en pediatría estamos acostumbrados a atender a TODOS los niños de inmediato en el momento en que necesitan intervenciones o tratamiento, lamentablemente nos estamos dando cuenta de que esto puede no ser posible y no podemos evitar sentir una avalancha de emociones: frustración, tristeza, temor. Nosotros también somos humanos y lo que nuestros ojos ven todos los días crea una montaña rusa de sentimientos que tememos que nadie más pueda entender.Sin embargo, tenemos la esperanza de que si compartimos solo un pequeño vistazo de lo que nuestros ojos ven y presencian todos los días, esa bondad y abnegación ganarán y que nuestra comunidad hará lo correcto.Le pedimos a usted (nuestra comunidad) en este momento que considere que sus decisiones y acciones de la vida diaria pueden afectar y afectarán la trayectoria de esta situación.Le pedimos que nos ayude haciendo lo siguiente: vacunen a TODOS los adultos y adolescentes elegibles en su hogar contra el COVID-19 y se use cubreboca cuando estén fuera de su hogar. Estas simples acciones de bondad no solo lo protegen a usted y a sus seres queridos, sino que también pueden comenzar a aplanar la curva de infección de COVID que necesitamos en este momento para ayudarnos a cumplir nuestra promesa a todos los niños del norte de Texas y nuestra comunidad."

Dr. Diane Arnaout, Pediatrician at Cook Children's Pediatrics Forest Park: 

The actions we all take in our daily lives will make a difference for these hardworking doctors, our amazing and exhausted hospital staff, and most importantly, the kids.

Don’t send your kids to school sick. If in doubt, get a test. Move the parties, get-togethers, and playdates outdoors – fall is coming, and it’ll be beautiful out.

With winter approaching, I worry about our already-strained hospital system. COVID is already putting us under pressure – and the flu will bring new challenges for us all. Please get your family vaccinated against the flu now. Kids need to be in masks in school – last year’s nonexistent flu season can attest to how well they work.

We are counting on our community to do what’s right. Please help us help your kids

I ask you to put yourself in the place of the parents of one of these children, who desperately need urgent or critical care, and who may not be able to get it because of the number of patients in our hospital.

There are 41 patients currently in Cook Children’s with COVID. 63 beds and four units that are using vital resources of staff, oxygen, ventilation, life support.

Cook Children’s will always strive to accommodate all of our community’s needs. But I beg to you ask yourself: what can I do to help?

• Send your child to school in a mask. Ask them to keep it on at all times unless outside or eating.
• All children in school over age 2 should be masking indoors. School districts should strive for universal masking right now.
• Quarantine all children who come in contact with a COVID+ child if unmasked and for longer than 15 minutes indoors.
• Get your kiddo the COVID vaccine if they’re over age 12. It’s safe and it’s effective.
• Please keep your sick children home from school.
• Postpone indoor gatherings for now- it’s not going to be forever. Just for now.
• Move the party outside.
• Open windows when you have people over.
• Limit the number of people who can attend sporting or theatrical events at schools so there can be spacing between families.
• Mask up and put at least six feet of distance between you and other people in meetings.

This won’t last forever, but Cook Children’s needs your help to be able to always have a bed available for your child should you ever need one.

As the medical director of our Infectious Diseases department, Dr. Mary “Susi” Whitworth has told us, “we never want to get to the point where we cannot prevent a preventable death.”

What played a role? In some cases, junk food and lack of exercise as the COVID-19 pandemic wears on.

Childhood obesity was already a concern in the United States. In 2018, the Centers for Disease Control (CDC) reported that 19.3% of the 2-19 age group were considered obese. That’s about 14.4 million children and adolescents with excessive weight that could lead to other medical problems like diabetes, heart disease, high blood pressure, and joint pain.

But doctors and dietitians fear obesity has gotten worse due to habits that changed during the COVID-19 lockdown and afterward, continuing today. A study cited by the National Institutes of Health (NIH) even uses the term “covibesity” to describe the phenomenon of rapid weight gain that resulted when people changed their eating and exercise routines during the pandemic.

If the early months of the pandemic set the stage for higher obesity rates, the toll on health is current and ongoing. Consider diabetes, for instance: Cook Children’s has seen 91 new cases of Type 2 diabetes diagnosed already this year.

Escalation in childhood obesity becomes an even more relevant and urgent concern given reports of higher risk of severe COVID-19 symptoms for those with obesity. The CDC points out that excessive weight can cause impaired immune function and decreased lung capacity, which may worsen the illness. The CDC cites one study that linked obesity in pediatric patients to higher rates of hospitalization, admission to intensive care, invasive mechanical ventilation and death from COVID-19. At Cook Children’s Medical Center, this rings true. Many of the patients admitted to the COVID-19 ICU are obese are require life-saving measures.

Alice Phillips, M.D., a pediatrician at Cook Children’s, described the accelerated rise in childhood obesity as an outcome of the dramatic lifestyle changes brought on by the COVID-19 lockdown beginning in 2020. Multiple times a day, Dr. Phillips encounters and counsels patients whose body mass index (BMI) has surged since their last checkup.

When the schools were closed, lots of homebound kids began to snack out of boredom. They watched more TV and did online learning in front of a computer – no walking required. Recess, PE classes and team sports were canceled.

“Parents have been trying to nurture their children during a very difficult time. Food remains a cultural norm of nurture for families, and we are seeing the unexpected consequences,” she said.

Dr. Phillips emphasized it’s appropriate to expect a child to pick up some weight during a growth spurt. Pediatricians track the curve using the BMI calculations, which take a patient’s age, height and gender into consideration. Obesity by definition occurs when BMI reaches the 95^th percentile or higher.

Dr. Phillips and her colleagues at Cook Children’s point out two trends: an increase in patients whose recent weight gain put their BMIs in the 95^th percentile for the first time, and previously obese patients who became even heavier.

“When you see an acute change in the BMI from the 75^th percentile to the 99^th percentile, that’s when it catches your eye and you say, ‘What was different this year that caused that change?’” she said. “All too often during the pandemic the families will say, ‘We haven’t been getting any exercise, and our eating habits are maybe a little worse.’”

She worries about the long-term consequences on their health. When she raises the subject of obesity with her patients, she speaks with sensitivity and tries to help the families feel empowered to set goals they can achieve.

“You have to be very careful that you handle that conversation in an empathetic way,” Dr. Phillips said. “I don’t want how I handle it to be part of the problem for this child.”

Here’s what’s important to know:

• Obesity commonly begins between the ages of 5 and 6, or during adolescence. The causes include overeating, genetic predisposition, stressful life events (such as divorce or a move), depression and low self-esteem.
• Obesity is a chronic disease that adversely affects both physical and mental health. It’s easy to diagnose but hard to treat – potentially setting up a lifetime of complications.
• Studies referenced by the NIH show that a child who is obese between the ages of 10 and 13 has an 80% chance of becoming an adult with obesity.

Susan Hsieh, M.D., a pediatric endocrinologist at Cook Children’s, is seeing more patients diagnosed with obesity-related spinoffs that used to be considered adult diseases: hypertension, high cholesterol and Type 2 diabetes. She also points to the COVID-19 lockdown as a tipping point for kids who gained 30-40 pounds since last year. “The body isn’t designed to take on that much weight in such a short period of time,” Dr. Hsieh said.

She explained that obesity causes insulin resistance, impeding the body’s ability to control the blood sugar. It used to be rare, she said, to see an 8- or 9-year-old diagnosed with Type 2 diabetes. Not anymore.

Data at Cook Children’s show that Type 2 diabetes has been on the rise, with 55 new diagnosed cases in 2018, 107 new cases in 2019, and 126 new cases in 2020. The count so far for 2021 is 91 new cases through early September.

Early onset diabetes, if hyperglycemia is mild, can be treated with oral medications. For those patients who require insulin injections, Dr. Hsieh encourages weight loss as a motivation to wean themselves off the injections. She urges families to address their child’s escalating obesity sooner rather than later.

“In general, it’s easy to gain weight and very hard to lose weight,” Dr. Hsieh said. “The more we educate, the better, because prevention goes a long way.”

The Endocrine Clinic at Cook Children’s offers a program called Risk Evaluation to Achieve Cardiovascular Health (REACH), targeting kids affected by cardiovascular diseases caused by obesity or other factors.

Since the start of the pandemic, registered dietitian Lauren Williams found that her REACH patients and their parents often report more junk food consumption and less physical activity. She counsels them to treat food as a source of nourishment.

Williams’ main message? “We need a healthy relationship with food. We don’t snack throughout the day when we’re not hungry. We move our bodies because our bodies were made to move. Exercise helps our mind; it helps our sleep. Get out and run and play even if it’s just with your siblings in your backyard, having fun.”

Cook Children’s also offers a one-time, free-of-charge class called Healthy Weight Healthy You, which promotes the MyPlate nutrition guide and other tools to eat right. The class is offered in both English and Spanish for children ages 5-18 and their parents. A physician’s referral is needed.

Another resource to fight obesity is the Cook Children’s Outpatient Nutrition Services, available only through referral from physicians in the network. Jean Mankin, a registered dietitian in the outpatient clinic, said the incidence of childhood obesity “exploded” during the COVID-19 pandemic.

“Almost every patient that I’ve seen will admit to boredom eating. And the parents will agree,” Mankin said. “The parents will say ‘I was trying to work… I was there for emergencies but the kids were left to their own devices and they were grazing all day on chips and cookies and crackers.’”

Now she works with families to undo the damage. Bad habits – constant snacking, inactivity -- can be corrected. But it starts with recognizing the problem.

The patients Mankin meets with often arrive with complications tied to the excess weight on their bodies. She lists orthopedic problems, respiratory issues, elevated lipids, elevated liver enzymes and sleep apnea among the ailments.

A one-hour consultation with Mankin encompasses a review of the family’s journal of food intake over several days; guidance on problems she identifies; a packet of information to take home; and lots of encouragement. No one is forced to get on the scale. Mankin says she frames the conversation around the proper nutrition necessary for growth and development -- avoiding the word “obesity” out of sensitivity.

“Some of these little ones and adolescents can easily get their feelings hurt. And when that happens, they shut down. I also encourage parents to be mindful of the language used at home,” she said. “I work really hard to focus on overall health and to keep a positive vibe in my office. Initially, many kids that come to me are somewhat fearful or trepidatious, but most leave with a smile on their face.”

She emphasized that parents must be committed to making changes in the family’s approach to meals and exercise. Improvements don’t usually happen right away. A follow-up visit with the dietitian might be needed after the initial consultation.

If you have a concern about your child’s weight, contact your pediatrician.

If ever there was an image that captures how many of us are feeling at this point in the pandemic it’s that of a splooting squirrel. Squirrels lay spread eagle—or sploot—on a cool surface to lower their body temperature.

Annie Stewart, LCSW, PMH-C, a clinical therapist in Cook Children’s Neonatal Intensive Care Unit (NICU), caught a glimpse of a splooting squirrel on her way into work recently. She snapped a photo of it, knowing that a picture is worth a thousand words.

“He looked like I felt,” Stewart wrote in a letter to her NICU team. “Indifferent to what was happening around him. Not his usual playful self. The picture of ‘meh.’”

Over the past few months we’ve worked to shed light on the mental and emotional health issues plaguing our youth, be them pandemic related or not. Suicide among children, for example, is at an all-time high. But not everyone is in crisis. Many kids, and adults for that matter, fall somewhere in between. They’re not drowning in despair, but they aren’t thriving either.

Like that splooting squirrel so vividly illustrates, they’re languishing.

Stagnant. Indifferent. Not depressed, but lacking motivation. Not happy, but not sad. Easily overwhelmed. Ambition and passions replaced with mediocre motivation. Little to no enthusiasm for things that once generated excitement and anticipation, like the start of a new school year.

“Languishing is typically thought of as the opposite of flourishing,” said Steve Chennankara D.O., a psychiatrist on the medical staff at Cook Children’s Medical Center. “It can be viewed as a temporary defense mechanism after a major loss or in the context of returning to normal after a major catastrophic event in one’s life. In any case, it is worth recognizing it, talking about it and seeking help if prolonged.”

Perpetual Pandemic

It’s not hard to see why some are languishing right now. After all, it’s been 15 months since the World Health Organization declared the spread of COVID-19 a pandemic. That’s about 70 weeks of daily COVID crisis news. More or less 500 days of normal life interrupted by masks and social distancing. For kids and teachers going back to school, it’s like Groundhog’s Day with yet another academic year punctuated by the pandemic. Health-care workers feel like they’re riding a never ending roller coaster as COVID surges wax and wane.

It’s exhausting, and we’re feeling it.

What we’re experiencing is life in a chronic survival state, according to Susanne Malone, LCSW, clinical director of My Health My Resources (MHMR) Tarrant County. She explained that our brains and bodies are designed to have a fight or flight response to crisis, but they aren’t designed to live in that state forever. When a disaster lasts weeks, months and years, we tire, run out of motivation and find it easier to disengage than to continue to embrace the challenge.

That disengagement can take its toll at home, work and school.

“This never ending feeling of angst many in the workforce are feeling manifests itself in two extremes,” said Leah King, president and CEO of United Way of Tarrant County. “It either leads to minimal engagement in one’s work, or hypersensitivity to normal challenges that one may encounter throughout the course of their workday. Many of us have lost the ability to process at a normal speed and at the appropriate level to manage emotions. So people may be a little bit more short with their colleagues than they ordinarily would.”

Beyond decreased motivation, indifference and uncharacteristic behavior, the problem with languishing is its potential to extinguish hope and lead to depression. In a time of crisis, hope is essential. It’s what gives those in despair a fighting chance.

“We don’t always know that we’re languishing,” said Dawn Hood-Patterson, Ph.D., MDiv, program manager for The Center for Children’s Health at Cook Children’s. “The danger is that languishing incapacitates our ability to hope for other things. We are muddling through to the point that we don’t even know that we have a problem or we don’t recognize that things are not the way that we want them to be.”

So how do we turn the tide when we can’t muster the motivation to do anything more than sploot like a squirrel? We asked a few community mental health experts and leaders within the workforce for their tips for moving from merely surviving to thriving.

Focus on health. Sleep, nutrition and movement are often the first healthy habits to go when you are under pressure, but they are the most important defense you have against the physical and mental effects of chronic stress. Make health a priority by getting enough sleep, eating healthy and moving your body.

“Health is literally our biggest warrior,” Malone said. “Research has proven that if we pay attention to sleep, movement and nutrition it helps us be more resilient.”

Go all in. Like that splooting squirrel that commits every part of himself to lowering his body temperature, we can do the same to lower our stress and revive our energy. Not literally, of course. But we can power down the distractions and go all in on an activity we enjoy. Immersing yourself in a single activity for a period of time can renew, revive and re-engage your focus and creativity.

“For me, this happened planning meet-the-teacher night for my kids’ school,” Stewart explained. “I know chairing a major PTA event is not enjoyable for many, but in doing so, I found flow. I found myself eagerly turning on my laptop after the kids were in bed to create flyers. I lost track of time as I made props for a back-to-school photo booth. I stayed up late to send emails and create QR codes. I didn’t mind. I enjoyed it. I moved from languishing to flourishing and it carried over to my personal and professional life.”

Celebrate the small things. What got you out of bed this morning? Was it a barking dog ready for their morning walk? Perhaps it was a crying baby, or kids that needed your help getting ready for school. Maybe it was that looming work deadline or fear of missing the school bus. Something compelled you to take that first step, get out of bed and push through. That’s a win. Put one foot in front of the other and build on that. Celebrate the wins, no matter how small.

“There may be something in your life that prompts you to take a course of action that you don’t necessarily want to, but you do it,” Hood-Patterson said. “I think that is undervalued and it needs to be praised. That may seem small to you, the fact that you got out of bed, but that shows your capacity to change your course of action.”

As students return to the classroom, Fort Worth ISD is celebrating the wins, be them big or small, while embracing the losses as teaching moments. They’re encouraging parents to do the same.

“We’re giving parents homework,” said Barbara Reynolds-Brown, LPC, clinical coordinator for FWISD Family Resource Center at Forest Oak. “We're asking them to help their kids set goals for the year. We’re asking parents to be involved in rewarding and to always give their kids some good, specific, credible and genuine feedback. We’re asking them to refrain from constantly pointing out their kid’s mistakes and understand that kids are going to make mistakes. Talk about the mistakes and the opportunities we have to learn from them.”

Let kids be kids. Play is a powerful part of a child’s development. Through play, kids can learn to relate, communicate and problem solve.

Over the course of the pandemic children have missed out on two things they crave most—engagement and consistency, according to Reynolds-Brown.

“Kids have become detached because, in school, teachers were right there with them, always engaging them during the day,” Reynolds-Brown explained. “They need that feeling of belonging. They need that engagement. They need their peers, and a lot of that is what they have been missing.”

That’s why it’s important to let kids be kids, and join them in play or an activity they love. It’s a good time to connect, restore some childhood normalcy and build hope for the future.

“We don't want to take that edge off of them still being children,” Reynolds-Brown said. “They lost a lot. They lost the prom. They've lost camaraderie. They lost the football games and the baseball games. Right now that's our normal, but it won't always be our normal. I don't want them to ever think that there's not something better beyond this. It may not be the same, but it's going to be something better. So keep them positive.”

Take a break. Leah King makes a point to model the importance of taking time away from work to rest, relax and regroup. She announces her days off to her United Way staff and reminds them to take their vacation.

“Even if you feel like you can’t safely leave your home, you still need time to step away from the computer just to refresh your mind,” she said.

Connection is key. Don’t be afraid to connect with others and share what you are experiencing.

“More than ever before, we have got to make it part of our regular conversation to check with people and see how they’re doing,” Malone said.

One way to build connections and improve your mood is to help someone else. Research shows that helping others takes your mind off of your own circumstances, increases feel-good hormones, feeds the part of your brain associated with reward and reframes your perspective.

Above all else, hold on to hope. It may seem like we’re riding a hamster’s wheel of perpetual pandemic, and that normalcy is just out of reach. But the sun still rises and sets. That alone is evidence of hope. Not a surety that another sunrise will illuminate the same circumstances as yesterday, but the blessing of a new day and a new opportunity to pursue and foster hope for yourself and others.

They shared how Cook Children’s is currently being impacted by a surge in COVID-19 cases and hospitalizations.

Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases, Corwin Warmink, M.D., medical director of Emergency Services, Kara Starnes, D.O., medical director of Urgent Care Services, and Bianka Soria-Olmos, D.O., pediatrician at Cook Children’s Pediatrics Haslet have all worked tirelessly to ensure our patients and families are receiving the best care throughout the pandemic.

During the news conference, the experts addressed what they are seeing in our urgent care locations, emergency department, and Cook Children’s system as a whole.

“We need compassion from the community and this is an illness affecting our children,” Dr. Starnes said. “We are hitting crisis mode and we can’t do it without your help.”

Cook Children's Urgent Care facilities are being stretched thin. Over the weekend, Cook Children’s was forced to close its Hurst location due to a lack of staff members and high demand for services.

"This is the first time we’ve had to take such measures. We closed in an effort to consolidate staff and safely take care of our patients,” Dr. Starnes explained.

On Monday, the six remaining urgent care locations saw 1,400 children. This is twice the number of patients the urgent care centers typically see.

Dr. Starnes stressed that if you believe your child has been exposed to COVID-19, it is best to find a local testing site in the community or use an at-home testing kit. You can find a list of local COVID-19 testing locations here. 

Cook Children’s Emergency Department (ED) is experiencing patient volumes not seen since the H1N1 pandemic in 2009. On Monday, the ED saw 601 patients with patients arriving every 2.5 minutes.

“We are breaking records we don’t like to break,” Dr. Warmink said. “I have been at Cook Children’s for 18 years and this is the worst it’s ever been.”

We encourage all families to come to the emergency room for emergencies but ask that they do not come for a simple COVID-19 test. This pulls resources away from critically ill and injured patients and takes up already limited bed space. Along with COVID-19, we are still seeing RSV cases but thankfully, they appear to be on a downswing.

“The adults in the room need to step up and do the right thing,” Dr. Warmink said. “If you send your kid to school without a mask, it’s not if they are going to get sick, it’s when.”

Dr. Warmink advises all parents, “Ask yourself if this can wait” before bringing their child into the emergency department.

Most children have mild illness with COVID-19, but that is not the case for everyone. Throughout the course of the pandemic, Cook Children's has hospitalized 1,129 children with COVID-19, with 241 of those admitted to the Intensive Care Unit (ICU). Throughout the pandemic, seven children with COVID-19 have died. Two died this past week. They were a 4 year old and a 15 year old. 

"We are seeing more severe illness than we have seen at any point during the pandemic. The January surge was nothing compared to what we’re seeing now,” Dr. Whitworth said.

As a result, on Monday, Cook Children’s opened up a third COVID-19 unit for the first time since the start of the pandemic. This unit has nine beds – and within the first 24 hours of being open, was completely full.

With Labor Day weekend ahead of us, Dr. Whitworth encourages everyone to be safe, mask up, and socially distance, as we cannot handle another influx at this time.

“Every child that has the virus inside of them has the potential to spread it to someone else, and they don’t mean to,” Dr. Whitworth said. “Much of what we are seeing is 100% preventable, children have to wear a mask.”

Cook Children's also set a record for COVID-19 hospitalizations on Wednesday with 35 patients. This is the highest number of COVID-19 patients hospitalized at the medical center at any point in the pandemic. The COVID-19 ICU was also filled. 

What can the community do to help?

All four experts we heard from on Wednesday have a few simple pleas:

1. Get vaccinated and get your child vaccinated as soon as possible.
2. Please have your children wear a mask to school.
3. Wash your hands frequently.
4. Re-think gatherings – if you gather, wear masks, stay socially distant and gather outdoors if possible.

Across the board, Cook Children's is seeing record numbers of families each day who are wanting rapid COVID-19 tests for their children.

"We understand this is a scary time, but want to remind families not to panic if your child was exposed to COVID-19," Dr. Starnes said. "We understand schools have requirements, but we need you to understand we do not want you to panic or rush in to be seen immediately after an exposure. Rushing to our urgent care locations puts a strain on our resources.”

The best thing you can do if your child was exposed is find a local testing-only site in the community or use an at an at-home testing kit.

Cough, fever, runny nose, sore throat, body aches, headache, vomiting and diarrhea are all common symptoms of COVID.

For children over the age of 3 months, these symptoms can typically be managed at home with symptomatic care. Medications such as acetaminophen or ibuprofen can help with fever and pain. You should encourage your child to drink plenty of fluids and it is ok if they do not have much of an appetite.

Parents should seek care for their child over 3 months of age if they have had 5 days or more of fever, difficulty breathing, inability to keep fluids down or stay hydrated (no tears or no urination for 8 hours or longer) or if their child is having pain or fever that is not helped by an appropriate dose of fever reducer/pain reliever.

Patients under 3 months of age who are sick should be seen in person and evaluated.

Also, if there is at least one known positive case at home and others are sick, it can be assumed that all have COVID and everyone needs to isolate at home for 10 days from the start of symptoms.

“We cannot magically create hospital beds at the drop of a hat,” Dr. Whitworth said. “Wear a mask no matter if you’re vaccinated or not, wearing a mask is not an option.”

Angie, Cason's mom, told Good Morning America that she worries her son might get reinfected with the novel coronavirus at school. She’s urging students to wear masks for the sake of her immunocompromised son, and all kids under age 12 who can’t yet get vaccinated for COVID-19.

Read the full GMA story here.

The onset of loneliness, anxiety and depression in teens and adolescents during the COVID-19 pandemic has fueled a sharp rise in reports of dangerous eating behaviors.

The National Eating Disorders Association (NEDA) helpline saw a 54% spike in calls for support and resources to treat anorexia nervosa, bulimia, binge eating and other illnesses. Experts blame the surge on factors including stress, isolation and excessive use of social media during the coronavirus lockdown beginning last year.

Health care professionals have long known that eating disorders can be brought on by major life changes. Specialists say that for some young people who already were predisposed, the disruptions from COVID-19 triggered a full-fledged illness or a relapse from their recovery.

“Eating disorders are somewhat of a secret disorder. The more isolated you are at home, the more these types of disorders thrive,” said Joy Crabtree, a licensed psychologist at Cook Children’s. “These disorders often go hand-in-hand with anxiety disorder and depression, and the pandemic has played a role in that.”

At Cook Children’s, we initiated the Joy Campaign – a weekly series of stories addressing mental health issues in children and teens – in response to an alarming rise in suicide attempts in the past year. Eating disorders carry an elevated risk of suicide, particularly in those who suffer from anorexia. One out every of five deaths among anorexics is by suicide, according to the NEDA.

But the hopeful news: Although serious and complex, eating disorders can be treated through a combination of medical, behavioral and psychological tactics. Early diagnosis and intervention lead to better outcomes, Crabtree said.

Keep in mind a few key points:

• Eating disorders cover a spectrum of mental and physical illnesses that in the most severe cases lead to death. Anorexia typically involves severely restricted calorie intake, dramatic weight loss and distorted body image. Binge eating involves rapid and often secretive consumption of large amounts of food. Bulimia causes cycles of binge eating followed by forced vomiting, misuse of laxatives and/or excessive exercise. More information and other types of eating disorders are listed here.
• Eating disorders happen more commonly in girls and women, although boys and men can struggle too. The disorders affect people regardless of age, race or body shape.
• The American Academy of Pediatrics reported the estimate that 0.5% of adolescent females in the United States have anorexia nervosa, and that 1-5% meet criteria for bulimia.

Depression often co-exists with eating disorders. When it comes to adolescents, studies cited by the National Library of Medicine recommend a strategy of aggressively treating the depression and not just the unhealthy eating behaviors alone. Studies also recommend routine monitoring for signs of suicidal ideation, which surface when someone doesn’t want to live anymore.

The reported rise in new or recurrent eating disorders remains a relevant story, even as many of the COVID-19 restrictions have ended, because these illnesses require specialized and sometimes long-term care. As one dietitian put it … eating disorders don’t go away overnight. Treatment options range from outpatient visits to residential care to hospitalization for complications from severe malnutrition (heart disease, organ failure and electrolyte imbalance in the most extreme cases). But access to treatment isn’t always available.

In the past year, inquiries about eating disorders have trended up at Cook Children’s, although the medical center’s behavioral health Intake department doesn’t keep an exact count. Crabtree sees a tie-in to the general anxiety and depression that the COVID-19 pandemic inflicted. She listed contributing factors such as last year’s school closures, cancelation of extracurricular activities and separation from friends.

What else came into play during the pandemic? Lack of routine for sleeping and meals. Poor coping skills. Messages about food hoarding. Fears about weight gain. Pressure to look thin in social media photos and on the Zoom screen.

“Seeing yourself on camera, seeing others on camera, making those comparisons has played a role” in the rise of eating disorders, Crabtree said. “It was kind of a perfect storm, all this focus on food and bodies. It was very overwhelming.”

She urged parents to watch for signs of eating disorders in kids. Red flags include preoccupation with dieting, dramatic weight loss, withdrawal from friends, fatigue, dizziness, fainting, anemia, hair loss and menstrual irregularities. Anyone with concerns should contact their child’s pediatrician or call Cook Children’s to discuss referral options or possible psychological or psychiatric treatment, Crabtree said.

Getting started on treatment

Jean Mankin, a registered dietitian with Cook Children’s Outpatient Nutrition Services, works with primary care physicians to help with food allergies, obesity, picky eating and other issues. When it comes to someone with significant weight loss, Mankin starts by trying to determine whether the patient’s weight fluctuation is intentional.

“If you feel like they’re purposefully withholding food or telling you that they’re binge eating or purging, it’s important to get help,” she said. “A lot of kids are finding themselves having issues they didn’t have prior to the pandemic.”

Mankin emphasized that adolescents need to eat a well-balanced and sufficient diet because all vital organs and bone are rapidly growing and developing at this stage. Anxiety and depression can cause a dramatic decrease in appetite for some, and for others it can lead to stress eating or binging. As long as mental health problems go unresolved, the eating behaviors won’t improve, she said.

At Cook Children’s, patients with suspected eating disorders are referred to local specialists such as Carol Ann Darwin, a registered dietitian in Fort Worth who has met over her career with clients from age 8 to age 70. In April 2020, Darwin started seeing a big increase in anorexia and bulimia mainly among the 13- to 17-year-old set. She called the pandemic a nightmare.

“I went from working three days a week to working six days a week just to get these kiddos in,” Darwin said. Some individuals with eating disorders had to be hospitalized with feeding tubes until spots opened up in residential treatment centers, she said. Dietitians, therapists and treatment centers in North Texas and nationally still have waiting lists up to a month, Darwin reported.

The pandemic caused an onslaught of maladies that Darwin’s youngest clients bring up: isolation, stressful dynamics in a quarantined household, frustration with online school, loss of control. Food became a crutch to comfort and to alleviate loneliness. The challenges that were particular to 2020 compounded the usual causes of eating disorders, such as genetic predisposition and being bullied.

There’s no quick fix; Darwin typically meets with her clients in weekly nutrition consultations for two or three years – although the time frame can be less for those whose underlying depression and anxiety are mild. She said she prefers to use “gentle nudging,” rather than scare tactics, to motivate her clients to start eating appropriately.

“I’ve had several (clients) where I thought, ‘Would this have happened if COVID hadn’t come along?’ Maybe not,” she said.

Disconnection and disappointments

Dawn Dillon, a therapist in Fort Worth who has specialized in eating disorders since 1998, characterized the current demand for mental health services as an explosion. Disordered eating can come from the instinct to take action during times of uncertainty and fear, Dillon said. She drew an analogy to the people who rushed out to buy toilet paper in the early days of the pandemic. The same instinct applies to food and body image.

“We take all these things that are messy, uncertain or scary, and we manifest it through our body,” Dillon said. “Instead of saying ‘I’m scared, I don’t know what to do,’ it gets put onto the body as ‘I’m fat. There’s something to do with that – I can lose weight. I can sculpt. Or I can tone.’”

Eating disorders can originate out of a misplaced attempt to manage distress when someone feels stuck or trapped. Dillon listed a variety of scenarios that particularly applied to life for teens and young adults during the height of the COVID shutdown: Disconnection from social support. Disappointment when prom and graduation got called off. When will colleges and dorms reopen? So many unknowns.

Additionally, refusal to eat can be a way that teens, like toddlers, exert their separate identity. “In a home with no personal space and no autonomy, a lot of times eating disorders will creep up because it’s a way to assert boundaries,” she said.

Once a patient’s medical condition and food intake have stabilized, Dillon said, the mental health piece of treatment becomes vital to get to the root of the anorexia, bulimia or binge eating. Everyone involved in treatment stays vigilant for warning signs of suicide.

No one chooses to develop an eating disorder. Dillon’s current clientele includes first-timers as well as patients with persistent struggles in and out of treatment. Some patients who were handling recovery well prior to COVID-19 had to return for more therapy.

“From the research, we know that life-stage transitions are high-risk times,” she said. “You look at this pandemic, and it was a huge transition that nobody planned for, nobody expected, and nobody knew how to do it. So it makes sense that there would be a rise” in cases.

Dillon acknowledges it can be a terrifying experience for families to go through. Don’t blame yourself or make it a power struggle, she advised. “It’s hard on parents on a fundamental level, but it’s not their fault. The goal is to be aligned with your loved one as the two of you fight against the eating disorder together rather than the two of you fighting with each other.”

One year into COVID-19, it’s clear the pandemic is taking a toll on the mental wellbeing of children and teens.

In March, a record 43 patients were admitted to Cook Children’s Medical Center after attempting suicide. This staggering figure is nearly double the number of suicidal patients seen during the same time period of 2020. Even worse, kids are dying. Last year, Cook Children’s recorded seven suicide deaths, marking the first time suicide was the leading cause of trauma deaths at the hospital, surpassing child abuse and car wrecks.

“The mental health crisis was already happening, then it met a global pandemic and these are the consequences,” said Kristen Pyrc, M.D., co-medical director of Psychiatry at Cook Children’s.

“They’re less engaged and have less interaction with others, and instead are spending more time online and in virtual settings. And it’s hard for them to be hopeful about anything because so many things, like prom and graduation parties, are canceled.”

The issue is not unique to North Texas. Doctors and nurses from across the nation are reporting similar statistics. In February, NPR released an article titled “Child Psychiatrists Warn That The Pandemic May Be Driving Up Kids' Suicide Risk.” It found that children’s hospitals across the U.S. are seeing up a 250% increase in suicidal patients in emergency rooms since the pandemic began. While there are no nationwide numbers on child suicides in 2020 available yet, experts agree there is reason to be concerned.

The Impact

More children are suffering from stress, anxiety, depression, and suicidal thoughts than at any time in recent memory. Pediatricians like Kathleen Powderly, M.D. from Cook Children’s Pediatrics Magnolia say children as young as 7 are needing help.

“I’ve had a couple of elementary school students, which you don’t see very often, who are actively suicidal or have already had a suicide attempt. I’ve also managed more kids on antidepressants since the pandemic because it’s hard to get into doctors right now,” Dr. Powderly said. “COVID-19 is not as impactful in terms of volume of cases in pediatrics, but our volume of psychiatric patients has increased quite a bit.”

Previously, Dr. Powderly was the medical director of Cook Children’s Hospitalist Group, the attending physicians who care for children in the hospital. She says her team was seeing an increase in suicidal patients before she transitioned into the office setting five years ago and that the pandemic created a perfect storm. On top of the stressors kids were already dealing with, they’re now struggling with isolation, virtual school, and a loss of activities.

“We’re not going to be able to flip the switch and just go back to normal when this is over,” said Dr. Powderly. “This is going to take some time to come out of. I’ve even had patients tell me they’re struggling with being around people.”

Members of Cook Children’s Youth Advisory Council shared similar experiences in a recent meeting. The teens said they feel more anxious being around their friends in person because they’re so used to only seeing people online now. In addition to new stressors, there is a severe lack of mental health resources across the board.

A Growing Need

“There weren’t enough psychiatric beds to begin with, and then COVID happened and the capacity was reduced because you can’t have patients sharing rooms,” said Dr. Pyrc.

The need for more inpatient psychiatric beds for children and teens has been known for years. In 2017, Cook Children’s opened the Rees-Jones Behavioral Health Center to help address the issue. The unit has 15 inpatient beds available for children between the ages of 2 and 12. As we reported when the center opened, the kids who end up here are patients with complex trauma, medical and social needs. They are often suicidal or have tried to hurt someone else. Eight out of 10 have had something traumatic happen to them. They have either been abused physically or sexually, or they have experienced some sort of neglect.

Teenagers who need inpatient psychiatric care have to be treated elsewhere but often end up waiting on the medical floor of Cook Children’s until a bed opens up in the community, which can take days. With more kids needing these services, it’s not uncommon for Cook Children’s to have a dozen or more patients waiting in a regular hospital room for a transfer to a psychiatric facility that can care for them.

“There are just not enough resources in general,” said Dr. Pyrc. “It’s an awful place to be in. This is a national problem, but it affects us here locally. We need more funding and we need more mental health professionals to care for these patients.”

On the outpatient side, finding a licensed therapist to see a child can take months. The waitlist just to see a counselor at Cook Children’s can be as high as 250 days at any given time. Even with easier access to appointments with virtual visits, there are not enough mental health professionals to meet the need.

Kia Carter, M.D., co-medical director of Psychiatry at Cook Children’s, has been a vocal advocate for increased mental health funding. Testifying in front of the Texas Senate’s Committee on Health and Human Services recently, she said early identification, intervention and treatment is essential to preventing further complications from mental illness. But there are roadblocks.

“We get insurances denying a specific level of care saying that a child doesn’t need an inpatient level of care. We also get a lot of pushback about medication,” Dr. Carter said.

She also asked lawmakers for increased support and to consider giving mental health care providers more leverage with insurance companies.

Hoping for JOY

In the meantime, Cook Children’s aims to bring awareness to the mental health crisis affecting children and teens with the launch of a new suicide prevention campaign.

The Joy Campaign is an acronym that stands for:

Just breathe.

Open up.

You matter.

“If we can just get kids to slow down, realize that what they are experiencing is temporary and that they have a long life ahead of them, I think we can make an impact,” said Dr. Powderly.

For the next month, Cook Children’s will be releasing a series of articles on Checkup Newsroom weekly that address many of the issues at play, such as the pandemic, the role of over-the-counter medications, social media, as well as how minorities and LGBTQ+ young people are impacted. We’ll also be speaking with families who have lost a child to suicide to examine the effects on parents and siblings.

If you feel your child might be struggling, here are some of the warning signs to watch for:

• Anger
• Declining grades
• Lack of concern about appearance and hygiene
• Changes in eating and/or sleep
• Self-injury such as cutting
• Less motivation
• Alcohol/drug use
• Acting highly anxious or agitated
• Recklessness
• Giving away possessions 

If you’re concerned about your child’s mental health, seek help early. Schedule an appointment with a licensed counselor. If your child is actively suicidal, call 911 or take them to the nearest emergency room.

Read this story in Spanish here.

“We usually see a cluster of patients from crashes in the three to four days before and after Christmas,” said Sharon Evans, trauma injury prevention coordinator at Cook Children’s. “People are stressed, and it’s the height of travel season. We don’t know what it will be like this year due to the pandemic, but we know this time of year is especially dangerous.”

Since 2015, an average of 12 car wreck victims were admitted to Cook Children’s between the dates of Dec. 20-30. Out of those, three were typically not restrained with a seat belt or car seat.

“If a child is properly restrained in a car seat, we may see some cuts and bruises, but they usually ok,” said Evans. “The ones who are much more seriously injured tend to be children in seat belts who are too small and should be using a booster seat.”

In Texas, children are required to remain in a car seat until they are 4 feet 9 inches tall or 8 years old. Experts like Evans say that is the bare minimum, and it’s more important to pay attention to a child’s size than their age since seat belts are made for adults and don’t fit small bodies properly.

“When children are using a seatbelt prematurely, the belt doesn’t fit across the center of their shoulders like it should and kids will tend to put it behind their back or under their arm,” she explained. “Now, their entire upper body is unrestrained. In a crash, this means the child folds over the seatbelt.”

She says these children can suffer cervical spine injuries, as well as serious internal injuries to the spleen, liver and intestines. This is why it’s so important for children to remain in a car seat or booster seat until they fit into a seat belt. Also, any child under 13 years old should ride in the backseat.

“There are no do-overs,” said Evans. “A lot of times we see families who say their child was really tired or fussy and didn’t want to get into the car seat or they wanted to lay down. We understand how that can happen, but families need to know that kind of normal decision can affect your life forever.”

Most Dangerous State

A recent report released by Go Insurance’s partner nonprofit, Go Safe Labs, shows Texas is the least safe state in the country for children in vehicles. Between 2015-2018, Go Safe Labs found that 1,172 children were injured or killed in traffic accidents in the state, with 55% in rural areas and 45% in urban areas.

Further data from the Texas Department of Transportation shows it’s been more than 20 years since the state has seen a day without a death on its roads. November 7, 2000, marked the last time that happened. Since then, more than 70,000 people have lost their lives on Texas roads, with an average of 10 people dying every day.

“You hear about wrecks every time you turn on the news and I think we’ve almost become desensitized to them,” said Evans. “You have to remember, it could be you and it could be serious.”

Due to the COVID-19 pandemic, this holiday season could see more deaths than usual.

According to a study by the Center for Transportation Safety (CTS) at the Texas A&M Transportation Institute (TTI), the number of Texas traffic crashes in April dropped by nearly 50% compared to 2017-2019 averages. While there were fewer crashes, researchers say there was a 50% increase in traffic fatalities. They believe the data is evidence that the risk of death and injury is greater when roads are more clear, likely because people tend to drive faster with fewer cars on the road.

“There’s no way to predict what will happen this holiday season, if there will be more people on the road or less,” said Evans. “But one thing I know for sure is accidents don’t take a day off.”

What Can Parents Do?

If you are traveling with children, make sure they are restrained properly. According to Safe Kids North Texas, four out of five car seats are installed incorrectly. For this reason, they offer free car seat checks to ensure your child’s safety. Due to the COVID-19 pandemic, car seat checks are being offered virtually only at this time. You can easily sign up for a check online by clicking here.

Normally, it's time for kids to pack their bags, kiss their parents goodbye, get on a bus, and head to Camp John Marc. Last year, 1,081 kids, 175 employees and 231 volunteers went through some form of this ritual.

But as we all know, nothing is normal right now.

The circumstances related to the COVID-19 pandemic meant the cancelation of all summer camps. Well kind of, because while kids won't be going away this summer, they can experience camp from the comforts of their homes.

For several years now, a volunteer program called Happy Camper brought the camp experience year round to the medical center. This summer, Cook Children's will bring a new program called "Happy Camper at Home" to kids who would have attended a diagnosis-specific camp.

Katie Campbell, Child Life manager at Cook Children's, said a lot of kids count on camp for their socialization during the summer. Cook Children's Camp for Kids allows patients to learn about their diagnosis and be encouraged by others who share their same challenges.

"A lot of the kids who have chronic illnesses, at school they may be the only person in their class with diabetes, or they may not know anyone else at school with asthma," Campbell said. "They get a chance in the summer to go camping for a week with kids who are just like them. It doesn't feel as isolating or different. That's something campers will miss this summer is having that opportunity to be with people that share the same challenges and seeing their medical team in a different location. It's different to see their doctor in their regular clothes when you come to the clinic vs. shorts and T-shirt or in their trunks swimming at the pool with you."

So while kids wouldn't be able to attend, the experience to be a part of camp life was too important to cancel entirely. With a lower census than usual because of COVID-19, Child Life specialists focused on creating a different camp environment from home.

"Once we decided to shift gears and do something different, we started meeting weekly, and then everyone got creative and hit the ground running," Campbell said. "Our hope is for kids to opt-in virtually. They will get to come by the medical center in mid-June and pick up their 'swag boxes' with a bunch of branded camp stuff as they would usually get. They will get things like a T-shirt, a flashlight, water bottles, a deck of cards, those kinds of things. But then we also started to think about what activities we could offer the campers."

A YouTube page with content created by Cook Children's Child Life Zone staff will be available for the campers to watch. Just like any other summer, the campers will receive a mix of fun and education through watching YouTube. The YouTube channel will be available to all kids, even for those who aren't a part of the camps.

The channel will offer cooking, crafts, games and scavenger hunts. The medical teams related to a child's specific condition will provide short diagnosis education videos. Plus, kids can watch the Laughter League, Cook Children's clown program, perform comedy and circus skills, origami lessons and more.

More confined to the campers themselves, a private Instagram account will be available during the summer, which will be the home of a live talent show, dog visits, crafts and more.

"The hope is to build a little bit of a community within Instagram," Campbell said.

Campbell has been at Cook Children's for 21 years, and this is the first time that her summer won't center around attending or planning a camp. She said she would miss going, but this summer will offer some unique positive aspects that generally wouldn't take place.

"One cool thing about doing camps virtually is for the first time we'll be able to include kids with cystic fibrosis in our camping program," Campbell said. "Those kids can't go away to camp because of isolation restrictions around having CF. They can't be together in a community setting. So it will be neat because those kids will be able to engage in camp programming when they haven't formally had camps they could attend in the past."

Another interesting aspect of virtual is that other family members will get a taste of what camp is all about during the summer. Other than Camp Sanguinity, siblings of patients aren't allowed to go to camps.

"I think it will be fun to see what conversations kids will have with their parents and siblings about what happens at camp," Campell said. "My hope is it fills in some of the blanks for families of why camp is so important. Maybe, parents get a chance to watch over their kids' shoulders or the brothers and sisters share in some of the activities. I hope it brings the spirit of camps into everybody's house, and other people in the families benefit from it."