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Back to School-How to Cope with Stress During Stressful Times

Nicole Thomas, M.D.

Child & Adolescent Psychiatrist

Pediatric Psychiatry Collaborative

Morristown Medical Center

Introduction: My name is Dr. Nicole Thomas and I am a child and adolescent psychiatrist in the Department of Psychiatry here at Morristown Medical Center. One of my main functions here is to serve as a consulting psychiatrist to the Pediatric Psychiatry Collaborative -a grant-funded state program that allows enrolled pediatricians the opportunity to consult and collaborate with a child and adolescent psychiatrist so that mental health care can be screened and addressed sooner on the primary care level when appropriate. In this role, I am in a unique position to learn about issues and challenges affecting children and adolescents in the community -there have definitely been some unusual stressors in the past few years. These are very uncertain times and not only are we as grown-ups feeling it, but our children and adolescents are especially feeling it as well. I wanted to talk a little bit today about how to deal with this time of uncertainty and stress as we prepare for the upcoming academic year, how to identify and manage signs of stress in children and adolescents in addition to parents and caregivers, and when to seek guidance from your pediatrician or a mental health specialist.

Back to school stress: Back to school time is definitely filled with a number of positives for children and adolescents -returning to a routine, with a structured and a fairly normal day to day. Kids are engaged, back with their peers and typical activities are up and running again. It also can come with some stressors as this is a time of transition -a new school, class, teachers, work/courses -academic pressures, peer issues, and social stressors can also start to emerge or re-emerge after the break that comes with summer.

Back to school stress+extra this year: This year, while dealing with unexpected changes and new variants of the pandemic is not new, it is definitely not the world we were living in 3 or so years ago. COVID-19 is still a concern and the downstream effects of a pandemic world are starting to play out. There are a number of unique stressors and challenges we have all been facing in the past few years, between the COVID-19 pandemic, the war in Ukraine, gun violence, mass shootings...just to name a few –bottom line is kids are dealing with a lot and exposed to a lot; especially depending on screen time exposure; there is potential for 24/7 media coverage/constant social media postings of all of the above and many difficult, hateful, and sometimes violent situations. Some groups are affected more than others, especially minority populations and the LGBTQIA community. Looking for some type of silver lining here, we do have to remember that kids are resilient and working through stressors with supportive parents and caregivers to help guide them can model effective ways to deal with stress in the future.

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Some Ways Kids Respond to Stress

*Kids of any age group can express symptoms of wanting to die, of wanting to hurt or kill themselves or others, or exhibit potentially dangerous behaviors!

Younger Kids

Tantrums or disruptive behaviors
Regressive behaviors
Changes in appetite or sleep
Separation anxiety
Changes in behavior at school
Physical complaints
Expressing feelings of anxiety, depression, irritability

Older Kids

Defiant or increased risk-taking behavior
Changes in appetite or sleep
Withdrawal from peers/family
Decline in academics
Loss of interest
Expressing feelings of anxiety, depression, irritability, etc.

Signs of stress in kids by age: Everyone deals with stressors in their own way. And to be honest, some types of stress can actually be good -just think about some pressure by your boss or teacher to get an assignment done by a due date –this kind of stress (that is stress in moderation or productive, positive stress) can be very motivating. Sometimes signs of stress look like symptoms of anxiety, behavior, or mood changes. In kids, this can look differently based on the age and developmental level of the child or adolescent.

CHART: Here are some examples (and by no means is this an exhaustive list or particular to any one child. EVERY CHILD IS DIFFERENT)...

Younger kids: tantrums, regressive behavior (going back to earlier behaviors, appearing to lose skills), changes in sleeping and eating, separation anxiety, changes in behavior at school, physical complaints, expressing feelings of anxiety, depression, irritability etc.

Older kids: behavior changes such as increased defiance or risk taking, changes in sleeping or eating, withdrawal from peers/family, decline in academic functioning, loss of interest, expressing of feelings of anxiety, depression, irritability etc

*Any age group can express symptoms of wanting to die or of hurting/killing themselves or others or exhibit potentially dangerous behaviors

Signs of stress in parents/caregivers: So what can parents do if they start to see some signs of stress? I think the important thing to realize also is that parents, caregivers, adults in general also deal with stressors, anxiety, or low/irritable moods. No one is perfect, but an important part of parenting also has to do with regulating your own emotions. I know sometimes that may seem easier said than done and that is not to say that hiding emotions from your children is what we would recommended, but it is important to processing your feelings, showing skills of regulation to demonstrate resiliency and modeling healthy coping skills can be a great help to kids. This is a great opportunity to see you put some skills in to action. This also can look like taking a break when overwhelmed, going for a run to blow off steam, going for a spa day to focus on some me time...there are many skills we use all the time that demonstrate how we deal with our emotions in healthy ways. Other ways parents and caregivers can help kids include providing kids with a narrative to process your/their/the world’s emotions (appropriate for their developmental level of course). I use this idea quite often when talking to patients and families that I work with –its' not just a technique that can be used for big, identifiable traumas (like hurricanes or war), but even every day things like people getting sick, a loved one or pet passing away, a transition, or believe it or not even breaking a favorite toy! A narrative is a way of giving a kids a story, giving details based on their developmental level (for instance, a 5yo may need a very different explanation and level of detail than a 15yo), providing a rationale for something that happened, and opening to floor for identifying emotions, validating those emotions that are understandable and ok; even sometimes proposing a solution. Another helpful part parents/caregivers can play is providing reassurance (this is so important to develop resilience or the ability to cope with difficult situations/emotions, recover, and learn to cope with future stressors)...reassurance often looks like being reminded that you (they) can get through it, that you (they) have skills to use that can help, and that you can help or get them the help they need to get through it. These are definitely uncertain times and stressful times, but remember, even though you may feel like you don’t have all the answers (and I don’t think any of us do as parents or medical professionals for that matter), it’s ok to not always know the answers and acknowledge what you can’t control or change; focusing on what you can control (every day decisions on the personal or family level; how you manage and respond to things to a degree) and what you can change can be helpful ways to deal with things. That brings us to coping strategies.

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Tips for Managing Stress�

Reassurance

Coping skills

Communication

Identifying emotions

Engaging in activities

Building supportive relationships

Maintaining a balanced lifestyle

Sticking to a routine

In general, children and adolescents and FAMILIES as a whole can benefit from some strategies to help deal with uncertainty and stressful times and events. We already talked about providing reassurance and modeling use of coping skills. Other strategies that can promote resilience and healthy coping include communication and check ins (asking your kids about how their day went; checking in to see what’s up if they look down or upset or if the teacher gives you a head’s up that they had a rough day), learning how to talk about and identify emotions (saying things like, I can see that you’re frustrated that xyz peer doesn’t want to be your friend anymore; let’s think of some ways we can help you feel better and spend time with other friends), fostering involvement in activities and building supportive relationships with families and friends (so extracurriculars, keeping family events going COVID permitting), creating and maintaining a healthy and balanced lifestyle, and sticking to a routine and sense of structure (as I said above, one of the benefits of going back to school is that most kids get back to a fairly regular routine...this can be such a good thing for a lot of kids; and probably even for us grown-ups). Just a note about something we discussed before –screen time. This is a very controversial subject (and touchy once kids reach an age where they or their peers have phones) and you should definitely talk to your pediatrician about recommendations depending on your child’s age. This can be a positive in moderation for some age groups (facetiming grandparents during the lockdown; having a way to talk with friends who we weren’t able to see for a while) but can be a slippery slope. Online activity should be monitored closely (not just for safety which is always a concern), but also overall excess screen time can be detrimental on multiple levels –not just with regard to mental health but also as we talked about above, heavy doses of difficult situations and content that they may not yet be able to process, so if you notice your child is struggling with what they are seeing or their interactions online, limiting it and talking about it can be helpful.

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Examples of Coping Strategies

WHAT DISTRACTS US: getting outside, coloring, playing, reading or journaling

WHAT BOOSTS OUR MOOD: spending time with family or friends, watching a funny video, listening to a favorite song, doing an enjoyed activity

WHAT PROMOTES MINDFULNESS: deep breathing, progressive muscle relaxation, guided imagery, invoking the 5 senses

Day to Day Tips that can help kids cope: Getting back to coping skills...Learning about and brainstorming coping skills is one of my favorite ways to engage children and families in managing stress and strong emotions. I’ve learned a lot of skills over the years from my own teachers, from reading, and sometimes even from my patients themselves. Some of these can be natural things that we do without thinking (like I mentioned before...taking a break when we feel overwhelmed); some brainstormed and practiced at home to deal with every day stressors (we’ll talk a litte more about that in a bit); some are learned and developed in therapy with a mental health clinician. Here are some examples to give you an idea.

Things that can distract us: getting outside, doing a task like coloring, playing, reading or journaling

Things that can boost our mood: spending time with family or friends, watching a funny video, listening to a favorite song, doing an enjoyed activity

Things that promote mindfullness (a fancy way of saying being present in the moment): deep breathing, progressive muscle relaxation, guided imagery, invoking the 5 senses

As you may see, some of these sound like skills a younger kid might be more likely to do, like playing or coloring, but to be honest, a little of these skills can be adapted to more ages and developmental levels than you might think. For example, one of my favorite activities is deep breathing –now for older children and adults, this may look like taking a deep breath in, holding for 10 seconds, and then exhaling for 10 seconds. Now for littler kids, counting to 10 might be a little tricky, but you can use their love of imaginary play here. For example, instead you can choose their favorite food and encourage them to smell the pizza....and then blow off or cool the pizza...this mimics the idea of deep breathing but can appeal to a younger audience. Some similar ideas are true of guided imagery and progressive muscle relaxation (which is a fancy way of saying tensing and releasing different muscle groups sequentially). You can find some helpful videos online to help guide you (but always double check anything online yourself to make sure it’s appropriate and be sure to supervise online activity for older kids).

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When to Seek Help

When to be concerned: Now sometimes, stress can accumulate and be difficult to deal with; it can lead to anxiety, mood, and behavior symptoms that can become longer term and impair functioning or even safety. This is not to say that anyone with a stress or stressors (adverse life events as we call it) will automatically develop impairing symptoms or have a psychiatric diagnosis. However, we do know that adverse life events can be one of the factors that increases risk for both mental health and other medical conditions –that goes for children, adolescents, and adults. Studies looking into children’s mental health during the pandemic are emerging and trends are showing increasing anxiety and depression and mental health issues in general. Unfortunately, children’s mental health issues were on the rise prior to the pandemic and COVID-19 and virtual schooling, isolation from peers and activities, and the uncertainty of worrying about themselves and loved ones getting sick didn’t help. In fact, the AAP, AACAP, CHA announced a state of emergency for children’s mental health in October of last year which highlights this point as the rates of kids heading to our emergency rooms across the country is on the rise too. There is a silver lining here though, because this is a call to action for more services, more support, and more access for kids to get the help they need.

When to speak with a pediatrician: Speaking of help, if you notice any of the symptoms we talked about today or have any concerns, I do recommend speaking with your child’s pediatrician. A pediatrician can be a great resource for tips and for exploration of any concerns. A pediatrician also can help determine whether your child needs additional support from mental health services and/or may benefit from treatment for the symptoms that are raising your concern.

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Where To Get Help...

If you’re concerned that you or someone you know may be in crisis:

Suicide and Crisis Lifeline (Previously the National Suicide Prevention Lifeline)

***Call or text 988 or chat 988lifeline.org

To find a non-urgent mental health provider near you:

SAMHSA's Behavioral Health Treatment Services Locator

American Academy of Child & Adolescent Psychiatry CAP FINDER

When to seek further mental health treatment/emergency services: If at any point, you have concerns regarding the safety of your child or adolescent or for any emergencies, resources always include going to the nearest emergency room or calling 911 if you cannot safety get there.

References: ***suicide hotline_________ A new resource is the new National Suicide and Crisis Lifeline, previously operating as the National Suicide Prevention Lifeline. (The existing Lifeline number, 1-800-273-8255, will continue to be available.) is now available.

To reach the Lifeline, people can call or text 988 or chat at 988lifeline.org

Thank you very much for joining me in this very timely discussion as our kids are heading back to school.

As I mentioned, in a non-urgent situation, your pediatrician, can be a great first stop to getting your child or adolescent the help they need. Schools can also be a resource. Some additional resources for finding a mental health specialist in particular are:

SAMHSA –substance abuse and mental health services administration

CAP FINDER

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More Resources...

AACAP.org (American Academy of Child & Adolescent Psychiatry) –Facts for Families on Disaster and Trauma Resource Center, Depression in Children and Teens, How to Talk to Kids about Mental Illness, Helping Children Cope

NIMH.NIH.gov (National Institute of Mental Health) –Child and Adolescent Mental Health. Brochures and Factsheets.

Healthchildren.org (from the American Academy of Pediatrics) –Mental Health During COVID-19: Signs Your Child May Need More Support, Childhood Trauma: 3 Ways to Help Kids Cope, Childhood Adversity: Buffering Stress & Building Resilience, Building Resilience in Children

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Atlantic Behavioral Health ACCESS Center �(888) 247-1400�

Atlantic Behavioral Health Crisis Intervention Services 24-hour hotlines

Chilton Medical Center: 973-831-5078

97 West Parkway, Pompton Plains, NJ 07444

Morristown Medical Center: 973-540-0100

100 Madison Avenue, Morristown, NJ 07960

Overlook Medical Center: 908-522-3586

99 Beauvoir Avenue, Summit, NJ 07901

Newton Medical Center: 973-383-0973

175 High Street, Newton, NJ 07860

Hackettstown Medical Center: 908-454-5141

653 Willow Grove Street, Hackettstown, NJ 07840

For more information about Atlantic Health System, visit atlantichealth.org.