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Dr Sarah Garwood: Hi, I'm Dr. Sarah Garwood, a Washington University Adolescent Physician with St. Louis Children's Hospital. And I'm a mom doc.

Melanie: Hey, welcome to MomDocs, the podcast from St. Louis Children's Hospital. I invite you to listen as we discuss teens and mental health during this COVID-19 pandemic. Joining us to help us understand is Dr. Sarah Garwood. So Dr. Garwood, tell us what's happening, the latest information that you know, how this is affecting our kids, mostly emotionally. I know that I have two teens and I see what they're going through. And I imagine parents all over the country are having this same kind of struggle. Getting them out of their bedrooms, getting them to motivate, to exercise. What have you been seeing?

Dr Sarah Garwood: Okay. Absolutely. And I also have two teenagers, so I've been seeing this in my patients and I also see it in my own home as well. So the coronavirus epidemic has definitely affected all of us, but for our young adolescents and even older adolescents, it really has meant a huge disruption in the kind of normal daily activities that they're used to. With not being able to go to school, not being able to see friends in person, many times having activities and events canceled, they've just had a lot of disappointments and, you know, a lot of loss of structure and schedule and sort of the daily things that kept them engaged and motivated and sort of moving forward and assignments at school and things like that.

So definitely, I'm seeing kind of a range of impact from some of our adolescents. Overall functioning pretty well, just having some dips in mood, sometimes having some listlessness, boredom, but mostly figuring it out, all the way to clinical depression and significant anxiety and even an increase in eating disorders and an increase in more risk-taking behaviors or poor coping strategies. So I think all of our teens are affected, but there's definitely been a range in how severe the effects have been and how well people are finding ways to try to cope around the pandemic.

Melanie: So what are some red flags and signs that we should be looking for in our kids? Because it's not unusual that they hole up in their bedrooms anyway, right? It's not unusual that the days they are home, they eat junk. How do we know that this is something different and that maybe we need to be contacting our professional to help us with our kids?

Dr Sarah Garwood: That's a great point because adolescence is a time of increased interest in privacy, being more focused on peer interaction than parent interaction oftentimes. Teens are really trying to work on their independence, trying to develop their independence. Then the pandemic has definitely thrown a wrench in that.

Some of the things that I suggest people keep an eye out for with their teens. It's normal to have some blues, to have some downs, but really if you see your teen with a persistent low mood, so day after day mood is really low. Teens can definitely have a brief increase in their mood around peers. That's actually one of the differences in adolescent depression is that they may experience some relief when they're around their peers. Teens tend to use their peers to help them manage emotions because they are so highly social at this phase of development. But if for the most part, their moods are really low, that would be something to pay more attention to.

If they are consistently using kind of unhealthy coping mechanisms, whether it's over eating, whether it's staying up all night and sleeping all day, whether it's spending all their time on social media. Those are also concerns. Anytime your child is engaging in self-harm behaviors, cutting, making comments about suicide, making comments about wishing they were dead. Those are major red flags that you should seek additional help for.

And then of course, substance use and increased risk-taking activities. So if your teen has threatened to run away or running away, or, you know, you find out that they've been vaping or using marijuana, drinking alcohol, other substance use that has increased from prior use, those are also pretty big red flags.

Teens can also show up in kind of some different ways from adults with their depression. And it's important to understand that. So teens can have more of an irritable or angry mood instead of being sad and down. They may have more aches and pains or what we call somatic symptoms. So suddenly they kind of have headaches every day or stomach aches every day that don't seem to be from any other physical cause.

Teens can also be very sensitive to criticism, has sort of lower self-esteem when they're struggling with depression. And then pulling away from interaction. So yes, they may want more privacy, but when they're really withdrawing from their normal interactions with the family, normal interactions with friends, that's another sort of red sign.

Melanie: Wow. I think that you just described so many teens and I hear you with these various signs that parents should be on the lookout for. And you're right, teens want that privacy right now. And when you're all in a closed house together, it certainly exacerbates that. So one of the things I've noticed as a parent, Dr. Garwood, is because we're in this situation and school is online, I've put this out there to my kids. There is no bed school, no doing school in bed. You must get up and sit at a desk, but their sleep schedules have gone to the wind. I mean they stay up all night on TikTok and Instagram, and then they crawl out of bed and get onto their Zoom meeting. Their sleep schedules, how can we get them to get some kind of a normal routine because that would help their mental health tremendously, wouldn't it?

Dr Sarah Garwood: You're exactly right. And we call that sort of getting up and doing activities, we call that actually even in the treatment of depression, behavior activation or behavioral activation. I think it's important to know that having that sort of regular schedule, regular routine, productive activities every day is actually not just a treatment for depression, but it's a really good prevention for depression. It's a good preventative mood tonic in a way that I talk to all my patients about.

So I think as much as we can, trying to encourage our adolescents to have a regular daytime and nighttime routine is very helpful. And every day, if we can kind of have checkmarks of things that we get done in a day, which would include, scheduling some social time, social distance time with friends or with other people. So that might be a Zoom call with a group of friends, it might be an outside visit, but having that social contact every day.

Engaging in some meaningful activities. If there's a school extra-curricular activity that's still happening online or is there some sort of volunteer activity or other meaningful activity that your kid can get involved in that they want to do. Having physical activity every day should be a requirement if we can at all enforce that. Doing some fun things that lead to, you know, enjoyment every day.

And then I have to say, I do talk to all my patients about the consistent sleep routine. So as much as we can help as parents with getting that regular sleep routine, going to bed at regular time, waking up at regular time, having same sleep hygiene that we would expect when school's going on. I know those things can be a struggle, but they are actually very important because the erratic sleeping and very low activity or low energy during the day can make mood worse.

And the weird thing is if you start doing behavioral activation, it actually can improve energy and it can improve mood. It's really important not to wait for the motivation before we do it. The old Nike slogan, "Just Do It," actually applies here that it's actually better to just have it, do it, even if you're not super motivated to get up and do it. Things like physical activity, for example, and trying as much as we can to encourage and enforce those things happening.

One of the things you can do to help with that sleeping at night, though, is having a curfew on the devices at night. So sometimes it gets less attractive to stay up all night when your options for activity during the night are reading a book or sitting quietly in your room. If you don't have access to electronic devices, it sometimes does seem to help with going to bed at a reasonable time.

Melanie: Well, it certainly does, and exercise being the other thing. And I mean, I'm Dr. Garwood, I'm an exercise physiologist and I am still finding it hard to get my kids to do something. I'm like, "Come on, let's go take a walk together. Let's go even walk around the back yard, come on. Why don't you guys go for a walk?" And I won't go. And as you say, that motivation builds on itself, right?

But getting them to do it the first time, getting them to see that happens. And my kids are both athletes and still it's not happening right now. So how can we kind of put all of these things together? This is, I think, the big question all us parents are going through right now, right? And you included. Putting it all together and getting them to be involved and look to the future and feel happy and any of these things. Help us out, doc.

Dr Sarah Garwood: Well, if I had the perfect answer to this question, I could probably make a lot of money right now, because I know we're all in it together and it's not easy and there's not one answer for everyone. So I think knowing your own kid, knowing what does help them, what things they have interest in.

I think allowing their feelings, accepting that they have feelings about the coronavirus and about their lives and the changes in their lives is helpful to, you know, acknowledge "Yeah. This kind of stinks. And yes, you're having some grief. And yes, these things are really hard," but also then following that up with, "I believe in your ability to cope, I know you can do this. I know that you are resilient and I know you can get through this. Yes, we accept that things aren't great, but you can cope with this. But some of that coping is going to require you to actively participate. It can't be me nagging you all the time. You have to also actively cope, because you're responsible for yourself and for your emotions."

I always try to emphasize getting back to the basics. Basic self-care, water, decent nutrition. How can you help others? Other people are struggling and you may be struggling yourself. Your family may have lost income and lost jobs. How can you help out? How can we support people who need our help and support?

And then what do you want to get better at? You've got some extra time these days. Is there something that you've wanted to do that you could actually work on or get better at? Trying to tap into that intrinsic motivation in some way with also encouraging some structure. I think some families have also even used incentive programs for a while. With my own kids back in March and April, when they were a hundred percent virtual school and actually didn't have a lot to do school-wise, I've really doubled down on the structure and chores and things like that and I assigned points to getting those things done. And then there were incentives, depending on if you got all the points. And actually that did help us kind of get started and sort of set up an expectation that these are the things you're going to do every day and I tried to provide some incentives to actually get in there and do it. And then that seemed to help.

If you have kids who are good with planners or calendars, letting them get a new planner that they like, having them fill in what they're going to do, what their goals are. Those are some of the strategies that, you know, for your own kid, those things may not be effective. I think just keep at it. One of the things we always talk about with teens is keep at it. Even though you may not get a great response the first time, keep trying to engage them, keep trying to get them out of the house with you for a walk, and be ready to listen when they want to talk.

Sometimes we want to do things with teens on our calendar or our schedule. And typically with teens, we have to expect that we're going to need to be on their schedule for when they want to talk about things or when they're ready to open up. Being receptive to our teens when they're ready to do something and kind of jumping on that opportunity is another strategy that people can try to use.

Melanie: Well, these are all really great pieces of advice. And I am absolutely going to try the incentive one for sure, because, you know, it doesn't work when you use negative reinforcement. "Okay, if you don't get some exercise, I'm taking your phone away." They're like, you know, "Whatever. Okay. I've got the iPad."

So I hear you. And that is absolutely great advice. Wrap it up for us. When you think parents should contact their pediatrician, when they suspect that their children are really having a tough time dealing with the pandemic and the physical distancing and the holidays coming up and all of it, tie it all together for us, Dr. Garwood.

Dr Sarah Garwood: I would say, first, there's never a bad time to talk to your pediatrician. I think whenever you have concerns, I always recommend your pediatrician as your first go-to talk about your concerns and let them help you assess your child or reassure you that this is pretty normal teen stuff. Big things to watch for, as I mentioned before, if kids are talking about or joking about being dead or suicide, or seeming really persistently sad and down for a prolonged period of time, you should seek help right away and take those thoughts, behaviors very seriously.

Trust your gut, even if your teen is telling you that, "No, I'm fine. Nothing's wrong." If you really are picking up at a gut level that there's something going on with your child, a good idea to reach out for help. Again, as we've said, acknowledge their feelings. Be persistent, but gentle. Continue to reach out to them and then be ready to listen when they're ready to talk. I think those are probably my biggest suggestions. And hang in there as a parent yourself, you've got to take care of yourself. You've got to model that coping as well. And modeling those positive behaviors, modeling taking care of yourself actually also goes a long way to helping your teen see how they can do it as well.

Melanie: Good advice, Dr. Garwood. And you're right, we have to put our own masks on before we can put our masks, which seems rather interesting to say now, right? We use the mask analogy because it was from the airplanes, but now it's really literally. But thank you so much. We certainly have to do that to care for our teens. And it's a tough time all around, but teens take things a little harder than the rest of us. So thank you so much for joining us.

And that concludes another episode of MomDocs with St. Louis Children's Hospital. For more advice and articles, check out the MomDocs website at ChildrensMD.org. Please also remember to subscribe, rate and review this podcast and all the other St. Louis Children's MomDocs podcasts, and share this show with your family and friends. We learned a lot of great information, and I think that if you share with your friends and your family on your social channels, we can all learn from the experts at St. Louis Children's Hospital together. I'm Melanie Cole.