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Are the kids (and parents) all right? Back-to-school anxiety

Editor’s note: This is an edited transcript of Facts from the Frontlines, a St. Michael’s Hospital Foundation COVID-19 podcast series in which experts provide the knowledge you need to keep you safe and informed. Host, scientist and parent Sabina Vohra-Miller talks to Seema Marwaha, a physician in the general internal medicine department at St. Michael’s Hospital and editor-in-chief of Healthy Debate, and Ripu Minhas, developmental pediatrician at St. Michael’s and an assistant professor in the department of pediatrics at the University of Toronto, both of whom are parents.

Sabina Vohra-Miller: Back to school jitters are normal every September, but this year it isn’t just kids who are anxious. It’s parents too, me included. A lot of us have understandable concerns around COVID: spreading at schools; vaccines for kids; and social anxiety. If that sounds like you, you’ve come to the right place. We’re going to talk about back-to-school fears and offer practical tips on where to go for help. But first, I want to hear how you two are feeling as parents. Are you ready to send your kids to school?

Ripu Minhas: It’s a really tough decision. I think it’s a tough time for everybody this year. It’s supposed to be a time for new beginnings and a fresh start, but I think families have a lot on their minds. We’re getting so much information from the media and from science communicators on the latest on COVID. And it’s really, really tricky. So, I have a 9-year-old son who’s going into Grade 4 at a new school. And we’re just thinking about if we really want him to go in person. He was home for much of last year due to various reasons. We chose to keep him virtual. And we really want him to be in a new school where he can meet friends in person and be able to hit the ground running. It’s really a tricky, tricky time.

Sabina: Seema, how are you feeling about sending a little one too? Is it school this year? Or would it be preschool?

Seema Marwaha: He’s starting preschool. I have a two-and-a-half-year-old little guy, his name is Archie. And I kind of feel of two minds. I’m really excited and happy that he gets to leave the house and see other kids. And when I went school-supply shopping for him, I got really excited. It was such an important milestone. But then there’s also this fear of the unknown. Like, I don’t know when he’s going to get vaccinated. And I’ve never seen the inside of the school that I’m going to be sending him to. After spending a full year and a half with him, almost 24/7, to send him to a place that I’ve never even been to is anxiety-provoking. As a parent, I always have this fear that I’m doing the wrong thing. I feel like it’s the wrong thing to keep them home. I also feel like it’s the wrong thing in some ways to send them to school. It’s nice to know that other people share the same fears and anxieties that I do.

Sabina: Absolutely. I think the framework for the entire pandemic has been that there are no easy decisions, only tough choices. And I’m in this very same boat. I have a 4-year-old who’s supposed to go into junior kindergarten. I remember a couple of weeks ago buying his new backpack – he has a cool rocket ship backpack and a lunchbox that matches – and I should be excited because this is a milestone for our family as well. But instead, all I felt was anxiety because I had no idea what September was going to look like. And especially because we’ve been thrown this curveball, Delta. This is really not something we had anticipated even at the start of the summer. So, it’s definitely a very anxiety-provoking time for me as a parent as well. So, Ripu, what kind of concerns are you hearing right now?

Ripu: A lot of families are going through the same sorts of thought patterns and processes and trying to figure out what information is important. How do I make a decision? How do I weigh out the benefits of in-person learning? Weighing the risks: when we think about infection; when we think about transmission to other family members as well, especially if you’ve got family members who are high risk or elderly at home. We’re hearing a lot about that from parents themselves. There are folks like you who are sending their kids off for the first time and we want to start them off on the right foot. This is supposed to be this fun social experience and you want that journey to start the right way.

And then there’s also worries from kids that are going back to school. They worry about having lost academic potential, missing out on opportunities for those really important social rites of passage, like school concerts or sports tournaments, as well. And so, although we’re hearing that the system is going to try to put all of those things back in place as best as possible, there is some uneasiness amongst youth themselves and from families around what that’s going to look like in terms of reality. And in terms of safety.

Sabina: You mentioned safety and you mentioned realities, what I’d love to know from you is: How serious are these concerns? And could you maybe share a little more detail on what they entail?

Ripu: Yeah, those concerns are really prominent. And I think they’re particularly tricky for families, and certainly for practitioners, because they may not know when kids and youth are worried, they may not be able to tell you in their words. So, we see it simmering below the surface or coming out in different ways. We’re seeing changes in their appetite, in their sleep, in their interest in doing things that they would have otherwise found to be fun or exciting. Also, having a bit of a shorter fuse. I think parents are experiencing that as well. We’re seeing patients that get bothered by things that wouldn’t have otherwise bothered them as much. And that’s impacting their relationships at home; it’s impacting their friendships. And we’re seeing changes in terms of physical health. They’re not able to be as active and also have more access to food at home, where in classrooms, you wouldn’t be able to snack and graze as easily. We are seeing increases in body mass index and concerns for being overweight and obesity across the continent.

From a mental health standpoint, for adolescents, we are seeing increases in referrals to mental health services for concerns around anxiety, depression, some eating disorders and even self-harming behaviours as well. We’re really seeing a range of different impacts, those non-infectious repercussions of the pandemic.

Sabina: It sounds like it’s really across the board with all age groups, and not necessarily just focused on teens, because I think we’re hearing a lot about teens and adolescents.

Ripu: Absolutely. Within the developmental realm, and certainly with our educational colleagues as well, I think there’s a worry of what is underlying here, and what we’re going to see in the months and years ahead as repercussions from this time in terms of the needs of these families and of these children as they grow and how well prepared our system is to be able to support them.

Sabina: That’s such a great topic. What challenges do parents face that compound their own concerns and what are the situational issues that may play a role, especially when it comes to racialized communities and the communities that have been very deeply impacted by the pandemic?

Seema: One of the things that we all have in common is that we’re parents. These anxieties that people have, I mean, I share them as well. Sabina, you and I work together at the South Asian Health Network where we’ve interacted with countless parents, hearing their concerns so that we can create educational materials to try to address some in anticipation. But I want to stress that every family is different, and every group is different, with different anxieties. It’s really important that we not paint a broad brush and that we understand that a one-size-fits-all approach for every family, for every school, for every place in the GTA is just not going to work. People have very specific anxieties around their own family situation – who lives in their household, whether they have to go out to work or not – but also are part of their ethnic community and their cultural community. That’s important.

But that being said, there are three major categories of anxieties that I’m hearing. The first revolves around balance and competing priorities. In our racialized communities, there are high amounts of essential workers who can’t stay home. You have to put food on the table; you have to work. And when you leave the house, you subject the household to an increased risk when you return. Then there’s that anxiety of sending your kids out to school. You don’t exactly know the environment you’re sending them out to. And so, this idea of work-life balance and the stress of work. I think we are going to see higher levels of stress anxiety among parents in the fall as we adjust to whatever our new normal is going to be.

Then there’s the second thing of control and risk, sort of push and pull. You want to send your kids out to have good experiences, but there’s a risk associated with every activity that you do. I’m speaking to you guys from Alberta right now. In Alberta, things are open. So, what happens is every decision falls on you to make the risk-benefit calculation, nobody’s making that decision for you. And each and every single one of those decisions causes some stress, you probably want your kids to go and do activities and spend time with friends and go to recess and do all these things at school. But each one of these activities comes with a certain risk.

The last, I think, is stigma and mental health. Opening up is really great for mental health but it can also amplify anxieties associated with the different activities and increase decision fatigue. In certain communities, including the one that I come from, talking about mental health is stigmatized. And all of the activities that I normally use to blow off steam – going to the gym, going on a vacation – aren’t available anymore, or they look very different, or they’re associated with their own stresses. So, they’re not total stress relief.

I think we were all expecting to have a break by now. You know, we were willing to kind of hunker down and do what we have to do, because in a year or six months, or 18 months, this will be over. And the thing about the Delta variant is that we realize now that this is going to go on and look different for some time. And I know for me personally, that’s also very anxiety-provoking.

Sabina: That is such a good point. We thought we were at the end of the pandemic, and now we’re being told that it’s not necessarily the end of the pandemic, and that in and of itself is really crushing to not just people that have children, but everyone in our society. I want to circle back. You mentioned risks and I think that’s such a great point. I’d like to switch over to talk a little about vaccines. One of the things that people don’t understand is that everything in life carries risks, right? Getting into the car and driving to work has a risk associated with it. But we take these calculated, informed risks, on a daily basis when the benefits outweigh the risks. That brings me to vaccines. We know that we have approval for those who are in the 12- to-18 age group, but we’re still waiting to hear what’s going to happen with those who are younger, and parents are anxious because they’re sending their kids to school. I’ll start with Ripu. What are some of the concerns that you’re hearing?

Ripu: We’re hearing concerns and fatigue around the idea that here we are, back to school for our youngest family members and community members, and we don’t have vaccines available. I know a lot of families have concerns about pediatric vaccines. And we kept hearing in the first and maybe even the second wave that this was mostly about adults and not as much of a concern for kids. So, families are wondering whether the vaccine is really necessary for kids? Is it safe? There is that concern a lot of families have about interventions or medical treatments, if you will, for developing bodies and developing brains. It certainly has been on parents’ minds about what this means for our kids.

“We thought we were at the end of the pandemic, and now we’re being told that it’s not necessarily the end, and that is really crushing.”

Sabina: One important thing to note with vaccines for the 12-to-18 age group is that overwhelmingly pediatric and health bodies across the world have said that the vaccines offer more benefits, and that the benefits outweigh the risks. Coming back to the point that there are risks with everything you do in life, you have to put the risks into perspective, and then into context. Many, many people look at the stats of COVID in Canada and they falsely believe that COVID does not impact children. In fact, our numbers are really skewed lower because the school year had, for the most part, been shut down other than for virtual learning for the last year and a bit. If you look at the stats, in other countries they tell a slightly different story. For instance, in the U.S., more than 500 children have died due to COVID-19 in the last year. And if you actually look to see which kids are being impacted, it’s generally those coming from racialized communities. And then if you look at other long-term concerns with respect to COVID, in the U.K. a study showed 33,000 kids have some degree of long COVID as well. So really, I think it comes back to the entire risk-benefit calculus. Do you have a sense of what some of the concerns that parents are having with vaccines? Or is it just the fact that once it’s approved for the under 12, you actually would see a quick uptake?

Ripu: We’re hearing there’s two groups of thoughts. Some families are really interested in getting a vaccine, keeping in mind that we vaccinate children for lots of other things as part of our routine health care that we provide. So, a lot of families understand and believe in vaccine science, in the safety, and they’re ready to move on. Then there are other folks that are concerned because there’s this idea that COVID is more so for grownups. If that’s where the bigger concern is, then can we just vaccinate everybody else and not have to tinker with things with our kids? People are really looking for information and they’re really hoping in one way or another to be able to move forward.

Sabina: Seema, I know you have done so much incredible work on vaccine hesitancy. Could you talk about the concerns you’re hearing, and would you know what this vaccine hesitancy looks like in the pediatric population?

Seema: We’ve done a lot of this work together, Sabina, and I know that what we’re hearing now is the same as what we heard in January from certain families – that the research or the data collection was rushed somehow or that we don’t have long-term data. And when you look at children, they change so rapidly year to year, so you really are concerned about that. A lot of the disinformation that gets spread on different types of channels is not unique to adults. It also impacts how people think about children. And there’s a lot of what is called cognitive dissonance. So, people will say things like, ‘Oh, you know, the rates are really low for children’ and that’ll stick in their minds. And they’ll use that to justify further decision-making even though that may not be up to date anymore or even correct. But there’s a whole other layer of vaccine hesitancy that we’re going to see around children. So much of it is based on doing a lot of work to prevent small, small, small instances of things happening to your children. My husband talks about this all the time. We didn’t give honey to our child until he was over 2 for the small chance that he might get botulism. Like when have you ever heard of someone getting botulism, but you do it, right? You religiously do it … safe sleeping rules … breastfeeding … it goes on and on. And it starts very early on as a parent, and you become very protective of your child. I see it in my group of friends, all smart, educated people who were not at all vaccine hesitant for themselves. But when it comes to their kids, they just have an extra kind of thing in their mind of, you know, should I be doing this? Should I be putting something in my child’s developing brain? Do we really have all the information? It really surprised me when I saw it. And my husband mentioned the same thing, where he just had a little bit of hesitancy, but he will definitely want to vaccinate our child. And I definitely do. Any vaccine that is approved for kids over 2 in Canada will be safe and effective; we will have the correct data. The processes and the checks and balances are there.

When you add culture, language and structural barriers, like we saw so much of for adults, then the vaccines are going to have to be available in schools. Otherwise, I’m not sure working parents will be able to make another trip to book another appointment. If it’s the same rigmarole that it was in the first rollout that might, in and of itself, create some barriers. Trying to anticipate what the concerns will be before a single vaccine is approved for children so that we can have the correct information on the ground and the right processes in place, I think is going to be very, very, very important to a successful rollout.

Sabina: I agree. Reducing the accessibility barriers is so key, but then also having that confidence in the vaccine is critical. And I think that what’s really reassuring is that Health Canada and the U.S. Food and Drug Administration have asked for more safety data than you would typically see for a pediatric vaccine approval. If and when a vaccine is approved for the under 12, we know that due diligence has been taken and has been paramount from the very beginning. We can rest assured that if and when a vaccine is made available to the pediatric population, that it would be safe. This has been such a fantastic conversation, but I think it’s time to wrap up. What I would like to do is ask a last question that I think is also on everyone’s minds. What can we do for our kids and ourselves, and especially for the families who need more support dealing with all these concerns?

Seema: I think that healthy parents equals healthy kids. We need to think about what we all need to be able to make it through the next six months or eight months or however long it’s going to be. What do we need for our mental health? What do we need for our physical health? What do we need for our own personal reassurance that we’re going to make it through sort of the next six, eight months together? As parents, we make sacrifices for our children all the time. We sacrifice our own health, wellness and well-being so that our children get what they want. In this instance, it’s really important that we do what’s best for our kids and we also do what’s best for ourselves. It’s important to advocate for safe school return, for safe policies when it comes to COVID and COVID vaccines, for masking and other safe societal behaviors so that we all can collectively make it through the next phase together. And then it’s really important to understand that we’re not perfect. A lot of parenting is about trying to be a plus all the time. And I’m just speaking for myself. I mean, it’s exhausting. If we’re going to make it through the next year together, we have to figure out the things that we’re going to focus on and prioritize. I know that that’s very sort of general advice. But for me, those are sort of the points that I’m taking forward into the next year to try to make it through.

Sabina: The general advice is really important, because like you said before, one size doesn’t fit all, and you have to adapt that for each family. Ripu, what do you have to say on this?

Ripu: It’s really important to think about those general concepts of wellness for ourselves as parents and caregivers and keeping an eye out for declines in our children or youth in their physical and mental health and their academic well-being. And having open conversations that are honest, but developmentally appropriate with our children about what’s happening in terms of COVID and how we’re all feeling. It’s important for us to model our wellness behaviours for our kids, including naming our feelings. How am I showing my coping behaviours to my child and what can we learn from together even if we make a mistake along the way. Sometimes it’s hard to put those feelings into words for grownups as well so having opportunities to get those feelings out in physical activities, in music and art – like I really like crayons and paper on the dinner table, maybe before a meal, to get some feelings out that way – and seeing if that leads to some conversations that are really important. Also, if you’re feeling concerned for your child’s well-being, reach out to your health-care provider and talk to them about resources that are available. I know that we’re compiling a list of some resources. But it’s really important to take care of ourselves and to watch out for some of those red flags.

Sabina: What a fantastic discussion this has been. Thank you so much Seema and Ripu for your reassuring advice on this really critical topic that is on every parent’s mind.

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Author

Seema Marwaha

Editor-in-chief

Seema Marwaha is a general internal medicine physician, educator, researcher and journalist.

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