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COVID-19 and child mental health

Dr James Best
Welcome, everybody. The RACGP acknowledges the traditional owners of the land on which this webinar is being broadcast, and we pay our respects to the Elders past, present, and emerging.
I would now like to take the time to thank our partner Emerging Minds.

Emerging Minds: National Workforce Centre for Child Mental Health is a workforce development initiative funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program. The project is led by Emerging Minds and delivered in partnership with the Australian Institute of Family Studies, the Australian National University, the RACGP and the Parenting Research Centre.

The project focuses on building workforce capacity to better support children and parents/carers and improve the mental health outcomes of children aged 0 – 12 years. The project focuses on building workforce capacity to better support children and parents and carers to improve the mental health outcomes of children aged 9 to 12 years.

I am Dr James Best – Chair RACGP Specific Interests Child and Young Persons Health

Now to introduce our presenters.

Dr Penny Burns is a Disaster Medicine Specialist and general practitioner, Penny Burns has championed the role of general practitioners in disaster response for close to a decade and been a decisive figure in helping primary health networks develop disaster management pathways.

Dr Nick Kowalenko began his postgraduate training in the Family Medicine Program with RACGP before training in child psychiatry. He is Vice-President of the International Association of Child and Adolescent Psychiatry and Allied Professionals. In his roles as deputy chair of Emerging Minds, Chair of Tresillian Council in NSW as a consultant to a variety of state and national NGOs and government bodies, he champions the promotion of children’s mental health.

He is Vice President of the International Association of Child and Adolescent Psychiatry and Allied Professionals.

The current situation for GPs, families and children – Dr James Best

The first part of the presentation where we talk about the current situation for GPS, families and children with the COVID-19 situation.

So really, with GPs, first of all, we have undergone, as I'm sure you're all aware, a massive change in our daily routines and practice. You'll see there and image there from a Four Corners episode, which followed a whole bunch of doctors from hospital and GP settings and nurses, as well. But just about how much, how traumatic it was for us and was actually quite confronting to watch that program. Just seeing how we were all thinking back in March and April, there was a huge amount of uncertainty. We didn't know where we were going to go. We didn't know what was going to happen. Even financially, we as employers or employees In our practices, we didn't know whether our practices were going to be viable. We didn't know whether our income was going to be maintained. And all of the flow on effects from that was playing on the back of all of our minds.

There was a lot of personal risk of COVID exposure, and what was really coming through with people were really worried about not only getting themselves, but maybe passing it on to family members, their children or elderly parents. Or someone in the family had immunosuppression, for example. So there was a lot of anxiety at a personal level. And then we also then had to change the whole way we conducted our lives, in terms of how you consult patients – which, is something personally I've been doing for 20/25 years and I've never undergone a change like that ever in my experience.

Where all of a sudden, I wasn't able to talk to my patients face-to-face most of the time.

And so, so, that changing consultation, and it's something that we often felt so comfortable with, was, all of a sudden, almost felt like, I personally felt a little bit of a loss that I wasn't able to see my patients face to face most of the time .
Then, also, we had changes at a practice level. You know, all the processes, it seemed like almost every day or every second day, there would be quite profound changes landing in the practice. Whether it be how patients come in to the practice, whether they come in for flu clinics, with how the script gets to the pharmacy, how the referral letter gets done. How we set up our computer, how we use software specifically for video consultation, all, this sort of stuff coming day after day there would be a new thing to cope with, and it was really stressful.

So that was at a personal level, from a GP point of view, but it also at a practice level. Our poor staff, our poor practice managers, are coping with all sorts of stuff. There was a complete shift in the landscaping of billing. We were getting new item numbers and it wasn't just a one-off change – it was a series of changes. The new item numbers will come and then some more new item numbers will come and then they had to be bulk billed. Then there was there was another item number for the people who would get the bulk billing, extra item number, and all this sort of stuff – all changing over a whole series of levels.

Our staff were having to be skilled in ways that they weren't used to, they had to be up-skilled and all these new processes. So there was a lot of stress at the front desk. There was a lot of stress in the admin area. We were having to, on the run, develop in-practice protocols. And I think we're all talking to each other a lot at this point, and all the practice managers were talking to each other. We're all sort of having to figure it out on the run.

And of course, we had PPE, and that was massive. I mean, it was really, really awful that we're all having to think, not only are we going to be exposed to this risk, but we're not even going to have the right equipment to do it. And, and I think, particularly in hospitals, that was, that was quite profound. And, and also, you know, we were having to try and set up flu vaccinations, and flu vaccination clinics and we couldn't get them. And we're still having trouble to, a certain extent.

Then there was exhaustion. I actually felt, and my colleagues would tell me, as well, that they would just be absolutely buggered at the end of the day, you know, Because you're having to focus so much, you're thinking and  you having to concentrate on what you're doing, because it's new.

And it was also frustrating, people getting bit snappy, including patients as well. ‘Why can't I see you?’ – this sort of thing? Also, for those who are involved with teaching, with registrars or medical students, how do you teach this? How do you teach a registrar how to consult, when they're talking on the phone to somebody? Also, all the training programs, there was, there was an awful lot of stress at that level, as well.

It varied from practice to practice. There was a whole lot of financial effects that were happening. Some practices were fine. The billing numbers and the patient numbers didn't really go down much at all, other practices, had quite profound drops and coped with it not so well. Some practices even closed for a while. There was a very variable impact on the financial aspect.

There was impact on families, and I'm talking about the families that we deal with, our patients. There were changes in family dynamics – people were losing their jobs by the truckload, people were having their financial situations turned upside down. There are people who, depending on the situation,  having to home-school, having to home-school and work from home at the same time. We saw all the reports about the increase in risk of substance abuse and domestic violence. We saw that Beyond Blue and, such organisations, like Lifeline were getting quite dramatic rises in people who were using the resources.  The homeschooling thing, I think, was really a big one, especially primary school kids,. How can you do that? We've got three kids in primary school and running around your ankles and you're trying to get them to actually sit down and do their work, and you didn't even understand what they meant to do and all that sort of stuff.

It was, I think, sort of viewed as a sort of cabin fever, or people were sort of being stuck in together and they weren't able to sort of escape each other, and I think this is probably why we're seeing that increased rise in violence and substance abuse. So, it was really quite isolating as a society on purpose and, and that this was really leading to what many people have been talking about, a flare up in the mental health issues.

Let's think about it from the children's point of view. Now actually we all heard that there was this low risk of children you know, with COVID that there was very few reports of any significant complications. However, that's changed a little bit recently with the immunological aspects and the possible risk of Kawasaki. But people always worry so much about their children and there was just this real fear, particularly, of being exposed to coronavirus, by going to school. Also, the children weren't able to be in contact with their friends, or they were worrying about their grandparents, or auntie whoever, who, you know, has got cancer. Children worrying about their pets – there's all these different aspects of what children worry about, they often wouldn't understand what was going on. They’d see that their parents were worrying, or that their relatives were worrying and everyone's worried about, you know, whether nanna is going to get it and all that sort of thing. Not only would they see this in the house, in the parents or in their relatives or in their siblings but that also see it in the media. And you know kids are online and maybe they'd be hearing COVID, COVID, COVID . . . and they are not quite understanding what it all means.

Here's a quote here from one of the parents that we talked to about this, where we said ‘What would you hope your young child could receive from their GP?’

And they said ‘we would like a calm, confident GP that provides information to ease your anxiety about this unprecedented situation we're all living in now. I hope for the future that we will all be OK’

So we should have this role of this reassuring voice to the child and I think that that's something that we should be able to provide and it's very valuable in this sort of setting.

I will now hand over to Penny who is going to speak on GP management in a COVID-19 environment.

GP management in a COVID-19 environment – Dr Penny Burns

Thanks James.

So, as James said, we've got this whole new norm for children and for parents, and we all know from basic principles that in order to support children, we need to support parents. I just want to go through what the child's experience might be through all of this, and how we might be able to ease the concerns a little bit.

So, there’s the children's experience of home. It's a very changed experience.

For some children there is a change in routine and environment – including the need to wear a mask, to wash hands, to wipe surfaces, to stay away from other people, other people are carrying this virus. Within the home, if they've got a sick parent or a sick sibling, they're also having to isolate within that home. There  is a loss of ability to leave home. Some people are living in very small spaces. There's loss of that sport, the activity that is physical activity. And there's loss of contact with friends. And so childrens’ influences, or experiences of the home are going to be influenced by how creative parents are in trying to make this new norm ‘home’ and there's a lot of beautiful stories about families dancing together, sitting on verandas, playing games together, baking together, creating movies of the isolation, sharing humor, and hanging with pets. So it's a little bit about recreating that space for children, so that it's a fun space, and it's a safe space. And this is going to be easier for some families and not as easy for others.
So there's a lot of things on the internet to assist parents with doing this. There's some wellbeing diaries. We know that routine is one of the most important things for families and one of the things I've had patients say to me is that we, you know, we get up in the morning, we don't have to get up, kids don't know what to do, they're watching television. So establishing or re-establishing a routine for children and for the families is one of those really key ways of taking life a bit more normal, trying to normalise things as much as possible and so these supports are available.

So the next experience for children is that experience of their families. And as James said, there's a lot of differences happening in families at this time. There’s parents trying to work at home, they're coping with stress as they lose jobs, they're trying to do with homeschooling, which is really difficult.

There’s that dark side of being enclosed in a confined space with potentially increase in domestic violence with some parents. And just your average parent being more stressed, living in a more stressful environment. Being forced to interact with siblings, this can be good and bad. Some siblings get on, some don't. And some parents will be seeing this as opportunity to help them work out how to get on.

Accessing help for physical and mental health exacerbations is a huge one. We have a percentage of children that require regular, ongoing visits to physios, to OTs, to doctors, to GPS. And all that health access has become much more difficult.
There's also, again James says, this frightening information coming out about COVID on the television, and we know from disasters, previous disasters, the World Trade Centre, some of the bombings that have occurred, that children are affected by watching this media. It’s really important that parents monitor the media, monitor how much they're watching, make sure that it's being watched with a parent or an adult available to explain, and it needs to be age appropriate explanations.
There is also that need within families for people to have time-out, alone-time as needed. So that's another important thing to include.

The separation from family members, that they might normally see a fair bit of, particularly grandparents, but sometimes if you're in a split family, seeing your mother or your father can also be affected by this, so parents need to be creative in how they assist their children in actually continuing that communication.

Then, there's children's experience through the environment. And one of my patients came in the other day and she said her four-year-old had told her ‘I remember when we used to go to the playground to play.’

For kids, outside has changed and for adults it's changed. You know, I drive down the road now and it's an open space, there’s is no one on the roads, no one in the parks – it's a very changed environment. Children are watching people walking around with masks and goggles. People are moving away from us as they walk down the street. There's a sense of loss of community, lots of isolation and aloneness. You know, the teams aren't getting together, and so it's really important that parents are able to sort of sort of step back and explain to children what's going on and why it's happening.

The fact that this is actually everyone coming together, trying to help beat this virus, and we're all working together. It’s about making it fun and making it to familiar, creating a bit of a narrative around why it's happening and sharing the bigger picture. So, showing how your child is actually contributing to this experience. Also helping them understand thatother people may be doing is more, you know, harder than they are and maybe it's a good time to think about what they might be able to do to help some of their neighbors.

Then, for us as GPs, our experience has change within general practice, and James has articulated that really well. Visually we’ve changed, as well. So now, you walk into my general practice, for example, and you can see there, we've got nurses at the front, they are masked, we’ve got these screens, there's lines across things, they’re not allowed to play with toys anymore. Everyone's distanced, you are not allowed to sit next to other people. And so it's a really, really changed environment. Children visiting this need to be prepared. They need to, again, it's really important that parents are able to walk them through it before they turn up. So they need to be warned that this will be different, like everywhere else – ‘Your doctor is also trying to fight the virus and they're trying to make sure that you don't catch the virus and keep the environment really safe for you.’

And so you can do lots of little things within general practice, like we've got this little yellow smiley face. You can have lots of little pictures around, you can have little soft toys that might be up out of reach, but they've got masks on. Just put in extra effort into realising that that child is probably in a very frightening environment and touching base with how they're traveling.

I think part of this too is also discussing what might happen if they need a nasal swab. And that's quite an uncomfortable procedure, as we all know, and I think making sure that children aware of why this is happening, what's going on in an age appropriate level is really important.

So one of the things, as we were saying is the media can cause a lot of issues, and we need to be really careful with that, and we need to be able to explain to children what's going on. So this, this sort of concern and anxiety in the community is creating concern and anxiety amongst children, even if they're not watching television. This video is, although it's not a COVID video..., is actually a beautiful one minute clip of a father explaining to his six-year-old son or helping his six-year-old son come to understand what's happened in the Charlie Hebdo terrorist attacks. And I think it's probably a really nice example of simple psychological first aid from a father to a son.
So, during that video, you can see how the child starts by being quite uncertain, quite frightened about what's happened, and they need to move home, and they need to get away. And, slowly, as the father supports him, addressing his concerns, helping him see how there's a hopeful outcome here that people are coming together, they are all working together, and we don't need to leave home, and you can feel safe and you can feel calm and you are connected to all these people. So, it's a really nice example of how that can be done.

This is just a quick slide about psychological first aid. Psychological first aid is a method of helping people in distress, so they feel calm and supported to better cope with their challenges. The really essential parts of psychological first aid, which is what GPS often do all the time, anyway, is promoting that sense of safety like that dad created trying to help his child feel safe. He was calm. He was down on his level, talking to him. He gave him a sense of efficacy. He gave him something that he could do to help feel like he had some power within this situation. So putting down the candles and the flowers was really about coming together, it was something he could do a show connectedness with all these people from all around with all coming together. And he gave him hope, hope  that these people were were coming together, and that would make sure that the bad people were not able to do what they do. And so, I think it's a really lovely example of psychological first aid.

The other resource that’s available, and there’s a link to this at the end in the resources. There's been some lovely videos, lovely story books out there, they're freely available on the net. This one's called My Hero is You. It's been done by International Red Cross and it's a lovely story about a young girl whose mothers a scientist, and even the scientists can't get rid of this bug. And then she feels quite frightened and uncertain about what to do, but her mum says that even kids can contribute, and even kids can be heroes.

And so, the story involves a dragon appearing magically to help her go around the world and talk to other children about what they can all do as their part in fighting this virus. They go to Egypt, to the pyramids, where they talk about social distancing. They go to a camp where they talk about how hygiene is really important. They go to the place in the mountains where a child's been infected, and has to stay away from others. But they can still connect and still be friends even though they can't come together. And it talks about how you can still link up with your grandpa, who is someone who makes you feel safe. So what to do when you’re frightened? I talk to my grandpa, sit in his lap, inthis case, you can still talk to grandpa. You can give them a phone call. So, it's a nice example of what parents can use.

One of the big issues that's coming up at the moment is school. The AHPPC, the Australian Health Protection Principal Committee, is strongly supportive of school and the routine it gives. There's been a lot of debate amongst our leaders and this is causing quite a lot of confusion and anxiety for parents as well. Some states are starting school, some are not.

There's been a lot of discussion and arguing about it, and I just wanted to give you some of the key points as I understand them, because you may be discussing this with parents, I’m discussing it with them all the time. So, the closure of schools has had a huge impact on lots of kids. They've been separated from their usual connections, they're not getting their usual routine, their education is being affected. And then there's those sort of issues, I guess that we've already discussed around lack of safety and fears of violence and and other things. The evidence though currently and where in early May now in 2020, because everything is changing, We have had that recent issue with, as James mentioned with immunological effects of Kawasaki, but in general, kids are not getting much, much less frequently infected, as far as we're aware. At the 25th of April, there were less than 150 kids that have been positively diagnosed, compared with 6.5 thousand in Australia. They are less severe infections in general. The death rate is much slower, it spreads less and they don't tend to be the primary spreader.

So, there's a lot of evidence around there that kids are not as a high risk group, although we still do want to protect our children.

So, there's no evidence about the risk of turning returning to school as being a very high risk, even though for other groups that would be, but there's a lot of evidence of the benefits.

I'm just going to read a quote from one of our parents:
‘If GPs can’t help I would hope for them to connect me with someone, so refer me to an appropriate service for more intensive support, if necessary, I would also want them to provide me with actionable information related to my concerns. This might mean printing me resources, or e-mail me, a link, or accurate web resources.’

I think it's really important that, as GPs, we've got our little pack of resources that we can go to.

Different people are going to want different things. Adults and teenagers might want access to very accurate Department of Health or New South Wales Health websites. There's a lot of the NGO's have got on their front page, the landing page of the website, they’ve got a lot of information about COVID. The NDIS has got a huge amount of extra information up there about what they're doing. We've got the Emerging Minds website and the Raising Children Network. There is the Kids Helpline, I use this all the time, my children dialed it when they were younger and were having trouble with bullying. At school, I find this really invaluable – somewhere kids can ring and just say, I've got these concerns, and then for adults there’s the COVID helpline and Health Direct, and then we have all our specialists.

I just wanted to finish on the last few slides with the conversation.

I think that one of the most important things at this time is about how we talk to our children, because afterwards, our children are going to have to make sense of this. We do know that if children are able to understand it in a healthy, hopeful way during the event that they won’t to end up more frightened when they see other media events in the future.

There’s been a bit of work done around the Oklahoma bombings in America, years ago, looking at how the management of media at the time played out later for children. So it's worth putting a lot of energy into how we discuss this with children. When children come in, there's some children, they don't understand that COVID is not every sickness, so they need to understand that coming to see you that ‘I'm coming in with a sickness but this isn't necessarily COVID’, you're coming in with a different illness.
I've actually written out what I might think of saying to someone, so I'm actually going to read that out to you, but you can make up your own version.

This is just a little example:

‘There's a bug going around, which is making people seek.’ So this is the little kids,  three and four-year-olds. ‘It doesn't tend to make kids very sick, but it does make older people sick. And so we all want to help protect our older people. And we know that a really good way to keep this bug away, like lots of other bugs, is to wash our hands. One of the ways we can do that, because you have to wash our hands for a bit of time time, is to sing songs wait while we go. What song do you want to sing while you wash your hands? Can you show me how?’ And if they said, I'm not sure, I might sing, Happy Birthday. ‘Do you want to do that while we wash our hands?’

So it's about making it a little bit easier to understand, telling them in their language, what they can do to help.

And then for kids over six we can be more specific. You can tell them more about the details. I talk about how the virus lives on the surface – ‘in droplets on surfaces that we touch and we pick up, and when we put our hands in our mouth or nose that's when the virus gets into our body and makes us sick. So that's why we really need to wash your hands all the time, and that's why some people are wearing masks’.

Then you can tell them what the symptoms of COVID-19 might be. They might start feeling hot. They might start coughing, they might get some shortness of breath and they might find that it's a bit harder when they run around because they're coughing a lot. But this is really different to when they short of breath, when they're playing sports. So they're running really hard and they feel short of breath, that's not COVID that's not being sick, that's just working your lungs really hard. Then checking in with them and asking them does that make sense? Do you have any questions about that? You can come back and talk to us any time and someone can answer your questions.
The other thing you can say is, it can sometimes seem a bit scary, but your mum and dad and all the doctors and nurses and the people in Australia are coming together to get rid of this bug or  this virus, and help protect our older people. And we're all washing our hands together, we're all wearing masks, all coughing into our elbows, and the virus is almost faded away in Australia, at the moment. So we're really grateful to everyone for what they've been doing. And in little while, with all those expert scientists out there, we may find that we have a vaccine, and the bug will not be able to affect us as much, and we'll be able to go on with what we did before.

This is a really beautiful video, and there's a link to this in the resources, and it's, it's called the Great Realisation.

And it's a story of a dad reading to a child, and he's in bed, and it's in the future, and he's reading a story to the child, saying that, you know, back in the period of the great revelation, there was this bug called COVID, and it came along, and, and, you know what it did was, it was actually really good for our planet and it changed the way that, we interact now. It was a time when people were not talking  together very much, there were playing on technology when they had dinner. They were driving in cars all the time, they were traveling all the time. And then this great bug came along known as COVID and people got together. People started having fun together, people remembered how to talk to each other, and people started playing games together. There are less people out traveling, animal started to come out in parks again. And in this beautiful story it says, and this is not the first great revelation that been other revelations since, but this was a really important time in our history. So it's a really lovely, positive take on how to reframe what's going on.

I just wanted to finish on a parent's voice:

‘In our house COVID-19 has created heightened anxiety for our daughter with ASD.  While she may not have the cognitive ability to understand exactly what the implications and impacts of COVID-19 are, she has responded on a feeling state level to the community fear, anxiety and uncertainty.  As a result her usual resilience and personal resources have been eroded to the point that she needs constant reassurance and some level of routine and predictability to her days.  Maintaining her usual routines has also been disrupted with so many services/schools and recreations closed.’

‘Therefore, a GP who is understanding and aware of the extra anxiety children are feeling in a COVID-19 world and the initiative to check on a child’s psychosocial and emotional wellbeing regardless of what the appointment is for.  Checking in on mum and dad would be great too.  Sometimes just an acknowledgement of how tough its been makes you feel a bit better.

‘I’d like to think our GP would also know where to refer us if she didn’t think we were managing well.’

And that's a really nice cue to hand over to Nick will take us through what would happen when we refer.
When to refer and what to expect – Dr Nick Kowalenko

Hello, I guess we'll get to that eventually. Thank you very much, Penny.

I'll start with what our family partners have been telling us within Emerging Minds at this stage. And these are really the kind of messages that they've been generating in terms of their concerns and worries they might will bring to their health practitioners, in general practice, but in other settings.

I thought this was a really orienting question that was really driving some concerns in parents, thinking about what they want from their GPs for their kids, well, what the hell am I missing? What does that mean for my kids? So this is a very linchpin kind of concern.

Penny has alluded to the importance of GP information be clear and authoritative, and also mentioned the importance of parents wanting specific links and some educational resources, or psycho-educational resources if it's about mental health concerns  and maintaining emotional health and wellbeing. Parents are talking about the importance of their kids having a say in talking with their GPs  and a sense of the GP is on their side and on their kids’ side. And, also, please acknowledge the strengths – my strengths, of my family, of my children, as you suggested.

And indeed, within the context of a practice itself – please include my kid, speaking to the GP and welcome them and explain why things have changed, especially if you're in PPE because it's really scary for my kid.

Explain why we're having online consultants. Please make sure you address privacy and confidentiality, with online consults. And some parents mention they really want the GP practices to demonstrate the ways in which that can lead with best practice. The presence of sanitisers, distancing, maintaining social distancing, PPE etc, and ensuring that they maintain the usual healthcare needs under COVID restrictions.

I want my GP to be extra reassuring, so demand, in a sense, for GPs to be more reassuring under these difficult circumstances. And please keep me hoping that we will all be OK.

But parents have also really mentioned the importance of GPs being curious about their practical survival. Wanting GPs to express concerns about how they are managing. Help me overcome those practical barriers. James has mentioned the importance of accessing some of the usual care tools, such as prescriptions. And please, check on my material needs, and my food needs.

James has introduced the importance of the changes that have swept across the general practice world and I've included the escalation of online consults. This also applies, of course, to allied health and to doctors in general. So for parents and kids, it's important to introduce the change, explain the rationale, about why it’s happening. Raise any difficulties that may be experienced in online consults, and try and talk about the limitations, and try and explain the measures that you're taking online, to address them. And address all those practical issues, such as payments, confidentiality, privacy, etc.

One GP mentioned to me that she’s been saying to her families that she was seeing online, was, look this is this online move is really a bit of a trial at the stage. Please give me some feedback about how it's gone for you, just to make it clear that this is really a rapid change and the GPs and all and allied health people need some feedback from patients about, how do we improve the methods for online practice?

It's really changed the rules for how we commit to our patients and sometimes to our families, particularly kids and their parents, and how we relate in the context of general practice, and, of course, in practice, more widely. And Penny mentioned the importance of connecting as being a key feature in maintaining psychological first aid.

Both James and Penny have talked about the impacts in a sense on parents when exposed to the crisis of COVID-19. We are all, but parents especially, catching up, with the speed of changes, and there are unpredictable and unforeseeable circumstances operating currently. And so similarly in the future, although it happens to look a fraction rosier at the moment.

But what has happened then, I guess what James has talked to so eloquently, was how preoccupied,  how threatened and sometimes how irritated and exhausted people are both in their work roles, but also of course at home, particularly in their role as parents. The implications of all this is that their kids kind of miss them, if they're absorbed in their own worries and concerns. This, of course, happens repeatedly every day when we as parents get absorbed by the crisis we're facing in our family life, or work life or somewhere else. And our kids can, of course, cope with that for brief periods and briefer and briefer periods, of course, if they are very young. And as both Penny and James have let us know, Beyond Blue and Lifeline and those sort of  agencies have had a massive increase in their calls and accessing their helplines information services by up to 40% in the case of Beyond Blue.

Penny has mentioned the importance of how do we construct our stories to speak to young children at different ages. So, I'll just briefly go through that. This is, of course, designing up or delivering, developmentally staged communications, in the context of general practice. But in these early years, it really hinges on the safety, the psychological confidence and surety in a sense of parents with these very young kids. And we're all pretty familiar that, and that's that centrality of the emotional availability of the pain, of the parents. I should say, sorry, which includes the inputs that big available physically. So there's a bit of a challenge for physical distancing, especially if it's outside the family. And of course, the very young kids often have very close, important contacts with their grandparents and others in their extended family network.

Everyone's talked about the importance of maintaining routines, of maintaining reassurance, and all these things are really required, and their continuity helps create an experience of ‘felt safety’, that experience. And, of course, because younger children and young kids so much more dependent on their parents as the sole source, or the primary source at least, of their own psychological safety.

And this is core dimension co-ordination, especially for your very young kids, of establishing that safety and a sense of safety that is highlighted – that's one of the key features of psychological first aid.

Of course, we're focusing on this age group of kids in this particular presentation. But, of course, families might have kids at any age and the Penny’s really gives us a nice example of how to address these issues, specifically. To the accurate information about the importance of rules to stay safe and the importance of imagination and magic, to help deal with these issues. Kids that are a bit more worried, can express the kind of concerns or behaviors that you can see down below. Or they kind of displace them onto their pets and talk about their pets worrying about this or their pets worrying about that and it starts to become very pet-focused and they express their anxieties about all those key relationships in their lives, through their pets and talk to you about that. And you can say what the hell’s my kids talking about the pets all the time, all those sorts of features their concerned about. And Emerging Minds has a podcast, really outlining the ways in which you can best speak to your kids about the many issues that are operating currently.

Kids of this age, the ‘tweens’, are becoming much more attuned to family and community fears, as they affect them, perhaps from outside the family. Whereas the younger age group are in touch with these things through the agency of their families. And they fear unexpected and unpredictable behaviours and reactions in their family members. The continue, of course, to be reassured by routine activities, we've got some Emerging Minds resources, that will come to the end of the webinar presentation. They often actually miss their school activities, of course, their socialising, and the games and they, too, can display these sort of symptoms, and changes in behaviour.

I was talking to one of my friends the other day with a six or seven-year-old kid. And she had been talking about, just in the last week or so, about meeting kids in the back lane. The way they are maintaining physical distance is to draw a circle that their kids must stand in, that's at least 1.5 metres away from the next kid in the lane. Well, that's a very creative and imaginative way of ensuring that kids can in fact, find ways to play with each other and maintain subsets of connection, but also understand the rules and begin to lock them in a very, real, concrete sense about maintaining physical distancing.

Adults and children together. Emerging Minds has a couple of fact sheets, which deal with the issues, that James has particularly raised, about the importance of the media and potential over exposure to it, and the concerns it can in raise kids, and also about how to best communicate with your child about COVID-19. And in that context, parents can share with their children some of their feelings, while they're also managing them, and talking about some of their vulnerabilities or concerns they have. They can share their worries words and how they go on to address them as a way of demonstrating modeling to their children, that there are ways, there are rules for addressing solutions. Provide coherent explanations about sensible responses to the COVID crisis, and, of course, it's important aspect of maintaining connections, how we as family members, who are all going to look after each other.

For GPs have been some significant changes, that James has introduced, about them, the patients, and us, as doctors, and how that’s changed, in one sense the crisis of COVID has caused us to have less differentiated roles. And what I mean by this, I'll explain a bit more. In one sense, none of us are immune, James has talked about the safety the concern, the threat in maintaining safety, both in the clinic, for our families, for ourselves and for practice staff.

One of the GPs I was talking to, was saying that what's really changed for them, they have noticed is how much more carefully they are self-monitoring their own health status – ‘Do I have kind of raspy throat’ – and wondering what they should do about maintaining, and their concerns about, their own health. But in the view of they may have the potential to effect a spread because the see so many people and are maintaining a wide range of contacts, for their work.

Many of us become a little bit more reactive, as we experience stress, and I'll talk more about that a bit more. And, of course, none of us are actually immune. While there is sort of surge of mental health concerns, formal mental health consultants are down by approximately 20 or 25%. Is theis because of safety concerns with those people experiencing mental health problems? Or is this roughly consistent with what's been a mild to moderate drop-off in GP consultations in general in the Australian community.
James has mentioned those features of GP's experience. I've talked about the importance of critical health monitoring of GPs health and their concerns about that. Of course GPs are maintaining their own very high expectations for delivering care and maintaining it, and the stress for their staff and their practices that James has mentioned. Less income has been a feature really in the last month or so. And it’s important to the very constrained life about work-life balance.  James has talked about this sense of ‘cabin fever’ arising in this context. And while this is perhaps not a problem it was, weeks ago, there is significant stigma expressed, sometimes in the community, against health workers. And a mix of kind of both praising them and holding them in high regard, but in the earlier days of the COVID crisis also people, for example, in supermarkets, being concerned and threatened towards staff who were, for example, carrying their ID cards into places like common large shopping centres to access food and resources.

This is just a sort of brief explanation that accounts partly for this sense of widespread community fear causing arousal throughout our whole community. And you can see that as arousal increases, it often improves our function in terms of looking at complex performance tasks. But, once arousal gets higher and higher, there's a point at which our functioning peaks, and we become too stressed and preoccupied with the arousal and it stresses us, it disorganizes us. It makes you feel anxious and agitated, and a functioning effects seriously drops off. And its particularly the case in the context of, if these stresses, arousal in this case, goes on for a long time. And if there are many sources of arousal, not just from this issue about the crisis. This is information coming from the Yerkes-Dodson curve, which was really developed by a psychologist prior to the pandemic coming into the world.

Penny has previously coined this phrase inside our conversations about ‘COVID-brain’. In the sense, that James has also alluded to, about so many GPs in the context of really busting to maintain their high standards of care. Feeling overwhelmed. Worn out. Many of them report sleep disturbance, this problem balancing demands of work, home and, of course, homeschooling as well.

And the fear that this is sometimes engendered about dealing with a crisis, combined with a sense of kind of resignation about it. It just a kind of colloquial term that we see sometimes, not only us as doctors, but also, of course, in so many members of our community.

James and Penny both introduced this idea about what about kids that have pre-existing problems. They are the common ones there. They both raised the importance of family and domestic violence. And I consult to one primary care parenting agency, they’ve had a100% increase to positive responses on the screening questions for the, for the experience of their clients, young parents, with young children, experiencing family and domestic violence in the last month.
Both Penny and James have alluded to the social disability that are arising from the changes around being able to maintain social connections, and the impact of this, in terms of missing out on school life, amongst other things, and the challenges to resilience and wellbeing.

They were well aware, in fact, and often try and prescribe, you know, physical activation as part of adjunctive treatment, in the context of mood problems. And this is what kids sometimes get in the context of sport and the imports of socialising, and these are all activities, that of course not only maintain health and wellbeing, but also maintain psychological resilience. James has talked about terrible impact of financial circumstances on many families. The concerns about grandparents and extended family members and the vulnerabilities that are high at this particular time, particularly by parents or parents to be.

Those who might be pregnant and other kinds of stressors or stress precipitants at this time arising from lifestyle transitions such as the HSC.

 So this is what the pandemic thunderbolt's really done It’s disrupted the population and had a particular impact right through every level, kids' lives, through their entire kind of network. And the pandemic disruption, of course, also includes its impact on GPs in every other setting. So it's really like a thunderbolt in our lives and we've all experienced that.

At the community level, this has really raised the importance about the significance of responding to a major crisis that involves everyone in the community.

And we've developed, within Emerging Minds, a short course for GPs to address this and you'll see that the resource. In one sense, we're all in this together, but we're also told often that GPs are the front line engaged in a war. It's a kind of interesting mix. In one sense, the whole community level, we're engaged really in some many different communities as professionals. We’re in the community more widely, we’re listening, connecting, acknowledging, recognising what's going on and networking.
But what does this actually look like?

This is slightly complicated way of my trying to just display this idea about the adjustment that we're experiencing currently in the population and what this looks like. And this is really impacted by a number of factors you can see on the left there, thinking about children. And this is how adjustment usually occurs in the context of the crisis. You can see there that March 2020 is the onset, really in Australia of this rapid increase in COVID thunderbolt, the crisis, and you can see there that we have a look at the green line, actually just focus on that, that's how we've all been managing and we've had a high level of functioning with a sort of low level of arousal. but sure a lot of things have happened to cause arousal.

And then, from about March, you can see that those of us that aren't necessarily struggling with underlying mental health problems, arousal takes off, are functioning, might go down a bit. But, look, look at the red line. What have you experienced that anxiety problems, or your anxiety, in that child that Penny conveyed, really arises, in many respects, because you've got some, sort of developmental disorder. Such as one of the Aspergers syndrome or autism spectrum disorder, where your anxiety, or your other comorbid condition really causes you to react far more sensitively and far more reactively to the common stress level everyone else is facing. And then your actual function is going decline in keeping it a kind of mirror image, of a combination of your experience of anxiety, and the broad based stress anyway.

But look, there are also that group were well aware of that have already experienced major traumas such as those experiencing the bushfires and the anxiety and the concern, and how we recover from that. This function is going to be drastically affected, much more drastically affected, by the impact of the COVID thunderbolt.

We can anticipate that this is going to go on for some time. And there are many people who are going to experience, not only at this time a drop off in functioning and increased anxiety from experiences such as bushfires, but unemployment and the financial impact of what will happen.

So what does this mean about your referral network? While your referral network, probably like mine, it's been quite affected by the COVID thunderbolt as well. With these sorts of impacts, there's been some confusion, there's been some variability and there have been some marked access changes. There have been a series of changed practical matters,that James has mentioned, both in general practice but also in specialist practice and allied health practice. And lots of variation, in how much they're either having face-to-face contact and wearing PPE or not or preparing for it. Some practices of my psychiatric colleagues have continued to be about 70% face-to-face. Some have moved to 100% online consultants. There are changing online referral options becoming available. Wait times are certainly changed.

Certainly in my rural networks some allied health options for online consults, and some access networks to specialist consultations have increased, but in other rural settings have actually decreased, so marked variability.

In the last month we had better be about a billion online consults in Australia, across this wide variety of GP, specialist – in the doctors networks, at least, I'm not sure about allied health networks. So this is all changed, and really, make to get an update as best you can, on your local referral network, what's happening with it, and who's maintaining their links. And this has been a serious challenge, probably been running just a few weeks, behind what's happened in general practice.

So we stand at this next phase. Chapter one of the COVID thunderbolt might have struck the next phase of the COVID storm, what's it going to look like? We can anticipate that there'll be medium and long-term consequences, all of them are not yet clear. But there will be a significant changes and there will be great disadvantages for many. Sure, there may be opportunities for creativity and other changes in benefits and revelations for some, but, I guess we'll be seeing that group of the population who are most adversely affected by this current experience.

Those adverse affects the burden of that will fall predominantly on young children, children,and youth, they will experience most of the psychosocial, adverse impacts and the consequences thereof.
So just keep that in mind as we proceed over the next year or two. OK, and some Emerging Minds resources emerging by the end of the year.

OK, thank you very much, James, I'll hand it over. Back to you.

Panel discussion

James Best:
Well, thank you, Nick. That was terrific. I suppose I've had a bit of ‘COVID-brian’ myself at times, and I've been on the wrong side of the Yerkes-Doson curve, certainly.
Penny, how do you see all of this, this ongoing massive crisis? It seems to be just just going on and on, it seems that it will be going on for a lot longer, how do you see this relating to, some of the other disasters you’ve seen and dealt with.

Penny Burns:
Look, I say this has got huge similarities, actually, except with the whole population of Australians involved in this one. But it's really, you know, some of the effects on the younger children will be similar, they are experiencing it through their parents and their families. And we know that that an ongoing effects after bushfires and other events, there are key periods where we need to be, as GPs, we need to be more surveillant, for these effects. Things like anxiety, depression, PTSD definitely, but also grief, bereavement, other events and then worsening of conditions that children already have, and that can include physical conditions, as well. As GPs we need to  identify those that we think we're more concerned about and to put in place strategies to actively outreach to them at various stages, three months, six months. Colleagues in Christchurch that I know they're, five years later, they were still monitoring patients who would come anxious every time there was a major quake.

James Best:
So, we really have to have our radar on a bit more and, in particular, on those who are at risk a bit more.

Penny Burns:
Absolutely. And one of the other things I wanted to comment on, particularly was that just because we're going back into that new ‘safe’ period, we're going back into a different time, any disasters we've talked about in the past, ‘bouncing back to that new norm, bouncing back to before’, and now we know that we actually don't bounce back. We bounced when new norm, because things will stay different and that can be a really scary place for children. One example, was after the Victorian bushfires, for example, one of the schools that burnt down. We were working with teachers and children in that environment and they, they got together and they were safe in these demountables. When they had to move into this new school, this new fancy school, they didn't want to do that because they felt safe where they were. So we have to realise that all this change is impacting in various ways on children.

James Best:
It’s something I've been trying to incorporate into my own practice is a ‘check-in’, a COVID ‘check-in’ With each consult, I'll just go, OK, how are you and also how are you going with all this? And sort of try and make routine. Early on, I had a bit of a bit of a stuff up where I had a patient come in that I knew very well had children with special needs. And halfway through the consult, she just burst into tears and said, you're not your usual self because I was so distracted. And I don't think my performance was quite what I was expecting and myself and it was a wakeup call. So I'm trying to be much more proactive, especially in with kids, especially with people who are at a particular risk, I say with anxiety or ASD or whatever.
Nick, you said to children, young people are, at particular risk, why is that?

Nick Kowalenko:
Look, young kids and kids at the age we are talking about are kind of in a pressure cooker. And the pressure cooker is all this stress going on around them. Plus the kind of disadvantages follow them. We know that, as I was saying, in primary care, parenting agencies, reports of domestic violence and family violence are up 100%. That we know there’s going to be an increase in drug and alcohol intake as a way of parents trying to cope with their own stressors in this context. And in a few months time, we'll see a lot more mood problems, depression and anxiety. Particularly in parents as they struggle with some of the persistence of these difficulties, such as the ones that arise in the financial sphere around employment, impacts on family members, the issues that you've raised, like losses.

And some of the consequences of not maintaing healthcare as well as we have in the past, and not accessing as readily, as we've talked about, sport, physical exercise. A lot of people have tried to maintain that in many respects as being a kind of key dimension, not only of maintaining health and wellbeing, but also about psychological health and wellbeing and emotional health and resilience. So those things are all sort of come home to roost in the pressure cooker and the release valve will be a lot through the lives of kids and youth. So the fact that there will be youth unemployment, of course, that will be higher probably than any other stage in terms of the whole spread of employment across all age groups. In the bushfires, we often found that the kids that had the more severe difficulties that became apparent, such as PTSD or mood problems, this often was much more eventually identifiable at the four, five, six month stage and then often even after that, for some time, heading forward. So this is this combination of, particularly for kids with pre-existing problems. I had some kids, I see with obsessive compulsive problems, of course, suddenly it the new norm almost to have some obsessive compulsive concerns, especially regarding COVID but it can also be disabling.

And those kids that have some of these pre-existing problems are just much closer to the tipping point because they're running with much higher levels of anxiety or mood problems or whatever it is. And they don't need much for chucked into the pressure cooker, to tip them over to more serious problems. That's the point at which we see probably some more issues arising. I think the issue you've raised, about how important it is to check-in for that, in general practice with parents and how you go in general, is also a key feature of the things that the parents have raised about wanting their GPs to do to make sure that families are OK.

James Best:
Penny, how have you seen this impact on your own practice?

Penny Burns:
So, it's been difficult in our practice, because obviously, people are much more reluctant to come in. They're coming in with less children so the children are coming in sort of as more separate individuals. We are currently doing lots of telehealth. Again, connecting with children. That's been a little bit hard, I find that I usually end up talking more to the parent, and the child is running around in the background. So I've actually lost a lot of connection. I've had a number of patients that really can't cope with not coming in face-to-face, and so they've come in. I've had one girl that really wanted to hug me. whe wouldn't normally hug me, but this was the stress of not being able to touch people. Then, we've had people coming in very, very, very, obviously stressed and distressed and, and having to spend a lot more time actually going through and giving a lot of information about what is COVID-safe. But we've tried to add extra things to our practice, like the ittle smiley faces an extra little bits and I'm trying to take the time, as you are James, particularly with children I'm asking them first, how they going.

And also asking parents, what do you need, what can we do to help out? And also making it freely available, but really difficult in this time because I feel like access has been removed. I've just started working respiratory clinic and that's a whole other world and very, very dry, isolating sort of environment and particularly for children coming in for swabs. And that's one of the things that I'm sort of trying to work out, how we make that better. I think, there's lots of ways we can do that as GPs, you know, just posters on the wall, all those sorts of things. But it's a really tricky time.

James Best: I totally agree, and I've certainly something that I've found is that I tend to, it's a bit of a trap that you can fall into, and say I'm just going to be pragmatic and solve the problem at hand and I'm going to forget about you as a person. So you’ve got to bring yourself back and so no, no – it's about connectedness. I’m wearing a mask and I'm wearing a face shield and glove and all that and gowns and even in a respiratory clinic I’ve still got to remember, this is a person I'm dealing with not just someone with a snotty nose.  

Penny Burns:
I think humour is really important in that. I put little little faces on on sticks and dance around the table and make jokes. And I think that we have to be bit light with it sometimes.

James Best:
And event talking about what television you're watching, what you're cooking – all these COVID things that we do. You know that we're in this together.

Well, thank you very much, guys. I think that was a really great discussion. I'd just like to, now remind everyone about our resources that was mentioned in the introduction that there's a little tab that Karen mentioned. That’s got all the resources that Nick and Penny and myself mentioned during the presentation. And I'd like you all thank you all for coming. If anyone's got any questions that weren't answered during the session and you'd like you can type it into the question box, and we'll try and get an answer back to your next couple business days. Thank you all for attending. I hope you found it useful. I did, and, and I hope to speak to you next time. Goodbye.

Other RACGP online events

Originally recorded:

16 May 2020

With much of Australia facing a resurgence in COVID-19 cases, and with Victoria returning to home schooling, this webinar explores the ways that GPs can support children and their families in this daunting environment, which has brought change, anxiety and stress.

Presented in partnership with Emerging Minds, this webinar will explain the current environment for GPs, families and children during the COVID-19 pandemic and describe appropriate management options, including when to refer, for a child experiencing mental health concerns during the COVID-19 pandemic.

The presenters explore ways to start conversations with your child and young patients on how they are feeling about the pandemic, and the impact of telehealth on the patient experience.

Learning outcomes

  1. Explain the current environment for GPs, families and children and those in your referral networks during the COVID-19 pandemic
  2. Describe appropriate management options, including when to refer, for a child experiencing mental health concerns during the COVID-19 pandemic
This event attracts 2 CPD points

This event attracts 2 CPD points


Dr James Best
FRACGP, Chair, RACGP Children & Young Persons Health SI Network

Dr James Best (facilitator and presenter) Chair, RACGP Specific Interests Child and Young Person’s Health Network, James has been a general practitioner for over twenty years, and his medical practice has a special focus on child development, child behaviour, parenting and children with disabilities. He has been widely published in medical and mainstream publications on these and other child health topics.


Dr Penny Burns
General Practitioner

Penny Burns is a General Practitioner based in Sydney. She has worked for over 20 years in urban and rural general practice and is a member of the RACGP Expert Committee - Practice, Technology and Management. She has been interested in computer and technology use in general practice since the early 1990s. Penny is interested in the use of technology to improve outcomes in learning. Over the last year she has been involved in delivering education sessions as part of the My Health Record in general practice national education awareness campaign. She is currently part of the CSIRO Primary Care Data Quality Content Working Group, which examines the use of data in general practice and is Deputy Chair of the Disaster Management Special Interest Group at the RACGP.

Dr Nick Kowalenko
Child and adolescent psychiatrist and Emerging Minds NSW Director

Began his postgraduate training in the Family Medicine Program with RACGP before training in child psychiatry. Nick is Vice-President of the International Association of Child and Adolescent Psychiatry and Allied Professionals. In his roles as deputy chair of Emerging Minds, Chair of Tresillian Council in NSW as a consultant to a variety of state and national NGOs and government bodies, he champions the promotion of children’s mental health.

© 2020 The Royal Australian College of General Practitioners (RACGP) ABN 34 000 223 807