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Disclosures: Berger-Jenkins and Goza report no relevant financial disclosures.
November 10, 2020
3 min read

AAP issues guidance on supporting children’s emotional and behavioral health

Disclosures: Berger-Jenkins and Goza report no relevant financial disclosures.
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The AAP released interim guidance for parents and clinicians who see behavioral or emotional stress in children because of the COVID-19 pandemic. It also updated guidance related to child care.

Among other things, the AAP urged that pediatricians —“experts in screening and assessing children for developmentally appropriate behaviors” — should “continue to advise families about emotional and behavioral responses and needs in the context of typical development.”

“As a pediatrician, I know that children don’t always know how to express their true feelings and they may even try to protect their parents from added worries rather than share when something is wrong,” AAP President Sally Goza, MD, FAAP, said in a statement. “This is one reason we want to see your children and teens during office visits, not just to stay up to date on immunizations, but to check on their social and emotional health, too.”

Families of color have been especially vulnerable during the pandemic because of structural inequities caused by racism that affect access to quality health care, food security, employment, housing and education, the AAP said.

Evelyn Berger-Jenkins

Evelyn Berger-Jenkins, MD, co-author of the emotional and behavioral health guidance and a pediatrician at Columbia University, called racism a “toxic stressor” and said toxic stress can lead to “responses, including fight or flight responses, in the body [that] are elevated and constant, leading to physical changes that we know are directly linked to many health conditions, including diabetes, cancer, etc., and passed on genetically from generation to generation.”

“Now, combine this pervasive stressor with the stress of a pandemic that has also disproportionately affected marginalized and minority populations, causing increased morbidity and mortality, and worsened disparities in care and access to care, and you have a storm of stress and disadvantage in a cycle that needs attention, intention and real/true effort to be broken,” Berger-Jenkins told Healio.

The guidance says children and adolescents may behave differently depending on their age group. Berger-Jenkins said this is also based on their developmental stage, their personality or the manner in which they choose to interact with the world.

According to Berger-Jenkins, infants respond directly to stress felt and expressed by their supporting adults and caretakers. If there is increased stress in those figures, the infant “will present irritability and [have] difficulty soothing themselves.”

Toddler-aged children are developing “a sense of autonomy and self-regulation,” in which they rely upon a structure. If their daily schedules are disrupted, they may display uncertain behaviors and regress, Berger-Jenkins said. She said they may also become disorganized and hyperactive.

Regarding school-aged children and adolescents, Berger-Jenkins said patients in this age group are developing a sense of an “independent self.” If there are any disruptions to that, they may “withdraw and/or turn to unhealthy behaviors to cope, such as social media, [and] substance use.”

“Their ability to think more abstractly often presents as inattentiveness, and this may increase frustration in parents but should be understood and met with patience,” Berger-Jenkins said.

The AAP recommended the following:

  • During the COVID-19 pandemic, it is especially important that pediatricians continue to advise families about emotional and behavioral responses and needs in the context of typical development. “It is not uncommon for children to have developmental regression during times of stress,” the AAP added.
  • Caregivers should be encouraged to have open and honest conversations with their children and adolescents about what they are hearing in the media. Avoidance of such conversations does not protect children.
  • Older children and adolescents may find the social isolation related to the pandemic overwhelming. Socializing with peers is a mainstay of child and adolescent development.
  • Parents and caregivers should explain to children and adolescents that screen time has its benefits as well as real risks. Families should be selective in choosing media, but for the time being, know media is being used more for education and socialization.
  • Pediatricians can remind families about the strength they provide for their children by being present, empathic and nurturing. Practicing techniques together such as mindfulness, relaxation and focusing on the present moment can help the entire family build coping skills to deal with uncomfortable and frightening feelings.
  • Children and teens can be encouraged to explore their creativity, passions and strengths to help others, volunteer and contribute to their community. Reframing and taking control of small things such as making their own masks or participating in volunteer opportunities to help the community can help children and caregivers feel less vulnerable.

The updated guidance on child care “aims to reduce risk of exposure and spread of infection to staff, children and families of early care and education programs,” the AAP said.

It includes recommendations that children stay home if they are ill and that child care programs develop a plan for what to do if a child become sick during the day.


AAP. Interim guidance on supporting the emotional and behavioral health needs of children, adolescents, and families during the COVID-19 pandemic. Accessed Nov. 5, 2020.

AAP. Guidance related to childcare during COVID-19. Accessed Nov. 5, 2020.