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How The Pandemic Could Harm Marginalized Children, According To A Child Psychiatrist

Jayden’s* father threatened him with a hammer. Sophia* suffers from cancer, compromising her immune system. Lara* lives in an immigrant detention center. Their problems were difficult enough, even before the coronavirus pandemic. For the most part, children are resilient and will come out of the pandemic psychologically healthy. The kids I worry about were already under-resourced, and have been further put at risk by the indirect effects of the virus.

As a child psychiatrist, I am a sponge to stories from all walks of life. Unfortunately, historically oppressed populations are at the mercy of the U.S.’s fundamentally flawed systems, which disproportionately impact people like undocumented minors, those in the welfare system, and low-income populations. Headlines have reported that these populations are more likely to contract and die from COVID-19, and others have portrayed the psychological effects isolation has on children. However, COVID-19 is exposing entrenched structural issues, and many children, who cannot speak for themselves, are in danger.

Jayden, age 16, whispered “I don’t feel safe, Dr. Chhabra.” His father, a methamphetamine and opioid-user, “ran at him,” hammer-in-hand. The apartment refrigerator contents have been chronically expired since his mother was killed in a car accident. The walls shared with his father are his only place to eat, sleep, and attempt to live. Feeling powerless, sometimes he punches walls, sometimes he skips school to smoke away the pain, and sometimes he doesn’t eat. I instinctually called Child Protective Services (CPS), but later, wondered if it was the right choice. CPS is an overworked and under-resourced service  —  would home visits be possible with limited staffing and contact? Like many during COVID-19, would Jayden be trapped indefinitely with an abusive, intoxicated parent?

Sophia, a 14-year old with a new cancer diagnosis, hyperventilates, her body invaded by ports and needles. The cancer has compounded underlying mental health issues, and now, did I really have to ask her about “the virus?” I chickened out and awkwardly mentioned the “news” and her upcoming hospital discharge. She looked downwards, crying, fearing that her family, living in a cramped space, and with no option to work from home, would put her immunocompromised life at risk. Her anxiety was rational. She did not have access to the internet for teletherapy or school, and only 9.2% of those in the bottom quartile for income can work from home. Would her parents have to decide between risking Sophia’s life and feeding the family? How would she receive mental health treatment?

The immediate risk of COVID-19 is just one concern, next to the ways the flow-on effects of the virus could tear apart these children's lives by jeopardizing their mental health, safety, and access to basic needs like food, shelter, and education.

Lara, a 5-year old girl and undocumented minor in custody of the Office of Refugee Resettlement, had already suffered sexual trauma and her father’s murder. For safety, her grandmother, on foot, delivered her to the U.S., only to be deported herself. An impending court date would determine her home: Mexico or foster placement. I wondered how the pandemic would put her future on hold. The U.S. held 69,550 migrant children in custody in 2019, and research shows even without COVID-19 stress, prolonged institutionalization results in greater mental and physical health repercussions. As Lara tugged softly at my sweater, joking that I was wearing a “blanket,” she smiled and said “I’m going home.” I wasn’t sure what home meant. Would she ever be stably housed with caregivers?

The immediate risk of COVID-19 is just one concern, next to the ways the flow-on effects of the virus could tear apart these children's lives by jeopardizing their mental health, safety, and access to basic needs like food, shelter, and education. While the government has been called on to increase funding and implement specific plans for marginalized populations, including undocumented minors and those in child welfare, targeted plans from mental health teams can protect Lara, Sophia, and Jayden’s lives, now.

For Jayden, housed with an abusive, substance-using parent, engagement in virtual mental health services will be key, especially with The Administration for Child Service’s (ACS), New York’s child welfare agency, stretched thin. Mental health providers can emotionally support Jayden, facilitate access to food, assess fluctuating safety risk, and coordinate with ACS, who is still providing visits in emergency situations.

For Sophia, suffering from mental health issues and cancer, free wifi offered in New York City could provide access to virtual mental health care and schooling. Social workers could assist her parents with paid family leave (although many companies aren’t following through), and navigating related basic needs, such as transport to medical appointments.

And for Lara, who wishes to be “home,” mental health teams, already present at her center, can advocate through legal liaisons, as court hearings have become even more complicated. Appropriate therapy during an especially dysregulating time for a traumatized child and contact with family may provide some semblance of stability.

While we await systemic change, mental health teams, more than ever, can speak for those not given a voice by providing flexible, comprehensive virtual care that accounts for COVID-19. Under-resourced children were already facing an inadequate healthcare system and network of family services. It is more important than ever that states look to those who have implemented helpful plans. Government expansion of safety nets can protect marginalized children, including those in the welfare system, immigration or juvenile detention, or low-income families, at this vulnerable moment. Equitable access to medical and mental health services, education, environmental protections, and appropriate housing, are paramount to disaster and post-disaster preparedness. And we, as Americans, must advocate so that the voices of those made invisible are heard.

I can’t help but find myself wondering what Lara, Sophia, and Jayden are doing right now. Is Lara cracking jokes? Is Jayden opening his fridge? Is Sophia adequately isolated? Wherever they are, I hope they are safe.

*The cases described in this article do not represent any one specific patient; rather they are a composite of various patient experiences, conditions and challenges. Details have been altered and fictionalized and names have been changed to protect patient privacy.

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