A COVID-19 Behavioral Health Toolbox For Families

Toddlers and Preschool ChildrenCommon Emotional Responses in Toddlers andPreschool ChildrenHow to Help Toddlers and Preschool ChildrenHeal and GrowCommon emotional responses to disasters intoddlers and preschool children include:1Healing and Building Resilience 3, 4 Having a hard time sleeping, being afraid of thedark, having nightmares. Eating too little or too much. Fear of being separated from parents andcaregivers. Acting like a much younger child. Being jumpy and nervous. Playing pretend and telling stories about thedisaster.Children under the age of five years may not beable to share their thoughts and feelings in words,but will often let you know howthey feel through their play anddrawings.Give honest andsimple answers.Young children may shut down, orbecome quiet, sad, and refuse totalk. They may also change thesubject when someone brings up a topic thatmakes them scared, confused, angry, or sad. That isanother way they may be telling you something isupsetting them.Give honest and simple answers. Children almost always know about “badnews” at some level. When children know thatsomething bad has happened, but no oneexplains it truthfully, they sometimes make upa story in their head that is worse than thetruth. For example, if their grandmother dies,they may not understand and instead believethat their grandmother did not love them andleft them without telling them. Share information and answer questions in asimple way that they can understand, based ontheir age. Tell children that what happened is not theirfault. Once information is shared, listen to them andgive them time to talk. If your child feels lovethrough physical touch, give hugs or snuggles.Establish and stick to a regular schedule. Help your child talk to and visit with family,friends, and other members of theircommunity, if this can be accomplished safely. Try to have family meals around the same timeevery day.Behavioral Health Toolbox for Families: Supporting Children and Teens During the COVID-19 Pandemic7

Try to put your child to bed around the sametime every day.Leave for school or start homeschooling ontime and at the same time every day.Provide a quiet place where they can take abreak. This can be a separate room or a quietcorner of a room.Include children at events for saying goodbyeto loved ones that have passed away, likefunerals and wakes. Leaving yourchild out of these major eventsmakes them feel alone and left out.It also makes it more difficult forthem to accept what hashappened. These events allowchildren to see how adults grieve,which helps them understand thatit is okay to show sadness.Children needextra attentionand comfort.Help Children with Feelings and BehaviorsWhen children go through a hard time, like livingthrough a disaster, they need extra attention andcomfort from their parents. It’s important to bepatient with upset children who may havetantrums or keep to themselves instead of wantingto be around other people.It’s also important to keep the family rules aboutbehavior the same, if possible. It is important evenin situations like the COVID-19 pandemic. Whenchildren aren’t given clear boundaries and limitsfor their behavior, it can make them feel less safeand more anxious.The foundation for helping children with theirfeelings and behaviors is to spend time with them,pay attention to them, give them praise when theyare doing things you want them to do, ignore mostof the behaviors you would like them to stop doing,and learn to talk with them in ways that encouragethem to let you know what they are thinking andfeeling.Below are some ways to encourage your child totalk about things, increase their positive behaviors,and help them manage their negative behaviors.Help Children with WorriesWorry and anxiety are common in disasters andoften show up in behaviors, such as avoidingseparation, having trouble falling asleep, orexpressing physical symptoms like tummy aches.One way to help your child to calm down is byteaching them a couple of very simple skills. Teachthe following tools to your child when they arecalm, and reward them for practicing them everyday. You can do them together! When they becomea habit, they can be a great tool for both you andyour child to use.Bubble Breathing: Buy bubbles that come with abubble wand. Have your child practice blowing thebiggest bubbles they can. To blow big bubbles,they need to blow slow and soft with steadybreaths. This breathing helps them feel calm.Behavioral Health Toolbox for Families: Supporting Children and Teens During the COVID-19 Pandemic8

Scrunches: Have the child lie down on their back.They should curl up and make all of their musclesscrunch up as tight as possible, like a pill bug or aroly-poly. Have them hold their scrunch for a slowcount to 3 and then relax. Do this a few times andthen have your child check tomake sure all their muscles arenow loose and floppy. This is agreat exercise to do right beforebed.Special time takesas little as 5minutes a day.Worry Thoughts: When childrenare worried, you may see themasking many questions or the samequestion over and over. This isn’tactually them seeking information, but is a way forthe child to check in and get reassurance from you.If you find that your child is asking a lot ofquestions but doesn’t feel reassured, try this: Help your child identify when they are havingworry thoughts. These often start out as “but,what if ”When you hear a worry question, turn itaround and ask your child to think about whatthe answer might be to their question.Once you’ve answered a worry question, it’sokay to put a limit on the questions.Repeatedly asking and answering the samequestion does not reduce a child’s anxiety.Instead, try “Okay, you can have 3 worryquestions before lunch, so think about whatyou want to ask. After that, no more worry questions until dinner.” This helps the child topush back against his or her worries anddevelop some feeling of control over them.Explain to your child why this is important bysaying, “We want you to be the boss of your lifeand not your worries. When you do brave actslike playing in another room by yourself for alittle while, you are the boss of your life, notyour worries.”Build in some rewards for brave acts. Thishelps your child learn how to face worries,which is the best way to overcome them. Don’tpush, but do encourage.Child-Directed Play or Special TimeA great way to help your child feel more connectedto you and learn to share their thoughts andfeelings is by using child-directed play, which isalso called special time. Special time is when thechild gets special playtime, just them and you withno distractions. It takes as little as 5 minutes a day.Special time helps decrease the frequency oftantrums and aggressive behaviors like hitting. Italso helps children follow directions, stay calm,and share thoughts and feelings. Here is how itworks: Pick a time to play with your child one-on-one,for 5-10 minutes. It works best if you can dothis daily, but even once per week will still begreat for your child.Behavioral Health Toolbox for Families: Supporting Children and Teens During the COVID-19 Pandemic9

Make sure that the TV is off and your cellphone is put away. Give your child all yourattention for this time.The rules are pretty simple, but harder to dothan you might think. Watch your child play,smile, and make eye contact. Try to only saynice things and give compliments.Most kids love special time. Special time is set upso that it is hard for your child to have a tantrum oract out. If you are not asking questions, your childcan’t refuse to answer. If you are not teaching, yourchild can’t ignore you. It is one time when yourchild can be in control in a safe way. If your childacts out by having a tantrum, hitting, yelling, oracting in an unsafe way, end special time and tryagain the next day.Guidelines for Special TimeDo:Don’t:*Give your child compliments. Say things like, “Greatjob playing so gently” and “I love that you sharedwith me.”Give directions. (For example, “Put the car overhere.”)Describe what your child is doing, as if you’re asports reporter. For example, if your child isplaying with a toy car on the floor, you can say,“Now the car crashed into the blocks. Wow, thewhole thing fell over!”Ask questions. (For example, “Why is that doggyover there?”)Repeat back what the your said to show you werelistening. For example, if the child says, “I’m makinga tower!” you can say, “Wow! You’re making thetallest tower!”Teach. (For example, “What do you call thatshape?”)* These are all okay to do other times, but get in the way during special time.Behavioral Health Toolbox for Families: Supporting Children and Teens During the COVID-19 Pandemic10

Positive AttentionChildren love and need attention. Often, if they donot receive enough positive attention for goodbehavior, they might start doing things to getnegative attention. Give lots of attention and praisefor behaviors that you want to see more of, likeusing manners or following directions. Ignorebehaviors that you do not want to see.The best way to give positive attention is withsomething called labeled praise. Labeled praise iswhen you give your child a specific compliment,instead of just saying “good job.” Labeled praisemeans saying, “Thank you forfollowing directions,” “Great jobsharing,” or “I’m proud of you forbrushing your teeth.”Children needboundaries to helpthem feel safe.Other forms of positive attentioninclude any type of praise, hugs,kisses, smiles, and rewards. Someexamples of rewards are an extrabook before bed, extra cuddle time,or a favorite snack. Give your child the type ofattention they enjoy. If your child does not likekisses, give a hug or a high five instead.When giving positive attention, make sure to: Look your child in the eye, smile, and speak ina way that shows you are happy.Be specific about the behavior that you liked,even if it is a small thing. For example, "I like how polite you are being," or "Thank you forpicking up your toys. That was nice."Give attention right after your child doessomething that you like.Help Your Child Manage Negative BehaviorsChildren need boundaries to help them feel safe.It’s helpful to understand that stress and traumacaused by the COVID-19 pandemic are things thatcan lead to negative behaviors. However, allowingchildren to become aggressive and destructivewithout intervening can increase anxiety inchildren.For behavior that is not aggressive or dangerous,such as whining or arguing, ignoring it can be thebest approach (see Table 3 on p. 12 for a list ofbehaviors). However, when you first beginignoring, the behavior may get worse. This isnormal. If you continue ignoring the behaviors, thenegative behavior will likely decrease and go away.Keep building a strong foundation using themethods outlined above. If your child has negativebehaviors that are aggressive or destructive (seeTable 3 on p. 12 for a list of behaviors), you mayneed to help them find different ways of expressingtheir anger and frustration that do not hurt othersor cause damage.When your child is very upset, it’s not the righttime to talk, explain, or reason with them. Whenthey are really upset, the part of their brain thatBehavioral Health Toolbox for Families: Supporting Children and Teens During the COVID-19 Pandemic11

thinks logically isn’t active. Trying to talk to themmay actually make your child even more angry.Time away, such as time-out, will help them calmdown and get to a place where they can talk aboutwhat happened. Then, you can help them thinkabout other things they can do when they’re upset,instead of hitting or breaking things.Table 3: Behaviors for Ignore Approach and Time-Out ApproachIgnore these behaviorsTime-out for these behaviorsWhiningHitting othersYelling or screamingBiting othersInterrupting without saying “excuse me”StompingArguingSaying threats of harmSaying mean words or swearingHitting or biting themselves (without causing harm)Kicking othersPushing othersSpittingThrowing toys at others or breaking toysDestroying propertyBehavioral Health Toolbox for Families: Supporting Children and Teens During the COVID-19 Pandemic12

The negative behaviors in Table 3 are indicators thatyour child needs some help to contain his or her bigfeelings. Time-out is just a way of giving your childsome time without attention. It allows both you andthe child to take a break from interacting and calmdown. Parents sometimes have worries that placinga child in time-out will make the child feelabandoned or traumatized because they are upsetand crying. Based on many studies of ways ofhelping children with behavior, there is no evidencethat this is the case.Time out allowsboth you and thechild to take abreak. †‡Children who are given firmboundaries in a positive parentingenvironment full of warmth, praise,and physical affection tend to behappier, calmer, and less anxious. 5,6Time-out works best for childrenages 2–6, if done properly. Beloware guidelines for time-out:When the child does something aggressive ordestructive, give one warning only. For example,“You tore up your sister’s drawing. If you can’tcalm down and stop, you’ll need a time-out.” †If the negative behavior stops, praise the child.For example, “Good job calming down. I knowyou were upset.” If the child continues to misbehave, do not havea discussion or give another warning. Say, “Youdidn’t stop. Now you need to have a time-out.”Take the child to the designated time-out area.This can be a chair in another area or simplyanother part of your home, such as the child’sroom.‡Don’t respond to the child’s yelling or arguing.Time-out does not begin until the child is quietand in the time-out spot. If the child leaves thetime-out spot, take the child back and say,“Time-out can’t start until you’re in the spot andquiet.” Repeat this each time the child leaves.Don’t get drawn into conversations orarguments.Once the child is quiet, set a timer forapproximately one minute per year of age. Forexample, if the child is 6, set a timer for 6minutes.When the timer goes off, go to the child to letthem out of time-out. The parent or caregiverdecides when time-out is over, not the child.Give the child a hug and praise for calmingdown. “Great job calming down. I know youwere really upset.”See pages 8–9 for tips on teaching children to self-calm. Teach skills when the child is calm, not while they’re upset.Research shows that having a time-out in the child’s room should not lead to them feeling negative about their room in the future.Behavioral Health Toolbox for Families: Supporting Children and Teens During the COVID-19 Pandemic13

School-Age ChildrenCommon Emotional Responses inSchool-Age ChildrenCommon emotional responses to disasters inschool-age children include:1 Acting confused or forgetful.Lots of tummy aches or headaches.Acting hyper or too silly, like they have toomuch energy. Tantrums, breaking toys, hitting, or kicking. Having lots of worries, like being afraid to bealone or asking lots of questions over and over. Not doing well in school or having troubleremembering what they learned.Children age 5 years and older may be able to talkabout something scary or confusing that happened,but they might not want to talk about it. Or, theymay have a hard time talking about their feelings.Children of allages may have ahard time talkingabout feelings.Children of all ages may have ahard time talking about feelings,such as sadness or fear, becausethey worry that they need toprotect their family. They mayworry about giving their parents orcaregivers another problem to dealwith. They also might not talkabout how they feel because theythink that everyone already knowswhat they are thinking and feeling without themsaying it.Pay attention to how your child is acting. This willhelp you notice if they are experiencing symptomslike the ones above, which could mean they needextra support from you. Does your child’s actions match what they aresaying? It is important to notice if a child says,“I’m fine,” but they actually look sad, angry, orconfused.Does your child change topics a lot whentalking? For example, each time a topic comesup that makes them think about somethingscary or confusing, the child quickly brings upsomething else to talk about, or might eveninterrupt with, “Let’s play a game,” or “I have togo pee.”How to Help School-Age Children Heal and GrowHealing and Building Resilience3,4Try to keep a regular schedule of waking, eating,doing activities, and going to bed. Switch betweenscreen time and physical activities. Build in somefun activities during the day, like board games,crafts, and pretend play.Talk to children in a way that makes sense to themabout COVID-19 and why they may not be in schoolBehavioral Health Toolbox for Families: Supporting Children and Teens During the COVID-19 Pandemic14

or having playdates with friends. Give honestanswers and information. It is okay to say, “I don’tknow, but I will try to find out.”Help your child think about the future. Ask them questions, like “What do you want tobe when you get older?”. Then, help themidentify things they can do now that willconnect to their future. For example, if your child says that they wantto be a veterinarian or help animals when thenget older, you can praise them for always beinggentle and kind to animals. Assure them howimportant that skill is for veterinarians.Encourage children to share their feelings bydrawing, or keeping a diary that they can write ordraw in.Help your childnotice the goodthings.Help your child notice the goodthings. Focus on the good thingsthat happen and the good thingsth

example, most four-year-olds do not understand that death is permanent. Teens may not understand or believe that they can be hurt or die and may take risks after experiencing major negative events. See Table 1 (p. 5) for common responses of children and teens to disasters. The most common symptoms of trauma in children and teens are changes in