How physicians and parents can increase compliance
When states reopened from mandatory lockdowns designed to stem the spread of COVID-19, adolescents and young adults emerged from their dens like bears starved for food and company. Despite new rules of engagement that included wearing face coverings and staying six feet apart, young people packed sidewalks, restaurants, beaches and parks, crowding tightly together, hugging, talking and laughing, with nary a mask in sight.
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Only days later, COVID-19 rates in this age group began to spike and have continued to climb. Adults were left wondering whether young people failed to understand the danger or chose to ignore the warnings.
According to Ellen S. Rome, MD, MPH, Head of the Center for Adolescent Medicine at Cleveland Clinic Children’s, their behavior was predictable.
“A sense of invulnerability—showing up here as an act of defiance—is part of the adolescent mindset,” she says. “This reaction is developmentally typical.”
Most adults understand that COVID-19 may make them sick enough to die. Therefore, they need to protect themselves from exposure to COVID-19. They also understand that asymptomatic carriers can spread the virus to someone else.
But adolescents do not tend to think so logically, because abstract thought—which includes the ability to understand consequences—does not tend to develop until age 18 or later.
Adolescence is also the time that independence grows, dependence on parents wanes and significant importance is placed on relationships with peers. These relationships may be difficult to maintain in the absence of personal contact. Young adults who forego face-to-face contact with friends and romantic relationships due to COVID-19 may experience boredom, loneliness, sadness and depression.
Healthcare providers should watch for signs of toxic stress that may manifest as anxiety, depression, self-harm or flares of chronic disease.
“Talk to parents about helping anxious adolescents find positive ways to calm their mind, such as yoga, drawing or painting, walking the neighbors’ dogs or learning to sew masks for friends and family to wear,” Dr. Rome suggests.
Although adolescents look to peers for support, direction should come from the parents. Physicians can use the same strategies to support parents during this stressful time or to counsel young patients when parental guidance is absent.
According to Dr. Rome, an authoritative style is most effective.
“Authoritative parents are lighthouses that provide a safe harbor and a way to reach it. They guide, encourage and step in when there are issues involving morality, ethics or safety—which certainly describes COVID,” she says.
“Authoritative figures help adolescents navigate current challenges by figuring out where they are coming from and playing to their strengths.”
A conversation about the need to wear masks and practice social distancing might begin by asking the teen to explain why the rules are important to follow.
If the teen doesn’t think that seeing friends would be personally dangerous, Dr. Rome suggests using an example the teen can relate to expressed in a loving way.
“Say, ‘I know this is super hard for you, but (grandma lives with us/I’m considered an essential worker/your sister is in fragile health) and can’t afford to get COVID-19, so we are all living this way. It’s not how life is supposed to work, and I’m so sad it impacts your freedom,’” says Dr. Rome.
For adolescents to fall in step, their parents—and friends’ parents—must model the same behavior.
“A 9th or 10th grader may be seriously challenged by a parent who tells them to socially distance, especially if their friends’ families are not taking the order seriously. As a result, they may engage in risky behavior by acting out—for example, sneaking out on Saturday night—or acting in—staying home, but feeling depressed and engaging in self-harm or thoughts of suicide,” she explains.
Dr. Rome recommends having a discussion about how the personal and family sacrifices brought on by COVID-19 can be beneficial to the community. This could include explaining how low infection numbers protect essential workers and leave room in hospitals for other emergencies. Encourage empathy by emphasizing how differences in housing, education, employment and other areas can impact COVID-19 spread.
Invite the adolescent to be part of the solution by becoming a caring and productive citizen. “Solicit their ideas, such as practicing random acts of kindness, setting up Zoom sessions with grandparents or selecting food to donate to local shelters. These are projects that feed their soul,” she says.
Have them focus on the positive by taking time to share what they are grateful for.
And take time to laugh. “Laughter is a great tension reliever,” says Dr. Rome. “It’s just fine for teens to find something funny on YouTube and share it with you or watch a funny movie together.”
Since adolescents crave independence, give them some leeway.
“Arrange a schedule that ensures they get sufficient sleep, but also have plenty of time for online socialization, exercise or other pastime,” she says.
As a final note, Dr. Rome advises being supportive and inclusive.
“Ask them about their fears, respond with empathy and invite them to create innovative solutions. You may be surprised at how well adolescents respond.”
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