The following is a transcript of an episode of From the Front Row: Student Voices in Public Health, the University of Iowa College of Public Health’s student podcast. In this final episode in our series on mental health, Alex talks with Dr. Laura Fuller, division director of the University of Iowa Department of Psychiatry and a clinical associate professor of psychiatry at the UI Carver College of Medicine. They discuss how the pandemic has affected the mental well-being of children, and Dr. Fuller shares some advice on how parents and caregivers can best help their children manage their mental health during this time.

Alex Murra:

Hello, everyone. Welcome back to From the Front Row, brought to you by the University of Iowa College Of Public Health. My name is Alex Murra, and if it’s your first time with us, welcome. We are a student run podcast that talks about major issues in public health and how they are relevant to anyone, both in and out of the field of public health.

Alex Murra:

Today, I will be chatting with Dr. Laura Fuller. Dr. Fuller is the UI division director of the Department of Psychiatry and a clinical associate professor of psychiatry at the University of Iowa Carver College of Medicine. Dr. Fuller earned her PhD and MA in clinical psychology from the University of Iowa and her BS in psychology at Iowa State.

Alex Murra:

Today, she is here with us to discuss how the pandemic has affected the mental wellbeing of children and share some advice on how parents and caregivers can best help their children manage their mental health during this time. Welcome to the show, Dr. Fuller.

Laura Fuller:

Thank you. It’s great to be here.

Alex Murra:

To start us off, can you tell us about your path to becoming a clinical psychologist and then why you chose to specialize in child psychology?

Laura Fuller:

Sure. I have had an interesting path to my current job. I think even when I was young, I knew that I liked helping people. I knew I liked kids. I’ve had jobs as a nanny and a lifeguard. I worked at a couple different daycares and things like that. I started out in college as a pre-medicine major, but then I realized how much I was enjoying my psychology classes, and so I switched majors. For those who don’t know what the path to becoming a psychologist is like, there’s a lot of school after your undergraduate degree. You go through and get a master’s and a doctoral level degree, and you complete an internship.

Laura Fuller:

Most people also do some post-doctoral hours because that’s how you get licensed. So I was nearly 30. By the time I became an actual licensed psychologist, I guess I was actually over 30, now that I think about it. My current job here at the U of I, also had an interesting path where after my post-doc here at the University Of Iowa hospitals and clinics, and pediatric psychology, I got a job out in Montana and I worked there for almost 15 years at a mental health center in a children’s school-based day treatment, and then at a children’s psychiatric inpatient hospital before I came back to Iowa in 2012.

Laura Fuller:

So it’s been an interesting and somewhat non-traditional path because I went away from the healthcare setting and did some different things and then came back almost 10 years ago now. So that’s not how everybody does it, but it’s been fun.

Alex Murra:

Yeah. I always think it’s so cool to hear about people’s career paths. It just shows there’s so many different ways to being in a wonderful position that you are in today. Moving into children’s mental health, I think a lot of people, well, they don’t really realize that children can experience mental health issues. Sometimes I’ve heard people just say like, “Oh, it’s just a phase or they’re just acting out,” or something like that. But studies have shown that as many as one in six children between the ages of six and 17 has a treatable mental health disorder. Can you talk about what are some of the common childhood mental disorders and why there are so many misconceptions surrounding children’s mental health?

Laura Fuller:

Sure. That was a great question. I think some of the most common disorders that we work with here in child psych include depression and anxiety, and attention deficit hyperactivity disorder, autism, obsessive compulsive disorder, post-traumatic stress disorder, and there are many others, but those are the top diagnoses that come to my mind when I think about what we do day in and day out. I think that some of the reasons why there are maybe misconceptions or a lack of recognition, there are several reasons. One, as you mentioned, sometimes it is hard to tell these things can sort of sneak up on you or on parents or families and become… At first they seem like just a developmental phase or just happening now and then. So it’s hard to tell when it actually slides into the realm of being a diagnosable type of disorder.

Laura Fuller:

I think it’s also that parents are busy with their own lives. They may have their own mental health or other issues that may make it hard for them to recognize what’s going on with their child, especially when it just seems like something that is happening with lots of people in the family. For example, I know a lot of families with ADHD, with many members who have ADHD and the parents sometimes just feel like that’s how everybody in the family is, but on the other hand, sometimes that makes them even more tuned into when it might be happening with their child.

Laura Fuller:

So it can go both ways. I think that another reason that there are perhaps so many misconceptions with children’s mental health, could be that there’s stigma. So along with that, there’s denial. People don’t want to put a label on it because parents or others may worry that that label will stick with the child for the rest of their lives or just naming it could make it real in a scary way.

Laura Fuller:

My hope is, and my belief is that things are getting better. I think that people are starting to really recognize that mental health is just like other aspects of healthcare. And we’re seeing that also in our society. For example, in insurance reimbursement. Most insurances now have mental health parity where mental health treatment is paid for as the same as health conditions like diabetes or high blood pressure, or anything else that you might have.

Alex Murra:

Yeah. I think it’s really lovely that some of the stigma is starting to slowly change. I’ve definitely heard more conversations surrounding mental health and the importance of mental wellness as well as physical wellness. When a child is diagnosed with a disorder and then is able to seek treatment, there’s many different types of treatment approaches. And one of the ones that I came across when I was looking at your work was collaborative problem solving. So what exactly is this approach and how have you used it in your work?

Laura Fuller:

Right. This is something I love to talk about. The original term was collaborative problem solving. The name has changed a little bit to collaborative and proactive solutions or CPS, as I often refer to it. It was developed by a psychologist who was at the time, he was at Harvard and Massachusetts General. His name is Dr. Ross Green. He developed it as an alternative to other types of more traditional reward and consequence treatments that have been the mainstay of psychological treatment, especially for kids with challenging behavior.

Laura Fuller:

More recently, we’re starting to think about it as kids with any kind of concerning behavior, not just challenging like behaviorally acting out, but any type of behavior that is of concern. And it is a non-adversarial, non-punitive approach. It has a strong research base. There are a lot of studies these days that are showing the efficacy of CPS in lots of settings. They’re using it in schools, not just in the US, but all over the world.

Laura Fuller:

They are using it in juvenile justice facilities. They’re using it on children’s psychiatric units, and just in regular family therapy. It is a treatment that sounds simple when you hear about it, but it does take some work and practice to get good at, first, seeing the children through CPS lenses rather than viewing them as doing things for attention or for escape or avoidance, thinking of the children instead as having lagging skills and thinking about the situations that keep coming up as being unsolved problems.

Laura Fuller:

So coming at it from that mindset is the first step in doing CPS effectively. Then you practice having lots and lots of proactive problem solving conversations that take a specific format, or you do things in a specific order so that the child knows that you are really trying to engage with them. You don’t have a solution that you’re going to shove down their throat. You’re going to try and figure out with them what they’re concerned about, let them know what you’re concerned about, and then come up with solutions that are truly kind of a win-win they work for both people.

Laura Fuller:

Through doing this process over and over again, over time, children do learn to think more flexibly about the things that are causing difficulties. They learn to consider a range of solutions. They learn to tolerate frustration better. So I really love this approach for people who are interested in learning more about it. There is an organization called Lives in the Balance, and there is a website called livesinthebalance.org. Just put all those four words together, Lives in the Balance and then .org.

Laura Fuller:

There are tons of resources, including all the research literature, citations, and books, and trainings, and examples, and podcasts, and paperwork teaching you about the approach. So that’s where I would recommend going or I would recommend reading books like The Explosive Child, Raising Human Beings, and Lost and Found. Those three are all by Dr. Ross Greene.

Alex Murra:

‘ll definitely have to check out that website and those books. I think it sounds like such a wonderful treatment approach, especially with this idea of just like centering the kids’ needs and building up their resiliency, making them better able to manage their disorder and whatever they’re struggling with. So we did touch on this a little bit, but thinking about stigma. We have discussed stigma in depth within this podcast series. And the context mostly of adult populations. So in men and then pregnant women. We’re wondering when we’re thinking about kids, are there unique context of stigma.

Alex Murra:

You talked about maybe the fear of what this would be if they had to grow up living with it and, what people would think about them. Then aside from what other types of stigma children can experience and what can we as professionals, or maybe even as community members do to continue to advocate for children who are struggling with a mental health disorder?

Laura Fuller:

Okay. That’s a lot. So help me out if I forget to answer some parts of this, but when I was thinking about a response to this question about whether or not children are subject to unique contexts of stigma, I thought of several things. I think that a lot of people do just think, “they’re just kids” and fail to recognize when things get more serious. In some cases, people are busy with their own lives, again, or they may have certain beliefs that get in the way. Children should be seen and not heard, or they’re too young to really know what’s going on with them.

Laura Fuller:

I also think that there are a lot of things that run in families. So there may already be stigma within the family that then continues to impact the child, whether it’s in a small town in Iowa or wherever and the families have all known each other forever. So the teachers at the school remember the mom or the dad when they were a kid and mom or dad’s mental health issues were unrecognized, and now they see the child as just being sort of the product of “bad parenting,” bad genetics or whatever. Sadly, I’ve heard that those terms used, and of course we don’t talk about kids and families that way in our clinic or in my thinking. But I have heard that kind of stigma talked about.

Laura Fuller:

I think that one big context of stigma for many children is school, right? That’s where kids spend a third of their time. And the children who are at risk because of being part of a racial minority group, or because they’re in special education or something like that, those kids are more at risk for not good outcomes like entering the school to prison pipeline, for example. There’s a lot of literature on that, that kids with special needs or who come from racial minorities are the ones who are suspended and expelled, and even being suspended or expelled once increases a child’s risk of entering the juvenile justice system kind of disproportionately.

Laura Fuller:

So the disproportionality in education is a big deal these days. In the literature, I know it’s being talked about locally here in the Iowa City School District. School is a big contest of stigma, but it can also be a big context of help. There’s a lot of school-based mental health going on. That’s one way to make sure kids are getting more of what they need through therapy and psychiatric services that are sometimes being delivered right in the school, which reduces the amount of transportation and remembering appointments and things like that, that extra burden that goes on families when they need to pick up their kid from school and take them to an appointment or do something extra when it’s right there in the school. That can be very helpful.

Laura Fuller:

I also think that kids, I guess, maybe stigma isn’t quite the right word, but kids are not adults. So they are also subject to not always being able to self-determine their own healthcare even if they feel strongly that there’s something that they need help with. They’re reliant on the adults in their lives to make that happen. So that’s another, I guess, impediment, maybe not a source of stigma, but an impediment to them getting help.

Laura Fuller:

So the other part of the question was how can we advocate for children who are struggling with a mental health disorder? I have several ideas there. I think that advocating for the child does involve listening to the child or adolescent and trying to clearly understand their concerns and sort of the context that they’re happening in. Helping the child or adolescent connect and get their needs met.

Laura Fuller:

We can help support them through expressing understanding, checking in, expressing concern, and also more tangible types of support if that is something that we’re able to do. Making sure to take them to their appointments, to be involved in their treatment, things like that. I think we also need to advocate for services. There’s a desperate shortage of services these days. So advocacy is really everybody’s job. I think the pandemic has something to do with it. Some practices closed. Some went to all virtual. Some kids just don’t do well with all virtual therapy and some types of therapies are hard to do virtually.

Laura Fuller:

So I think just advocating for there to be good availability, good training, and that a range of services, not just going from outpatient to inpatient, but having a range of supports and more availability in all communities and not just the big cities where there are a lot of providers. I will say also that even in the bigger cities there aren’t always enough. We have a long wait list for therapy in the child psychiatry outpatient clinic. And it’s my understanding that a lot of practices in town here in Iowa City also have long wait lists. There’s a huge need, and I think in the big picture that also points towards a need to keep training high quality providers in evidence-based types of treatments.

Alex Murra:

I actually just saw when I was checking my email this morning that there’s funding initiatives with the UI to try and create training resources and outreach programs. I think it was called like, I think it was the Iowa Center for School Mental Health, something like that. I’ll have to double check, but I saw that in my email this morning. I thought that was really interesting.

Laura Fuller:

Yeah, that’s correct. I know some of the people who are involved in that and it’s going to be a really cool thing.

Alex Murra:

So for the next question, we’re kind of moving on to the effects of the COVID-19 pandemic. It’s been going on for quite a while now. I think there’s a lot of people who are thinking about how the pandemic has altered the lives of children. So can you talk a little bit about what ways the pandemic has affected the mental wellbeing and health of children over the past year?

Laura Fuller:

Yes. I’m not an expert in this research, but there are certainly plenty out there talking about the effects of the pandemic on children’s mental health. I was looking at one article from US news and world report that was talking about in fall of 2020. There had already been a vast increase in the number of emergency department visits by children and adolescents. But at the same time, outpatient visits had declined. And that points toward there being less availability of the outpatient help that people need and maybe even a disruption in what they were getting. And that prompting an increase in emergencies in mental health.

Laura Fuller:

I think that there are a lot of reasons why access decreased. I was mentioning that a minute ago that some practices closed. They couldn’t figure out how to do therapy remotely or wanted to focus on other things or needed to focus on other things like taking care of their own children in their own homes and schooling them, et cetera.

Laura Fuller:

I think that some practices eventually shifted to telemedicine. There’s been a lot of positive feedback about that, but also for some people, it hasn’t worked as well. I think for example, for some young children who have very short attention spans, and if the therapy is focused on that child, it’s really hard to keep them engaged with a computer screen doing talk therapy for an hour.

Laura Fuller:

I think that also a lot of people have had fears of being in person, and some of those are well founded, I think at the hospital. For a while I was seeing people and I was wearing a mask and a face shield all the time and other people were wearing masks, all the people, all the patients who came here. In some ways that was super safe. We all stayed well this whole time doing those things, but it was an impediment as well.

Laura Fuller:

It’s hard to read facial expressions. It’s just hard to feel quite as normal with all of that personal protective equipment. But everybody was doing the best that they could. You think things are starting to get back to normal, but I don’t think that we know yet the full impact of how it’s going to turn out. There’s a whole series of articles from the US news and world report, and there’s a more recent one that came out in March of 2021 talking about how children’s mental health could be the next wave in the pandemic, the crisis of children’s mental health.

Laura Fuller:

I think that there have been a lot more diagnoses of things like anxiety and depression in children and adolescents. I think there’s some talk of this pandemic qualifying as another of those adverse childhood events or ACEs that we talk about that increase the risk for future problems, both in health and in mental health and also in things like job performance and lots of other areas of life.

Laura Fuller:

I also think that we are not going to know for awhile what the impact is going to be. We know that there have been health effects of just being on lockdown for so long. The things everybody talks about like the COVID 15 and the weight gain that a lot of people have had or the isolation and things like that that have made people feel more depressed, or the chronic worry about getting sick that have led people to feel more anxious. Kids missing out on school, especially the at-risk kids.

Laura Fuller:

So I think that there’s a lot that we will find out in the coming months and years about the longterm effects of all of this. But I do think that it will be significant. Also, you mentioned resiliency. I also think that people are resilient. I’ve seen many examples of that throughout this whole past year and a half. I have a lot of hope that many good things will come out of it. I also think that it would be naive to think that there won’t be some significant long-term mental and physical health effects and learning effects from the pandemic.

Alex Murra:

Yeah. I’ve heard people talking about the effects of just having kids, not being able to socialize with their friends and public school or being able to play on the playground. It’ll be interesting definitely to see the impacts of that and moving forward. You touched on this a little bit, but schools are starting to reopen. Hopefully in the fall, kids will be back in person for the most part. Do you think that there might be any other issues that might arise as children are trying to adjust to this new normal in school?

Laura Fuller:

Yes, of course. I do think that there will be other issues that arise. I think overall people are looking forward to children returning to school in person and all of the good things that will come from that. So I want to start on that positive note and say, “Yes, I think that that will be a really great thing that we will be able to hopefully do it safely.” We don’t know exactly what’s coming in the future with the talk of variants and all kinds of other things that could be happening. But I think we’ve learned a lot from this.

Laura Fuller:

So even if there are some bumps in the road, I do think that many good things are going to happen as the result of most kids returning to school in person in the fall. I think that some of the issues that arise, we’ve already talked about the chronic stress of the pandemic, the stress of families being cooped up together or feeling isolated.

Laura Fuller:

I I’ve heard many kids and teenagers talk about that. When they’re alone, they feel depressed and yet when they’re around people, they feel anxious. That’s a pretty common thing these days and it’s really amplified. I think those things are probably true all the time, but it’s really amplified right now. So those situations are stressful. The lack of mental health resources I think is going to continue to impact us.

Laura Fuller:

There will be a lot of schools saying, “We need help for our kids,” but there aren’t enough people and not enough resources to deliver all of what we need. I think that parents and families, some are still struggling with how to come out of this smoothly, how to help reassure their children, that things are safe, how to go back to work and just reintegrate in all those different areas of life. I think that’s happening a lot as we speak. It’s July 2nd and I think that those things are happening right now. They’re getting better, but they are hard.

Laura Fuller:

I think that the physical health impact, and for people who actually got sick, also the physical health impact of the illness itself, for some are pretty significant. So coming out of those things also will be impacting kids as they return to school. I think that we can’t forget how stressful this was for teachers, not just teachers, but all the people involved in education and working at the schools and in the school districts. So in some cases, people are feeling burnt out, very tired from the chronic uncertainty and so many changes. One after the other that had to be integrated and had to be made to happen even though we weren’t quite sure how to do them.

Laura Fuller:

I think another issue is that people are in such different places. Some people are still quite scared. They’re not sure what’s safe. They’re not sure what they’ve been doing that has helped keep them safe. So they want to just keep doing all the things so that they keep being safe. I think people with younger children who the adults in the family are vaccinated, but the younger kids can’t be yet. That’s stressful. I think that it will be helpful once there are vaccines for all ages.

Laura Fuller:

I guess I want to end on this question with my certainty that we’re headed in a good direction. I think that there is a lot of hope for things being better in the future. We’re just going to have to be attuned to what’s going on with people, try and help get them what they need. If some kids are more behind than others, we will have to figure out how to identify them and get them help. Many of them will probably be able to catch up pretty well over time. And there’ll be a smaller subset just like there always is who need more help and we’ll need to figure out how to deploy those services and how to pay for them.

Alex Murra:

Yeah. I also think there’s a lot of hope for the future. I think it’s lovely to see the things just slowly start to improve, people coming out. I had someone in my neighborhood had a little birthday party for the kid, and that was the first time I’d seen that in a year. But it was so lovely to see just these kids going out and doing normal children things. So what can parents or caretakers do to alleviate this stress that the pandemic has placed on their child?

Laura Fuller:

I have some ideas about that. Some of this will sound familiar. I would first say listen to your child and try to provide them what is needed. So if the child is saying, “I’m not sure what’s safe,” you could help educate them, help teach them ways that they have good habits that can help keep them safe. You have to do all of this, of course in age appropriate language. You’re not going to go into depth about research studies with a six-year-old, but to the extent that it’s appropriate. You’re going to try and listen and then try to communicate with the child, let them know what you know. Let them know what’s coming up, I guess.

Laura Fuller:

Help them sort of structure things, know what to expect. I think we all do better when we mentally prepare rather than when we’re surprised by things. I also think the communication with others, like communicate with the child, communicate with the school, communicate with other supports and resources so that everybody knows what’s going on. Then try to realistically reassure the child. Give them some information about when you know that things are pretty safe, when you know that certain healthcare practices work well at keeping people safe.

Laura Fuller:

Reassure them that there are people in a lot of places carrying on with their lives and seeing each other in person and doing okay. Reassure them in a realistic way. Teach an update. I think I kind of already said this. As you know more, you can also update the child about what you know, what you’re hearing from national organizations like the Center for Disease Control. Or a lot of kids know who Dr. Fauci is. You can maybe talk about that.

Laura Fuller:

I’m guessing that there’ll be a lot of Dr. Faucis out at Halloween this next year for trick or treating. I’m kind of predicting that will be a costume that’s popular. I also think just being patient, trying to see it from your kid’s perspective, modeling healthy behavior, modeling healthy handling of all of this goes along ways.

Laura Fuller:

So those are my main bits of advice for what parents and caretakers can do. I think we’ve all tried to keep things as normal as possible, but for a lot of us it hasn’t been. So just acknowledging that too and saying this has been a weird year, year and a half, and we are heading in a good direction and maybe even try and engage the child in predicting what they think will happen next. It’s kind of fun to hear what’s on their minds and what they think things are going to be like.

Alex Murra:

Thank you for all that advice for what parents and caregivers can do. So to finish off one of the questions we like to ask everyone is what is one thing that you thought you knew, but were later wrong about?

Laura Fuller:

So many things, Alex, but I thought of two things. One, I think when I started out as a psychologist, I didn’t have kids, and I think that I assumed I do more about what being a parent was like than I actually did. I have since learned some things about being a parent. Not that you can’t be a good psychologist, if you don’t have kids. I don’t think that’s true, but I definitely thought I knew knew more about parenting than I actually did when I didn’t have kids.

Laura Fuller:

The other thing that really struck me when I was thinking about this great question was that I thought I knew a lot more about diversity and multicultural things and what life might be like for someone who had a different background than me. And I will say that this whole past year and the Black Lives Matter movement, and a lot of the training and reading and things that I’ve done since then and talking with people has definitely made me realize how much I don’t know and how much I still need to learn in that area. So I appreciate that question.

Alex Murra:

That was a great answer. I think with both of those things, you can always read so much and, but you’re never really going to quite know everything. You’re never going to have that lived experience that those people have. So we got to listen to them and try and learn from them. Well, Dr. Fuller, thank you so much for coming on and talking with me about children’s mental health. I hope you enjoyed it. And I know our listeners will enjoy listening.

Laura Fuller:

Thank you so much. It was a real pleasure to be here. And I hope that what I’ve had to say is helpful.

Alex Murra:

That’s it for episode this week. Big thanks to Dr. Fuller for coming on with us today. This episode was hosted, written, edited, and produced by Alex Murra. This episode concludes our mental health segment on From the Front Row. That segment features an episode on men’s mental health and masculinity, an episode on women’s mental health and postpartum depression, an encore episode about delivering mental health services on a college campus, and this final episode about adolescent mental health.

Alex Murra:

Just because our segment is coming to a close does not mean mental health and talking about mental health just goes away. It’s okay not to be okay. I wanted to share with you an organization titled the National Alliance on Mental Illness, better known as NAMI. This organization has two different resources. One being a call-in helpline and the other being a text line, both with trained counselors to support you free of charge at a variety of hours of the day, the text line being 24/7.

Alex Murra:

We will post this information about this free resource in the description of today’s episode. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts, and SoundCloud. If you enjoyed this episode and would like to support the podcast, please share it with your colleagues. Our team can be reached at cph-gradambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Stay happy, stay healthy, and keep learning.