Social isolation and loneliness in children and adolescents came into focus during the COVID-19 pandemic. Even prior to that, though, surveys had found that 10%–20% of teens were struggling with isolation or loneliness. Social isolation occurs when relationships are interrupted, lost, or nonexistent, while loneliness refers to feeling alone or lacking intimate relationships (de John Gierveld J and Havens B, Can J Aging 2004;23(2):109–113; Ernst JM and Cacioppo JT, Applied and Preventive Psychology 1999;8(1):1–22). The two often co-occur, but a depressed child may have caring friends yet still feel lonely. Autistic children experience the same rate of loneliness as other children; however, some have no friends but do not experience loneliness (Schiltz H et al, Autism 2024;28(6):1471–1486). What is the impact of social isolation and loneliness on the children and teens we see? How can we address these issues in our patients?

Impact of isolation and loneliness on mental health

Socialization is important from an early age, and adolescence is a particularly sensitive period where peer interactions play a crucial role, influencing how teens navigate social situations and how they regulate their emotions in stressful settings (Somerville LH et al, Curr Dir Psychol Sci 2013;22(2):121–127). Social isolation and loneliness affect depression, suicidality, and cognitive performance in children and teens in the following ways:

• The odds ratio (OR) between loneliness and depression—in other words, the association between the two—is 1.32 in children and 2.05 in adolescents over 15. Generally speaking, an OR of 1 indicates no association between exposure and outcome, >1 suggests a higher likelihood of association, and <1 suggests a lower likelihood.
• The OR of suicidality in teens is 10.9 for those who suffer from acute loneliness and 18.89 for those with chronic loneliness.
• Feeling excluded is associated with mental health issues, including mood disorders and drug dependence (Calati R et al, J Affect Disord 2019;245:653–667).
• In one systematic review, social isolation was associated with impaired cognitive function, although the impact varies among studies (de Laia Almeida IL et al, Rev Paul Pediatr 2021;40:e2020385).

Social determinants

Social determinants, such as racism and the COVID-19 pandemic, contribute to feelings of isolation for many young people (Brandt L et al, Transl Psychiatry 2022;12(1):398). Young people who experience racism can feel that no one cares or that no one is able to help them. Elevated feelings of isolation following the pandemic are associated with anxiety and depressed mood in children and teens (Orben A et al, Lancet Child Adolesc Health 2020;4(8):634–640).

How to assess your patients for ­isolation and loneliness

• Talk to children and teens about whether they feel lonely or isolated. Do they feel connected to parents, peers, etc? Do they experience pleasure connecting? What does it mean to them if they feel isolated or lonely? Do they blame themselves? Others?
• Seek reports from parents and teachers. Use nonjudgmental language, eg: “Different kids are more, or less, connected to the people around them. Tell me about your child’s/student’s levels of connection to others.”
• Consider using scales to assess loneliness vs social isolation. Options include the UCLA Loneliness Scale (www.tinyurl.com/nh9fnnv3), or the UCLA 3-Item Loneliness Scale if time is limited. The Social Network Index is a 12-item scale that assesses contact ­networks.
• Ask about co-occurring social anxiety disorder, depression, suicidality, and neurodevelopmental problems.

Interventions and therapies

Tailor your recommendations to the child’s developmental level. Consider the pros and cons of nurturing existing relationships (including digital ones) vs trying to increase the number of people your patient knows.

For social isolation

• Younger children may respond better to play-based approaches.
• Older children and teens may benefit from didactic lessons and role-playing. The latter can help them feel more comfortable with back-and-forth interactions and banter.
• Several programs for children and teens with social communication challenges or autism use natural symbolic play (eg, DIR®/Floortime™, The PLAY Project). These programs are founded on principles of child development and can facilitate interaction and connection with typically developing children as well.

For loneliness

• Help children and teens identify their feelings.
• Gently challenge cognitive distortions associated with loneliness.
• Consider mindfulness-based therapy to help kids and teens learn to tolerate painful emotions (eg, accepting the feeling of being “different” without judgment).

For both

• In the office, use a Wait-Join-Build approach to responsive care: Give your patients time to tell you how they are doing, join them in talking about their ideas, and build solutions to problems without dominating the conversation.
• Involve parents, caregivers, teachers, or siblings in tracking isolation, loneliness, or other symptoms, and (where developmentally appropriate) in facilitating social activities for the child or teen.

For autistic children

• Many autistic children benefit from community activities with like-minded peers or social skills groups. These can be held in the community, with time afterward to review what went well and what to work on.
• UCLA’s Program for the Education and Enrichment of Relational Skills (PEERS) has produced meaningful and enduring gains in social function (Laugeson EA et al, J Autism Dev Disord 2012;42:1025–1036).
• There are promising pilot results for Winner’s social cognition approach (Crooke PJ et al, J Autism Dev Disord 2008;38:581–591).

For autistic children, wearable smart devices may help them understand facial expressions and social cues, reducing social isolation and loneliness. Technology can be a helpful intervention for all children and teens experiencing these issues.

Using technology

In 2021, Santos et al measured social isolation during the COVID-19 pandemic, noting how “active” video games such as Wii Sports and multiplayer dancing games increased interaction. Encourage connection rather than consumption (eg, excessive scrolling of social media or short videos) with:

• Cooperative gaming and tech-related hobbies with like-minded peers
• Video chatting for face-to-face ­interaction and associating facial expressions with verbal cues

When speaking with parents

You can offer the following advice:

• “Your child learns about connecting and relationships from you. Take time with your child, explore their interests with them, and make time for your own friendships and activities.”
• “Reach out to your child’s school and ask about your child’s social connections. Work with staff to facilitate social connections in class, at lunch, and on the playground. Enroll your child in activities with schoolmates.”
• “Teach your children to manage conflicts using ‘superpowers’: not taking things personally, listening to everyone’s perspective, and speaking up when someone is being mean.”

CARLAT VERDICT

Check whether social isolation or loneliness is driving depression and other problems in children and teens. Help parents and caregivers such as natural symbolic play, cooperative gaming, and role-playing.