The Checkup

Emerging From the Pandemic With Acne, Facial Hair and Body Odor

Young people experiencing the body changes of puberty without being in school are facing a unique set of challenges. Here’s how parents can support them.

Credit...Janice Chang

A pediatrician friend saw a 10-year-old girl recently, for her yearly checkup. Like so many children (and so many adults) among us, she had gained a little extra weight over the past year, but she was fundamentally healthy. “The mom says to me, ‘You know, she’s very self-conscious, she’s developed over this last year, and none of her friends have, and it makes her so uncomfortable and it makes her sad,’” said the pediatrician, Dr. Terri McFadden, a professor of pediatrics at Emory University School of Medicine.

The child had been attending virtual classes, and she was worried about going back into the classroom looking different; her mother had tried to explain to her that different people develop at different rates, Dr. McFadden said, but “she just felt she wasn’t normal, she wasn’t like her friends.”

Most of the children in Dr. McFadden’s practice have been out of school for a full year, she said, and while many are eager to return to their friends, some are anxious about going back. Many have gained a significant amount of weight, which alone can make them worried about how they may be received by their peers. “School can be cruel,” Dr. McFadden said.

While some schools have already gone back to in-person classes, circumstances vary across the country. Many children in the public school system in Atlanta, where Dr. McFadden practices, have been at home for more than a year. Some may be returning to school in bodies that have morphed over months at home, and while classmates may have noticed certain developments like a cracking voice, acne or facial hair on Zoom screens, other changes will be much more evident in person.

“I definitely have seen a lot of people with a lot of weight gain and worry about going back,” said Dr. Holly Gooding, the head of adolescent medicine at Emory University School of Medicine. She always asks teenagers how school is going, she said, and nowadays, many of them say they’ll be going back in the fall. That presents an opportunity to ask more specifically about re-entry, she said, and open up the subject of body image.

Dr. Chanelle Coble, an adolescent medicine specialist at N.Y.U. Grossman School of Medicine, said that young people are experiencing the body changes of puberty without the supports they would usually get from their peer group, and that is part of the general stress of the pandemic year. In her New York City practice, Dr. Coble said that she has seen higher than usual rates of severe anxiety and depression, as well as disordered eating, including among 11-, 12- and 13-year-olds.

Some of these were children who gained weight early in the pandemic, and then, perhaps in reaction, started restricting their eating. In some, the weight loss has been so severe that they have stopped growing, or stopped menstruating.

“Puberty is a general time of angst for people,” said Dr. Jennifer Miller, a pediatric endocrinologist at the Ann & Robert H. Lurie Children’s Hospital of Chicago, and an assistant professor of pediatrics at the Northwestern University Feinberg School of Medicine. It’s a stage when adolescents tend to be sensitive about changes in their bodies and how others perceive those changes, and the anxieties of returning to school — or more generally to life after lockdown — make that more pronounced.

Dr. Jami Josefson, a pediatric endocrinologist at Lurie Children’s Hospital and an associate professor at Northwestern, said that going back to school after being out may be like seeing a relative you haven’t seen in a long time — there will always be comments about how the child has grown and changed.

Some children will be taller, some will be more developed, some boys will have changing voices while others won’t. “This is all a normal part of going through adolescence, but it might seem a little more sudden,” Dr. Josefson said.

Families should talk with children about how these changes are normal, about how everyone’s body changes, but not in unison. Dr. Coble suggested, “start with the basics, how are you eating, how are you sleeping?”

If your children have been truly isolated, think about helping them ease back in — perhaps by encouraging them to spend socially distanced time outside with one good friend. Pandemic or no pandemic, children and families need reliable information about puberty. Dr. Adiaha Spinks-Franklin, a developmental behavioral pediatrician at Texas Children’s Hospital and an associate professor at Baylor College of Medicine, sends families to Amaze.org, which has videos aimed at kids, and to the Healthy Bodies Toolkit site developed by Vanderbilt University.

Even in nonpandemic times, life is often harder for early developers, who remain emotionally and intellectually the same age as their peers, but who may look significantly older. Dr. Carol Ford, a professor of pediatrics and division chief of adolescent medicine at the Children’s Hospital of Philadelphia, said that the children who develop early always need more support, and that may be particularly true now, when the changes may be starker after an interval away. Parents need to be ready to have concrete and detailed conversations about issues like personal hygiene (yes, your sweat starts to smell different) and the developments still to come (menstruation, wet dreams).

Some adolescent specialists have raised questions about whether the emotional intensity of lockdown and the pandemic year may actually have contributed to early puberty; Dr. Spinks-Franklin said, “I’ve had quite a few of my girls start their periods during the pandemic.” She has wondered whether stress has had something to do with that, or whether it is just regular development.

One preliminary analysis out of Italy that was published in March suggested that referrals for early puberty in girls were significantly increased during the first six months of the pandemic, compared to the same six-month period of 2019. From March to September of 2020, 246 children, almost all girls, were referred to Bambino Gesù Children’s Hospital in Rome to be evaluated for suspected precocious puberty, compared to 118 during the same months of 2019. The authors raised questions about the possible links to stress, higher caloric intake and increased screen use, to be addressed with further research.

If you think your child might be developing too early, schedule an appointment for an in-person checkup, and ask their pediatrician to discuss issues of puberty and body image. After the 10-year-old’s mother brought up the subject, Dr. McFadden talked with her patient, reinforcing the message that the body changes of puberty are normal and healthy. She talked with the mother about speaking with the child’s teachers, “so there will be a cadre of folks looking out for her as she re-emerges into in-person school.” And she and the mother discussed the risks that can attend early development in girls, who may be taken for older than they are, or preyed upon.

Make sure that your child has clothes that fit her changing body and doesn’t seem to be popping out of too-short pants or too-tight shirts, which will draw attention to the changes. Talk about whether a child developing breasts wants to wear a camisole or bra. Talk through the logistics of getting your period at school, and make sure she knows where to go if she needs help or supplies.

Though Dr. Miller sees patients for puberty-related questions and problems, her own sense of puberty during the pandemic also reflects her experience as a parent. “We have an 11-year-old daughter who is emotionally a roller coaster,” she said. Her daughter’s school recently had the “puberty talk,” in person, and her daughter reported, “The best part was being in one room with all the girls.”

Her daughter then asked her pediatric endocrinologist mother why anyone needed to be a doctor focusing on puberty, Dr. Miller said, “Since all I do is talk about how it’s a completely normal thing for your body to go through.”