An Epidemic Within a Pandemic

Mental Health Issues in Children and Teens are Surging During COVID-19

In November, The White House called for improving access to mental health services and care for the nation’s youth, citing significant increases in the number experiencing moderate to severe anxiety and depression in recent years—and especially since the start of the pandemic.

At the same time, a “national emergency” in children’s mental health was declared by the American Academy of Pediatrics (AAP) the American Academy of Child and Adolescent Psychiatry (AACAP), and the Children’s Hospital Association (CHA). In early December, the U.S. Surgeon General issued an advisory to address the nation’s youth mental health crisis.

Anhdao Zabarsky, assistant program director of the Children’s Behavioral Health Initiative at CHD, said she and her team have indeed seen a dramatic increase of mental health issues among children and youth as COVID-19 subjected many young people to social isolation, loss of routines, and traumatic grief.

“We’re getting more referrals from many different providers, including local crisis providers, primary care providers, schools, and state agencies,” she said.

It’s no secret that those working in the mental health field across the country have seen a spike in the number people suffering from anxiety and depression related to the pandemic. The most notable impact, however, has been the rise in children and adolescents experiencing new or worsening mental health problems. The AAP pointed out that in 2020, emergency room visits for mental health reasons rose by 24 percent for children ages 5 through 11, and there was a more than 30 percent surge in visits for those between 12 and 17 years old. Since the start of the pandemic, Boston Children’s Hospital reported a 40 percent increase in admissions of children with suicidal thoughts or attempts.

“We’re indeed seeing an increase in anxiety and depression with adolescents in our In Home Therapy and Therapeutic Mentoring services,” said Zabarsky. “We see a lot of that in younger children too, but it manifests itself differently. Younger children will tend to be more clinging and there are more inattention issues. Parents are also noticing an increase in their children’s worrying and irritability.”

Increasing Family Stress

The explanations for this crisis are multifaceted—some are simple; some are more complex. Physical isolation, especially in the early part of the lockdowns, as well as ongoing uncertainty and fear, clearly took their mental toll, but less obvious has been the pressure put on parents as many have worked from home and at the same time fulfilled their role as caregivers. “That overload of responsibilities is still putting parents under extra stress, which can impact the family’s functioning, as well as the risk of emotional and behavioral problems among their children,” said Zabarsky.

The pandemic caused widespread disruption to in-person learning, which certainly increased family stressors. “Also, children function on predictability,” said Zabarsky. “Routines help them grow, develop, and learn. The social isolation at the beginning of the pandemic hit them so suddenly and hindered their ability to develop. For example, we’ve all heard that children fell behind academically because of COVID. But there was also a loss of formative social experiences. For children entering kindergarten, that was put on hold, and at that age they’re developing a lot of social skills. Now, they’re older, and they’re behind in that regard.” Consequently, teachers are now seeing self-centered behaviors—kids are having a difficult time taking turns, waiting until others finish speaking, working in groups, and displaying empathy. “Their development also depends on how much preparation for school they’re getting at home,” she said. “Parents who are really struggling—trying to balance the responsibility of working at home and parenting at the same time—may not have enough time to help with their children’s transition into school.”

During COVID, children and teens also missed important milestones, such as sports, music recitals, school plays, proms, and graduations. When talking about grieving a loss, many people think about mourning lost loved ones, but there other forms of loss can cause grief as well. “There were other ways to conduct these events, like drive-by graduations, but it’s just not the same,” she said.

Children’s Mental Health Before the Pandemic

Even prior to the pandemic, the rates of mental health concerns and suicide had been rising for at least a decade. By 2018, suicide was the second leading cause of death for youths between 10 and 24. In Massachusetts, the percent of adolescents reporting a major depressive episode increased by more than 22 percent from 2013 to 2017. Many children with mental health needs were simply not receiving care before COVID-19, and then the pandemic dramatically worsened an already growing public health issue.

According to the 2021 UNICEF State of the Word’s Children report, the problem is that for the last decade, too many children have had unaddressed mental health conditions—and across the globe, far too little commitment and investment has been made by governments to address these needs.

The opioid epidemic of the last several decades hasn’t helped the situation either. When parents with substance use disorder have unaddressed mental health concerns, that in turn has led to challenges with their children because many of them are unaware that their kids and teenagers need treatment.

Also, multiple studies have found a link between social media usage and increased mental health disorders. Too much time on social media has been linked sleep problems, impulsivity, risk-taking behaviors, body image issues, and low self-esteem—all potential threats to mental health.

“I think social media has a huge influence on children and their mental well-being,” said Zabarsky, “and in the past few years, the problem of cyberbullying has been brought to our attention.”

The Brighter Side

Not every outcome from the pandemic is dour news, however. Zabarsky saw children spending more time with their family members, “and many of them really enjoyed that—especially being together at meals,” she said.

With CHD’s ability to provide telehealth as a covered benefit in Massachusetts, Zabarsky has even seen some increased access to mental health services. “In delivering services to those who are economically disadvantaged, where lack of transportation used to be an issue, we were able to expand beyond our catchment area and help people who might not have been able to obtain services in person,” she said. In some cases, the challenge at first was providing family therapy in areas in which Wi-Fi service is poor. Also, maintaining a young child’s attention using telehealth is sometimes difficult. “With adolescents, some of them are ‘talkers,’ so they didn’t mind telehealth at all, but others would prefer to get off after 10 minutes and go play video games with their friends,” said Zabarsky. “Regarding the latter, using telehealth, we were not able to fully engage with many of those youth as we would if the therapy were in person.”

Zabarsky has high praise for her staff in getting incredibly creative during COVID. “They created virtual therapy rooms and added different therapeutic games they had found online, as well as some different physical activities, such as yoga,” she said. “The therapeutic mentor or clinician would actually engage in the activity with the youth. Our staff used different online sites—music and art—to encourage youth to use creativity to express themselves. It was really neat to see that develop.”

She also credits her staff with being adaptive, not only quickly switching from in-person therapy to telehealth, but also creating a communication system in which they shared resources. “They helped one another, connecting virtually and sharing ideas about how to engage with the people we serve,” she said. “They really hung in there. On top of all that, we were transitioning to a new electronic health records software.”

Zabarsky said the management team has done a superb job supporting staff during a stressful period that has seen a frenzied work pace and long wait lists for appointments as COVID continues to affect our communities. “Our supervisors have encouraged self-care among our staff, which is extremely important during this time,” she said.

Where do we go from Here?

Another challenge, Zabarsky pointed out, is the pandemic exacerbating the already dire national shortage of child therapists. “That will continue to impact the availability for people to access mental health services,” she said.

The AAP, AACAP, and CHA are urging policymakers to take several actions, including an increase in federal funding to ensure all families can access mental health care, an improvement in access to telehealth, promoting and paying for trauma-informed care services, and addressing workforce challenges and shortages so that children can better access mental health treatment.

While COVID made mental health issues worse, it also provided a teaching moment, highlighting a lack of capacity in the U.S. mental health care system. According to a 2020 report by the Kaiser Family Foundation, there are only enough mental health professionals in the country to meet 26 percent of the need of the population.

“There are so many things that need to be done to draw people in the mental health field,” said Zabarsky. “We all know that it’s hard work, and there is a high rate of burnout. I hope the government re-evaluates its commitment to the country’s mental health care system and we have more resources for children,” she said.

In the end, all children will not be socially, emotionally, and mentally affected by the pandemic equally—disruptions from COVID-19 will impact them to different degrees and in a variety of ways. Zabarsky is hopeful that the pandemic will not weigh heavily on children’s overall mental health in the long-term and manifest into significant problems later in life. “Children are resilient,” she said, “and I think with the right supports in place they’ll be able to work through many of these issues.”