The Buzz This Week
Last month, the Centers for Disease Prevention and Control (CDC) released its latest Youth Risk Behavior Survey Data Summary and Trends Report, including survey data from a nationally representative sample of U.S. high school students from 2011 through 2021. Although a handful of metrics related to adolescent health and well-being showed improvements (such as self-reported substance use, risky sexual behavior, and experience being bullied), most of the data revealed disturbingly high increases in mental health challenges and negative experiences. Experiences of violence, depression or similar mental health concerns (feeling sad or hopeless), and suicidal ideation and attempts all worsened significantly. A separate study published in Pediatrics this past February found an overall 4% increase in suicide deaths in youths in the first year of the pandemic, with higher rates for certain cohorts, including a 20% increase for those age 5-12, for American Indian/Alaska Native youth, and Black youth.
Overall, more than 40% of high school students reported experiencing persistent feelings of sadness and/or hopelessness in the past year. For female high school students, the proportion was even higher at nearly 60%, and for LGBTQ+ students, it was 70%. More than 20% of high school students seriously considered attempting suicide, with higher percentages for female students (30%) and LGBTQ+ students (45%). The trends show that prevalence of those challenges have been rising steadily for a decade. Several metrics, such as persistent feelings of sadness or hopelessness in females, showed the largest uptick in rates between 2019 and 2021, which likely correlates with the onset of COVID-19, when young people’s lives were profoundly impacted by lockdowns, home confinement, social distancing, isolation, and drastic shifts to day-to-day schedules and activities.
A systematic literature review published in SAGE Open Medicine in 2022 looked at 35 studies of the mental health impacts of the pandemic, with more than 65,000 participants between the ages of 4 and 19, all conducted between December 2019 and December 2020. The review found that anxiety, depression, loneliness, stress, fear, tension, and anger were the most common mental health issues reported. Children and adolescents with psychiatric and/or developmental disorders (e.g., attention deficit hyperactivity disorder, lack of stress regulation, severe obesity, and chronic lung disease) were found to be especially vulnerable to the mental health effects of the pandemic.
In addition to those risk factors, a psychiatric epidemiologist at the Harvard T.H. Chan School of Public Health underscored the impact of access to resources. He noted, “initially everybody was stressed and anxious, but those who could work from home, who had enough devices, and had access to the internet, they coped and began to value having more time together as a family and got into a virtuous cycle.” Those who lacked access to resources or had parents or guardians who were not able to stay at home to support their children with home-based schooling and general coping fared worse during lockdowns. Per the Harvard psychiatric epidemiologist: “We were all in the same storm, but we weren’t in the same boat.” Other factors that contribute to the decline in youth mental health, preceding the pandemic and likely to continue well beyond, include the negative impact of social media and the increase in gun violence in schools, increasing anxiety among children and adolescents.
Longitudinal data has revealed racial and ethnic mental health disparities. Historically, rates of mental illness have been lower for people of color, but studies suggest that a strong stigma associated with mental illness in certain communities can lead to hesitation in discussing these challenges with clinicians, which translates into disproportionate underdiagnosis as compared to other racial and ethnic groups. In addition, barriers to accessing mental health care can exacerbate underdiagnosis. During the peak of the pandemic, there was a disproportionately high decline in mental health services utilization for Black, Hispanic, and Asian children compared to non-Hispanic white children.
Parents and teachers have been acutely aware of the impact of the pandemic on the children in their lives. A 2020 survey of 1,000 parents found that more than 70% said the pandemic had taken a toll on their child’s mental health, and 69% said the pandemic was the worst thing to happen to their child. A majority of respondents (64%) believe the pandemic will have a lasting effect on their child’s development, and nearly two-thirds believe mental health consequences will be greater for children than adults. A 2020 survey of 675 American Federation of Teachers (classroom teachers and paraprofessionals) found that only 15% felt comfortable or equipped to address the trauma and grief being experienced by their students related to the pandemic.
Appreciating that the pandemic has had a marked negative (and potentially lasting) impact on child and adolescent mental health, it is important to remember that these issues were present at high levels well before the pandemic. They will likely continue to be of concern even when the world fully moves into the post-pandemic “new normal.” Dr. Victor Fornari, Vice Chair of Child and Adolescent Psychiatry for Northwell Health, stated in an NPR interview, “Even prior to the pandemic, youth mental health has been a serious concern. And although it’s not as widely discussed, around 1 in 5 youth will experience at least one psychiatric disorder before the age of 18 if they are in good physical health and don’t have any developmental disorders…. If you have a chronic medical condition or a developmental disorder, that could be as high as 1 in 3, prior to the pandemic…. The base rates of serious emotional disturbances were already present, although often not spoken about, not identified…but the pandemic really dramatically increased those rates.”
Why It Matters
It’s possible that a portion of the continued rise in mental health challenges in children and adolescents is related to increased willingness to report mental health issues as the associated stigma has decreased. That would certainly be a positive trend that could lead to children getting the care and counseling they need at an earlier age.
However, significant access barriers for pediatric mental healthcare still exist. They include an inadequate supply of trained providers, a lack of preparedness and training for pediatric mental health screening and management, limited resources to invest in developing pediatric mental health programs in healthcare or in other community settings (e.g., schools), lack of policy support, and inadequate insurance. The imbalance between the supply and demand of mental and behavioral healthcare means many mental health specialists can accept cash payments only, which limits access to those who cannot pay out of pocket. Pediatricians and other primary care clinicians are often the first line of care for children and adolescents experiencing mental health challenges, and yet very few have the training or time to adequately diagnose and treat these patients.
The number of children who seek care at an emergency room for a mental health crisis increased by 24% for children ages 5 to 11 and 31% for ages 12 to 17 between January-October 2019 to the same period in 2020. But emergency rooms are not always staffed with specialists in pediatric mental health care. Furthermore, a recent study published in the journal Pediatrics found that without follow-up with a specialist after a mental-health related emergency visit, more than a quarter of children have to go back to the emergency room for additional mental health care within the following 6 months. But those follow-ups don’t happen about half the time. One of the authors, an emergency medicine physician, stated in an interview with CNN, “The emergency department is a safety net. It's always open, but there's limited extent to the types of mental health services we can provide in that setting. This really speaks to inadequate access to services that these kids need…. We know what a child needs, but we're just not able to schedule follow-up due to shortages among the mental health profession. They're widespread across the U.S.”
In fact, the CDC found that only 20% of children with mental, behavioral, or emotional disorders receive care from a specialized mental health provider. In order to get children the care they need and reverse the growing mental health crisis, a multi-pronged approach will be required. Some examples include:
- Integrating behavioral health and primary care. This involves partnerships and coordination between primary care and behavioral health specialists, to ensure that patients are screened for mental illness in a primary care setting, without overburdening primary care clinicians with having to learn an additional specialty. It is a model that has been shown to improve access to mental healthcare, though there is not good research to date to understand the level of adoption of these models.
- Expanding the number of people trained to screen and potentially care for children with mental illness. Several states (such as California, Ohio, and Oklahoma) are implementing a youth “system of care” philosophy, as was described in a new piece this week from The Commonwealth Fund. The approach is “community-based, family- and youth-driven, includes nontraditional partners (e.g., faith-based programs and housing providers) and that uses wraparound planning processes…[which is] an evidence-based model of care coordination that puts a family and young person at the center of a highly structured, team-based planning process. Services should reflect the cultural and linguistic needs of young people and their families, with staff who look and speak like the people they serve.” The idea behind this approach is to identify and help address mental health challenges before they develop into a crisis requiring an emergency room trip, especially given the aforementioned challenges in accessing mental health professionals on an outpatient basis in a timely manner.
- Targeting at-risk groups. Organizations can improve racial and ethnic mental health disparities and mental health care access inequities by identifying at-risk groups, pinpointing inequities in access to care or quality of care provided, understanding social determinants of mental health, and then putting programs into place specifically tailored for those groups.
Healthcare provider organizations can help lead the way with these changes, incorporating pediatric mental health service growth into their broader strategic plans, ensuring that sufficient funding is earmarked for mental health investment and support of daily operations, and engaging/partnering with local schools and community organizations to jointly address this crisis. Payers also play an important role: providing adequate payment that would enable provider organizations to grow and improve pediatric mental healthcare services. Finally, policymakers can help move that forward with reimbursement parity laws, which have been in place for almost 15 years but have not been well-enforced, and requiring certain minimum levels of coverage.
While another pandemic, ecological disaster, or other event that could have profound impacts on children’s mental health aren’t easily controlled, the rising next generation in the U.S. deserves better approaches and solutions, increased and equitable access to mental and behavioral healthcare, and a commitment from all involved stakeholders to solve this crisis.
American Physiological Association:
Children’s Mental Health Is in Crisis
Improving Children’s Behavioral Health
Editorial advisor: Roger Ray, MD, Chief Physician Executive.