How to confront COVID-19's toll on kids’ mental health

Anxiety, depression, and self harm have all increased during the pandemic. Here's what experts say and what interventions are needed.

A small group of children play outside, while socially distancing, on the playground of a Manhattan elementary school on October 1, 2020.
Photograph by Craig Ruttle, Redux

Every day, Emily Herring meets with troubled kids: a boy who was tossed out of class after an angry outburst, a child whose parent died of COVID-19, another who is afraid of infecting her live-in grandparents. Sometimes she sits down with kids who just need to talk.

Herring is one of 101 mental health service coordinators who are building a pilot program in Alabama public schools that launched in October 2020. She and an intern provide services to 1,600 kids from kindergarten through high school in four Fairfield City schools. Sitting about 10 minutes’ drive outside of Birmingham, Fairfield City is a low-income minority district where students face violence and other challenges that are now compounded by the pandemic, she says. She likens the situation to an electrical short circuit.

Over the last year Herring says she has witnessed “a massive increase in depression, suicidal ideation, and self-harm behaviors.” The trend mirrors what parents and educators in both public and private schools have reported across the U.S.: The pandemic has taken a serious toll on kids’ mental health.

Experts have noted that mental health has become an epidemic within the pandemic for kids and adults. In a recent national poll conducted by C.S. Mott Children's Hospital46 percent of parents reported that their teenage child had developed a new or worsening mental health condition since the pandemic began, with girls more prone to anxiety and depression than boys. Three-quarters said their child’s ability to interact with friends had suffered.

With more than 730,000 documented deaths in the U.S., many teens are mourning the loss of parents, family members, or friends. Some kids have caregivers who are suffering from long-lasting COVID-19 symptoms. Some parents lost jobs, plunging families into financial hardship; many caregivers were—and still are—highly stressed, making them less available to help their struggling children.

“This has been a really rough road for kids and adolescents,” says Jamie Micco, a cognitive behavioral therapist at the Concord Center in Massachusetts.

The issues kids face continue to evolve as vaccines remain unavailable for those under 12 and families face new challenges in this next back-in-school chapter. But because of the pandemic, there has been a collective awakening about the importance of mental health to overall wellbeing, and it’s reducing stigma. People are talking about mental health on the phone, over dinner, on Zoom calls, and in places where not long ago, the topic would have been taboo. School districts have adopted mental health days, and some have built mental health awareness into their curricula, a step that could bring enormous lifelong benefits. Kids are also more open to reaching out for help.

“A lot of our students who would never seek help are coming to my office saying they're desperate,” says Herring. “Nearly every day I have students say to me, I've never told anyone that before.”

A shortage of mental health facilities

During the first year of the pandemic, mental illness among children and adolescents increased significantly around the globe, according to a recent analysis published in JAMA Pediatrics.

Pandemic-related disruptions bred anxiety and depression as daily schedules crumbled with the loss of sports, music, and other extracurricular activities and compounded by the absence of milestone events, such as birthday parties, proms, and graduations. Social isolation has been particularly tough on teens, who are at a stage in mental development when they are seeking independence from parents and companionship from peers. “It was definitely making them miserable,” Micco says.

Texting and social media proved a poor substitute for face-to-face connections. An endless stream of posts on Snapchat, Instagram, TikTok—where kids feel pressured to constantly put their best selves forward—sometimes devolved into cyberbullying. Eventually, some teens got sick of video calls and texting and not seeing people in person, “so kids would go longer periods of time without socializing,” Micco says.

Therapists and hospitals started seeing more kids in treatment for suicidal thoughts and attempts, as well more cases of girls who are cutting, burning, or otherwise harming themselves. In the U.S., suicide is now the second leading cause of death for 15- to 19-year-olds.

One in four parents of teens have sought professional help for their child, and many children have improved with treatment and adapted well to the new normal. But the pandemic has exposed a lack of options as hospitals and treatment centers have become overwhelmed.

“There's a clear shortage of qualified mental health professionals,” says Heather Potts, a child psychologist at Boston Children’s Hospital, “and the complexity of the cases we're seeing are definitely more severe than they were in the past.”

The need for services was so great that therapists and clinics had to shut down their waiting lists for new patients. Kids in distress flooded emergency rooms, which were seeing 31 percent more teens. Many languished there or on medical floors for days or weeks waiting for a bed in a psychiatric ward or treatment facility.

It’s an ongoing crisis nationwide, even in urban areas with greater capacity. Statewide, 174 children are currently stranded in Massachusetts emergency rooms. “I think we're going on almost a year now [at Boston Children’s Hospital] that we’ve been over capacity for kids who are waiting for an inpatient bed,” says Potts.

Back to school stress

This year, as more schools have opened up for in-person classes, some kids have said it's been a huge a relief to be out of the house and back with friends. But this transition has spurred a fresh round of mental health concerns.

Even the most eager kids are worried about being in large crowds, being behind in school, being out of shape for sports, or getting along with friends. Having to get up, get ready, and go to school instead of pulling on a T-shirt and plopping in front of a computer at home also created serious anxiety. “I think a lot of our students that had been virtual had barely left the house for 18 months,” says Herring.

Some kids still worry about catching or spreading the virus; infections among children remain high. About three in five parents of middle- and high-school students say their child would feel safer if most students and teachers were vaccinated against COVID-19.

For younger kids who can’t yet get a vaccine, pandemic restrictions like wearing a mask, social distancing, and not touching other kids on the playground are stressful.

Even schools that embraced mental health awareness before the pandemic have not been immune to the pandemic’s impacts. Mary Beth Ricks, director of the Montessori Bowman School in Palo Alto, California, was a teacher during the Columbine school shooting and 9/11 terrorist attacks. These experiences, along with early data on the pandemic’s effects on kids nationwide, raised a red flag for her that COVID-19 could spark a mental health crisis.

She instituted an online open call on Tuesday evenings for parents; most participated every week. A therapist still comes in every Wednesday to meet with students and teach classes. When their school reopened after four months of virtual learning, teachers were trained to recognize the early signs of anxiety and depression.

Despite small class sizes and careful attention to student’s emotional well-being, anxiety levels are higher than before, Ricks says. More girls have eating disorders, and generally there’s more anger. When she asks kids why they’ve yelled or used their fists, they often say they’re “tired of COVID.”

Kids’ social skills suffered during the long months in isolation, making even simple conversation feel awkward and working through conflicts more difficult. On top of that, our “stress buckets” are overflowing, Potts notes. “We only have so much cognitive capacity to manage things, and though many of us are trying to move on, there is this additional ‘new normal’ stress to manage.” She’s seeing a lot of irritability, defiance, and arguing.

Anger is armor, she says. "For some people, it feels safer to show anger over sadness and worry, which some of my kids call ‘weak emotions.’” Herring and her colleagues have also seen a dramatic increase in fighting this year across Alabama school districts.

“I guess all of that trauma has just built up, and I think it's coming out in aggression,” Herring says.

Innovative interventions and lessening stigma

Experts are especially worried about the pandemic’s long-term emotional fallout. Hoover believes that the worst is yet to come: The longer the trauma continues, the greater the impact. She also believes that stress and financial burdens will bring more family separation and divorce. There’s already evidence of greater substance abuse.

“I don't want to sound too doom and gloom, but without intervention, kids are going to suffer, and it's going to be long-term injury,” Hoover says.

Decades of research document the serious long-term consequences of chronic childhood stress. It can alter the structure of the brain and nervous system, which impacts learning, memory, decision-making, and more. For some children, it manifests in disruptive or aggressive behavior, poor grades, drugs or alcohol use, or a tendency to form unhealthy relationships. Stress can also cause lifelong health problems, from heart disease to cancer.

To counter this effect, many schools have brought in mental health support over the last year, says Sharon Hoover, a professor of child and adolescent psychiatry at the University of Maryland School of Medicine. That’s important, because 75 percent of kids get their mental health services in schools, and they're six times more likely to complete treatment and programs offered there.

Some states also have begun programs that use “social emotional learning.” The curriculum teaches empathy and responsible decision-making, and it helps children understand and manage their emotions.Some communities have trained teachers to weave these concepts through every subject. Teaching breathing and mindfulness helps students notice when their emotional thermometers or distress levels rise so they can practice calming techniques.

“Amid a global pandemic, it’s more important than ever to provide children with support and tools to build resilience,” says Vanessa LoBue, who teaches psychology at Rutgers University, Newark.

Some districts even evaluate social emotional development on report cards next to math and reading, says Hoover. Participation has also been shown to improve students’ grades by about 11 percent.

The federal Substance Abuse and Mental Health Services Administration funded training for every teacher in the U.S. to take a five-hour course on how to support students as they returned to school. Congress has allotted $190 billion over three years for schools to help students recover from learning deficits and support social emotional development. These programs are always necessary, though, and Hoover and her colleagues fear that this investment in mental health will disappear when this round of funding ends.

As their kids have struggled, some parents sought a behavioral therapist to work with their child one-on-one or in family therapy. Other more specialized therapy has been needed for specific problems such as self-harm. This private or group dialectical behavior therapy teaches kids how to regulate emotions and handle distress.

Another strategy that parents and teachers have employed is to give kids more exposure to nature, because time outdoors is correlated with fewer behavioral and emotional problems. (Also find out how silence can help kids’ mental health.)

The advent of telehealth counseling has been a small silver lining of the pandemic because it greatly increases access to mental health care, especially for rural and other underserved communities. It also makes therapy available to kids with working parents who can’t shuttle them to appointments: Kids can log on with their therapist from home. 

Editor's Note: This story originally misspelled the name of the Montessori Bowman School director. It is Mary Beth Ricks.

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