The state of mental health amid the pandemic and school reopening

Current research

Mental health care visits

Health care visits offer a concrete look into the state of children’s mental health during the pandemic. They also offer insight into the uncertainty around the true scale and the causes of pandemic-related mental health issues. Such data is obtained from emergency department visits and health insurance data.

Emergency department visits. While the overall number of emergency department visits for children was down during 2020, the proportion of children’s emergency department visits related to mental health rose sharply in 2020—by 24% for children ages 5 to 11 and 31% for ages 12 to 17 (Reference: Leeb et al., 2020). CDC researchers interpret this to be a result of mental health stressors during the pandemic, combined with unintended effects of school closures and lockdown measures limiting access to regular mental health care.

Health insurance claims. Health insurance data showed a similar trend. While all medical claims for children ages 13 to 18 significantly decreased through 2020, the proportion of mental health claims dramatically increased. Notably, the proportion of medical claims for self-harm, overdoses, and generalized anxiety disorder nearly doubled during the first two months of the pandemic (Reference: FAIR Health, 2021). FAIR Health researchers interpret the trend of an increasing proportion of mental health insurance claims as a sign of the impact of mental health issues during the pandemic.

Both studies point to widespread mental health issues in children across the US. However, these data likely do not represent the range or gravity of mental health issues among all children, such as those with low access to health care, or children who may have sought care outside of a hospital for mental health emergencies. These studies also can’t explain how or why the proportion of mental health care visits increased.

Cross-sectional national research

Much of the existing research on the state of children’s mental health during the pandemic has been in the form of cross-sectional national surveys. In such surveys, children across the US (and/or their parents) were asked to reflect on their mental health. Sometimes they were asked to compare their present mental health to their mental health prior to the pandemic.

In May 2020, a study by researchers from University of Denver and Washington University in St. Louis found that children enrolled in urban schools were experiencing academic, mental health, and physical health hurdles (Reference: Scott et al., 2021). During this period, a survey by Harris Poll and 4H found that two-thirds of teens thought that the pandemic would have lasting mental health impacts on their generation (Reference: 4-H & The Harris Poll, 2020). When asked specifically about stressors related to the pandemic, over 40% of teens cited the inability to see people in person, online school, and being stuck at home with family. And 61% said the pandemic increased their feeling of loneliness.

In June 2020, national survey research indicated widely varying mental and behavioral health impacts of the pandemic, with 1 in 7 parents reporting worsening behavioral health for their children since the pandemic began. A study by Vanderbilt and Northwestern researchers also found an association between the experience of worsening physical health and behavioral health. (Reference: Patrick et al., 2020).

In a Fall 2020 Challenge Success survey, adolescent students in remote, hybrid, and in-person schooling reported that their stress had increased compared to Fall 2019, especially in terms of academic pressure (Reference: Challenge Success, 2021). During this time, a JED Foundation survey found that nearly a third of parents reported that their child’s mental health was worse than before the pandemic. Further, a majority of teens were concerned with preparing emotionally for school, their personal sense of safety, their physical health, and their mental health (Reference: The Jed Foundation, 2021). A survey by Common Sense Media, Hopelab, and the California Health Care Foundation found that social media use during the pandemic was both a key coping mechanism as well as a source of negative mental health impacts (Reference: Rideout et al., 2021).

In January and February of 2021, the EdWeek Research Center found that nearly two-thirds of high school students attending class completely in person reported more problems in school than in January 2020, with nearly three-quarters of hybrid and remote students reporting the same (Reference: Student Mental Health During the Pandemic: Educator and Teen Perspectives, 2021). The Trevor Project’s 2021 survey found that more than 80% of LGBTQ youth reported that COVID-19 made their living situation more stressful, and that only one-third of LGBTQ youth reported being in an LGBTQ-affirming household (Reference: The Trevor Project, 2021).

Overall, these surveys engage participants in ways meant to provide insightful national snapshots of children’s mental health at different points in the pandemic. However, they likely do not represent the experiences of children in communities facing mental health disparities, who may not have been reachable by typical phone or online outreach, or whose mental health issues may have prevented them from responding. They also do not provide insight into variation in mental health at more local levels, like cities or counties.

Local cross-sectional research

Nearly half of the Chicago parents surveyed by Northwestern University researchers between November 2020 and February 2021 talked with their child’s primary care doctor about mental health concerns in the past year, and 44% percent reported an increase in mental health symptoms in their children, ages 2 to 11, compared to before the pandemic (Reference: Davis MM, Heffernan ME, Smith TL, Bendelow A, Bhatti PK, Macy ML, Cicchetti C, 2021).

Longitudinal survey research

Longitudinal research follows the same survey participants over time. Such research can provide insight into children’s mental health trends over the course of the pandemic and provide direct comparisons of mental health status before and during the pandemic. This method provides richer insight into trends over time compared to snapshots of different populations at different times. For example, a Canadian study of adolescents found that depression and anxiety scores during the pandemic were higher than predicted based on 2-year mental health trajectories (Reference: De France et al., 2021).

In the US, a few mental health studies have been published that tracked the same youth over the first few months of the pandemic. A study by University of Houston researchers found that among children ages 10 to 14, those with mental health issues before the pandemic had reduced issues during the first couple months of the pandemic (Reference: Penner et al., 2021). In a study of youth in Long Island between March and July 2020, anxiety and depression symptoms increased in the first month of the pandemic and peaked in April before decreasing, paralleling COVID-19 infection rates (Reference: Hawes et al., 2021). The Stony Brook University and Temple University researchers found that school concerns were associated with more severe anxiety and depression symptoms.

These longitudinal studies suggest that students may have experienced the pandemic very differently depending on their mental health state prior and the course of infections locally.

Health equity lens

Though data speaking to the experiences of hard-hit communities are scarce, national surveys highlight inequalities in mental health amid the pandemic. For example, among children age 12 to 17, ED visits for suspected suicide attempts were 50.6% higher among females in winter 2021 compared to the same period in 2019, whereas among males, these ED visits increased only 3.7% (Reference: Yard et al., 2021). In survey research, girls and children of color consistently stood out as populations potentially experiencing more mental health symptoms and more stress during the pandemic.

It is also important to remember that mental health issues can interact with other lingering health problems, as access to health care has been limited during the pandemic, especially among children of color, children in rural areas, children with special needs, children in families with low incomes, and those in families of mixed immigration status (Reference: McMorrow et al., 2020). As such, student needs as they return to schools in the fall (and beyond) may differ unjustly based on pre-existing social inequities.

Unanswered questions & next steps

Throughout the pandemic, medical experts have anticipated a long-term wave of pandemic-related mental health issues as people deal with the impacts of death and loss in their community (Reference: Simon et al., 2020) and as children feel the long-term effects of financial loss, academic setbacks, and lack of access to regular mental health care (Reference: Fegert et al., 2020). To this end, there is a need for long-term research to understand the true impact of the pandemic on children’s mental health. This includes risks that may interact and compound over time, as well as sleeper effects that may not be immediately observable (Reference: Wade et al., 2020).

Amid the uncertainty of the variation in children’s current mental health issues and the long-term impacts of the COVID-19 pandemic, school leaders and educators must anticipate children’s mental health needs as they prepare for a return to in-person learning this fall. This will require optimal funding for staff like counselors, therapists, and social workers. It will also require research and networks of practice to share lessons learned as school communities find ways of nurturing students’ mental health in real time.

References

4-H, & The Harris Poll. (2020). Teen Mental Health. Harris Insights and Analytics.  

Challenge Success. (2021). Kids Under Pressure: A Look at Student Well-Being and Engagement During the Pandemic. Challenge Success.

Davis MM, Heffernan ME, Smith TL, Bendelow A, Bhatti PK, Macy ML, Cicchetti C. (2021). Youth Mental Health in Chicago During the COVID-19 Pandemic (No. 3; Voices of Child Health in Chicago Report., Vol. 3). Ann & Robert H. Lurie Children’s Hospital of Chicago.

De France, K., Hancock, G. R., Stack, D. M., Serbin, L. A., & Hollenstein, T. (2021). The mental health implications of COVID-19 for adolescents: Follow-up of a four-wave longitudinal study during the pandemic. The American Psychologist.

FAIR Health. (2021). The Impact of COVID-19 on Pediatric Mental Health: A Study of Private Healthcare Claims. FAIR Health.

Fegert, J. M., Vitiello, B., Plener, P. L., & Clemens, V. (2020). Challenges and burden of the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality. Child and Adolescent Psychiatry and Mental Health, 14(1), 20.

Hawes, M. T., Szenczy, A. K., Olino, T. M., Nelson, B. D., & Klein, D. N. (2021). Trajectories of depression, anxiety and pandemic experiences; A longitudinal study of youth in New York during the Spring-Summer of 2020. Psychiatry Research, 298, 113778.

Leeb, R. T., Bitsko, R. H., Radhakrishnan, L., Martinez, P., Njai, R., & Holland, K. M. (2020). Mental Health-Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic – United States, January 1-October 17, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(45), 1675–1680.

McMorrow, S., Gonzalez, D., Caraveo, C. A., & Kenney, G. M. (2020). Urgent Action Needed to Address Children’s Unmet Health Care Needs during the Pandemic. Washington, DC: Urban Institute.

Patrick, S. W., Henkhaus, L. E., Zickafoose, J. S., Lovell, K., Halvorson, A., Loch, S., Letterie, M., & Davis, M. M. (2020). Well-being of Parents and Children During the COVID-19 Pandemic: A National Survey. Pediatrics, 146(4).

Penner, F., Hernandez Ortiz, J., & Sharp, C. (2021). Change in Youth Mental Health During the COVID-19 Pandemic in a Majority Hispanic/Latinx US Sample. Journal of the American Academy of Child and Adolescent Psychiatry, 60(4), 513–523.

Rideout, V., Fox, S., Peebles, A., & Robb, M. B. (2021). Coping with COVID-19: How young people use digital media to manage their mental health. Common Sense and Hopelab.  

Scott, S. R., Rivera, K. M., Rushing, E., Manczak, E. M., Rozek, C. S., & Doom, J. R. (2021). “I Hate This”: A Qualitative Analysis of Adolescents’ Self-Reported Challenges During the COVID-19 Pandemic. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 68(2), 262–269.

Simon, N. M., Saxe, G. N., & Marmar, C. R. (2020). Mental Health Disorders Related to COVID-19-Related Deaths [Review of Mental Health Disorders Related to COVID-19-Related Deaths]. JAMA: The Journal of the American Medical Association, 324(15), 1493–1494.

Student Mental Health During the Pandemic: Educator and Teen Perspectives. (2021). EdWeek Research Center.  

The Jed Foundation. (2021). National Survey: Youth Well-Being During COVID-19. The Jed Foundation.  

The Trevor Project. (2021). 2021 National Survey on LGBTQ Youth Mental Health. The Trevor Project.  

Wade, M., Prime, H., & Browne, D. T. (2020). Why we need longitudinal mental health research with children and youth during (and after) the COVID-19 pandemic [Review of Why we need longitudinal mental health research with children and youth during (and after) the COVID-19 pandemic]. Psychiatry Research, 290, 113143.

Yard, E., Radhakrishnan, L., Ballesteros, M. F., Sheppard, M., Gates, A., Stein, Z., Hartnett, K., Kite-Powell, A., Rodgers, L., Adjemian, J., Ehlman, D. C., Holland, K., Idaikkadar, N., Ivey-Stephenson, A., Martinez, P., Law, R., & Stone, D. M. (2021). Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12–25 Years Before and During the COVID-19 Pandemic — United States, January 2019–May 2021. Morbidity and Mortality Weekly Report, 70(24), 888–894.