A mental health checkup for children and adolescents, a year into COVID

A school year like no other is about to end. The weather is warming up. In many places across the United States, COVID case numbers have been dropping and continue to decrease, meaning camps and other summer outdoor activities can likely proceed.

Yet it's been a long road, one that's taken a significant psychological toll on children and adolescents in the short term. Emergency Departments (ED) are reporting more visits for mental health struggles, with admitted patients staying longer. Incidence of anxiety and depression have increased, exacerbated by the social isolation and loneliness induced by the requirement to stay away from all but a small circle of people.

"Big picture, it's been a really tough year," says Emily Becker-Haimes, director of the Pediatric Anxiety Treatment Center at Hall-Mercer, located at Pennsylvania Hospital. "We're seeing a lot more demand for services. We're seeing our patients take longer in treatment than they typically would have. There's a lot going on in kids' lives."

Though the long-term consequences aren't yet known, particularly given how the pandemic disproportionately exacerbated adverse childhood experiences, Becker-Haimes and other Penn experts remain cautiously optimistic. "Most kids are pretty resilient," says Sara Jaffee, a professor of psychology in the School of Arts & Sciences who studies the effect of stress on children. "It's likely that once things go more back to normal, they will not experience lasting and impairing symptoms."

Losing the safety nets

When schools closed their doors—some of which only reopened minimally or still haven't done so at all—it brought to light what many educators already knew: that these buildings offer children much more than just a place to learn.

They provide healthy meals for some, plus socialization opportunities and routine for all, Jaffee says. "Little kids need routine. Teens need routine. We all need some structure to our day, and the school day that provides that," she says. "This past year, everyone was just a little discombobulated."

Critically, the school setting gives adults outside the home a chance to watch for signs of abuse. "There was a lot of concern on the part of child welfare professionals about what would happen if teachers, who are mandated reporters, did not have eyes on kids at risk for family violence," Jaffee says. "There's been interesting data coming out on that." She points to a recent JAMA Pediatrics paper assessing call and text volume to the national child abuse hotline Childhelp.

In that study—a collaboration between Penn, Children's Hospital of Philadelphia (CHOP), and Arizona State University—the researchers found that immediately after quarantine orders and school closures began, Childhelp experienced an increase in calls and texts compared to 2019. That was followed by a significant drop in volume. By May 2020, calls had rebounded, and text messages were on the rise.

"Decreased exposure to school-based mandated reporters," the researchers write, "may have contributed to the initial call decrease."

Teachers and other adults at school are often the first to notice mental health problems in their students and can often facilitate initial treatment through the school or elsewhere. The same is true of primary care physicians, but many young people actually missed or skipped annual checkups during the pandemic.

That meant two important touchpoints disappeared, says Marcus Henderson, a child adolescent psychiatric nurse with Penn Nursing. "Children who would normally access a mental health provider in school, at an outpatient clinic or office, now more of those children are going to inpatient facilities or the ED," he says.

More ED visits

Polina Krass, an adolescent medicine physician at CHOP and Penn, and colleagues recently corroborated that finding in a study published in JAMA Network Open. The researchers collected data from nearly 11,500 ED mental health visits for the three-year period between Jan. 1, 2018, and Jan. 1, 2021, with April through December 2020 constituting "during the pandemic," for purposes of the study.

Specifically, they were looking for changes in factors like demographics, admissions, and length of stay both in the ED and once admitted, says Evan Dalton, a CHOP pediatric hospital medicine fellow who contributed to the research. The team found that for 5- to 24-year-olds, since the start of COVID, there's been an increase in the proportion of these visits for mental health conditions, an increase in the percent of these patients who require admissions, and longer stays overall.

The uptick in these visits aligns with a worrying trend Krass says has been happening for the past decade: More and more children are showing up in emergency rooms seeking help for mental health. The highest estimate she's seen is that these make up 9% of all adolescent ED visits.

Children and adolescents who require this kind of help end up at the hospital for a range of reasons. They're referred by an outpatient doctor or therapist, brought in by worried parents or emergency personnel, sent by a school. They also face a variety of challenges, including anxiety and depression, ailments that have both intensified for young people during the pandemic.

"We're having trouble getting kids the mental health help they need to prevent them from escalating to requiring a hospital stay," Krass says. "Our goal is to put ourselves out of business. Any Emergency Department visit by a patient for a mental health condition is a missed opportunity for earlier intervention."

"Different pandemics'

Part of the challenge in trying to protect and support young people's mental health during the pandemic is that no two have experienced it in exactly the same way. The Penn experts agree that home circumstances matter, perhaps above all else.

"Simply put, there were different pandemics for different kids and families," Jaffee says.

Children whose parents' jobs weren't at risk and could seamlessly transition to working from home, whose school districts provided them with equipment like a computer and some in-person socialization opportunities, they likely experienced stress but not trauma, according to Jaffee. "But if one or both of your parents lost their jobs, if your family was worried about being evicted, if people around you were getting sick, this was probably a pretty traumatic experience," she says.

That's likely because kids tend to mirror what the close adults in their life are feeling. "Kids whose parents are managing a little bit more comfortably also seem to be managing well, which fits with what we know," says Becker-Haimes. "Kids are little barometers and pick up what their caregivers do. If caregivers are having a hard time, that can impact kids having a hard time."

Put another way, "parents have been stressed," Henderson says. "When parents are stressed, their children see that and began taking on that stress."

Despite all of that, most children and adolescents will bounce back in the long run. That doesn't mean disparities that surfaced during the pandemic will not come into play, particularly for those who, pre-COVID, had already been experiencing housing insecurity, food insecurity, or financial instability, Henderson says. And those who have been bullied or who have social anxiety, some of whom likely felt relief at the school closures and lack of social situations, they'll face completely different obstacles altogether.

"We've all gone through a very difficult year. We all may experience strong feelings and emotions, and that's okay. We don't need to get rid of them, and we can learn to cope with them," says Becker-Haimes. That goes for the young people, too.