School closures. Family strains. Isolated and quarantined friends. Even when young people haven't directly experienced COVID-19, the pandemic has strained their mental health. Often severely.
Even before the recent wave of omicron-related cases, a coalition that included the American Academy of Pediatrics declared a national emergency in child and adolescent mental health. Its October statement reported "soaring rates of mental health challenges among children, adolescents and their families."
In December, U.S. Surgeon General Dr. Vivek Murthy addressed the crisis with a report that said young people face "devastating" mental health challenges.
All of it may leave parents asking some important questions.
Which kids are at risk?
"Kids and adolescents are going through a lot," said psychiatric epidemiologist Karestan Koenen, a professor at the Harvard T.H. Chan School of Public Health in Boston. Tweens and teens seem to have been hit especially hard.
"The biggest risk is any kind of prior mental health problem," including preexisting anxiety, depression or attention deficit hyperactivity disorder, she said.
The surgeon general's advisory spells out how youth from various racial and ethnic groups also are at increased risk. For example, Black youth were more likely to have lost a parent or caregiver to COVID-19 than their peers. Asian American, Native Hawaiian and Pacific Islander youth reported increased stress due to hate and harassment related to COVID-19.
What unique stresses are kids facing?
Kids lack the adult advantage of resilience during a crisis, said Dr. Rebekah Fenton, a Chicago pediatrician. "This may be, for many of them, the first big thing that they're living through."
Children may face "stress from either losing family members or the fear of family members becoming sick," she said.
But their worries also might not be obvious from an adult's vantage point.
Koenen recalls that when students were hurriedly sent home in March 2020 when the coronavirus was first spreading, the main concern of her son, then a seventh-grader, was the deadline for a project he was supposed to be working on in class.
Then there's the whiplash from different learning modes, Koenen said. "A friend of mine said his daughter started high school three times," bouncing between in-person, hybrid and remote learning, each with a different set of teachers and classmates.
The changes were especially rough on kids with learning disabilities, who might depend on the structure schools often provide, she said.
Youth also might absorb stress from their parents, she said, who struggled with their own jobs or how to manage at-home schooling.
What's the effect of all that stress and worry?
One global analysis of youth published in JAMA Pediatrics found that depressive and anxiety symptoms doubled during the pandemic, with 25% experiencing depressive symptoms and 20% experiencing anxiety symptoms.
Data from the Centers for Disease Control and Prevention found that in early 2021, U.S. emergency department visits for suspected attempted suicides were averaging 856 per week for 12- to 17-year-old girls and 196 per week for boys of the same age. That was 50.6% higher for girls and 3.7% higher for boys compared to the equivalent time period in early 2019.
"There are people who have never had experiences with mood issues like depression or anxiety that are now struggling with those things," Fenton said. "There's others who had them to a smaller degree that felt manageable but now are feeling them intensely enough that they need therapy and/or medication."
What should a parent watch for?
Stress and anxiety can take many forms. Fenton, for example, has seen kids who say their chest feels tight or they're having trouble breathing, or who had anxiety-related high heart rates and high blood pressure.
Problems are not always that clear, said Koenen, whose son is 14. She acknowledges it can be tough for a parent to distinguish normal adolescent moodiness from a problem that needs professional help.
For her, it comes down to how much their behavior is interfering with their day-to-day functioning. It would be normal, for example, for a kid who played sports to be bummed if games were canceled. And "it's normal for adolescents to want to spend a bunch of time alone in their room and stuff. But if they're even more withdrawn, or not eating, or expressing their own distress to you, then you should take that seriously," Koenen said.
Fenton's warning signs would include an adolescent who:
‒ is spending more time on their phone in a way that isn't about hanging out with friends;
‒ seems more sad or anxious, or has new physical complaints; or
‒ is developing anxieties around food or their bodies.
The American Academy of Pediatrics lists additional symptoms of distress at healthychildren.org.
How can a parent bring up concerns?
"You can always start by very openly asking about them and recognizing that a lot of these things don't have easy answers," Fenton said.
It's not about finding an immediate solution, but about listening, and "to keep lines of communication open so that adolescents can recognize that their parents are somebody who is there for them when they're ready to talk."
What else can a parent do?
Be supportive. New data published in the Journal of Adolescent Health suggests supportive relationships with family and friends, and healthy behaviors such physical activity and better sleep, may protect teens' mental health during the pandemic. A study in the journal European Child and Adolescent Psychiatry last July similarly emphasized the importance of good sleep habits, less screen time and connectedness to parents.
Also, Koenen said, parents should take care of themselves "because that will help our kids." One of the biggest predictors of depression and anxiety in kids is parents' own mental health and distress, she said.
The surgeon general's report offers online resources for youth, parents, professionals and educators. For someone in crisis, the National Suicide Prevention Lifeline offers immediate help at 800-273-8255 or suicidepreventionlifeline.org/chat. The crisis line telephone number is scheduled to be shortened to three digits – 988 – in July.
Koenen said mental health services are overloaded right now but your pediatrician is a good place to start. Many health insurance plans offer options for mental health services, which also may be provided through employee assistance programs. Accessing services by video or phone might be an option.
"My role is really just to listen first and see if there's any support that I can offer," Fenton said. An office visit often "is the first time that teens will tell me that they have been experiencing thoughts of suicide, or that they've been hurting themselves."
From there, she might talk about the value of therapy or medications.
Fenton also talks about the value of COVID-19 vaccination, which allows as much freedom as possible right now, and it relieves a significant source of stress.
And, she said, stay hopeful. She has seen patients who get support and are now thriving, or at least finding their way. "That's what encourages me," she said. "This does work."
Editor's note: Because of the rapidly evolving events surrounding the coronavirus, the facts and advice presented in this story may have changed since publication. Visit Heart.org for the latest coverage, and check with the Centers for Disease Control and Prevention and local health officials for the most recent guidance.
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