Pediatric Mental Health in the Wake of COVID-19: Identifying Solutions

Sonia Nagy Chimienti, MD FIDSA

On January 1, 2022, the amerICan psyChOlOgICal Association (APA) Monitor on Psychology published its 2022 Trends Report, an outstanding 14-part report on emerging trends in mental health (1). One of the trends included was “Children’s mental health is in crisis”. This comprehensive report noted that two years into the COVID-19 pandemic, demand for mental health services amongst children and adolescents had reached “all-time highs”. Pre-pandemic data from the Centers for Disease Control (CDC) (2) indicated that almost 1 in 5 children suffered from a mental, emotional, or behavioral disorder, with only 20% receiving care for their mental health condition. Data collected in the period 2013-2019 (3) indicated that 20.9% of adolescents aged 12-17 had experienced a major depressive episode, and in 2018 and 2019, approximately 7 of 100,000 children aged 10-19 years died by suicide. The APA trends report cited a 2020 national survey coordinated by Children’s Hospital of Chicago (4) that queried 1,000 US parents about the impact of the pandemic on the mental health and well-being of their children. Seventy-one percent of the respondents indicated that the pandemic has impacted the mental health of their child, and 69% stated that the pandemic was the worst thing that had happened to their child. Data published in Morbidity and Mortality Weekly Report (MMWR) in 2020 indicated that mental health emergency department visits between March and October 2020 rose by 24% for children aged 5-11, and 31% for those aged 12-17, in comparison with data from 2019 (5). Since 2000, there has been a 4.5-fold increase in death by suicide due to ingestion in children aged 10-12 (6).

In September 2021, Dr. Arthur C. Evans, Jr., Chief Executive Officer of the APA, testified before the U.S. House of Representatives on this issue. His comprehensive written testimony, “Putting kids first: addressing COVID-19’s impact on children” (7), provided a compelling and sobering overview of the current state of mental health in our children, and highlighted ways in which we can act to help mitigate the long-term negative impact of the pandemic on the mental well-being of youth and young adults. Dr. Evans’ testimony indicated that a strategic, population health-based preventative approach would be critical to supporting children and their behavioral health needs now and beyond the pandemic. Moving away from traditional acute-care models and investing in resources that meet children where they – and their caregivers - work and play, can be effective and impactful. Specifically, increasing available mental health services in schools and in community health centers can improve access, focus on prevention rather than crisis management, and may help to prevent some acute decompensations. Inpatient services are currently not sufficient to meet the needs of children with mental health crises; many children wait for days if not weeks in emergency departments and on inpatient wards, awaiting the specialty care that they need.

Notably, Dr. Evans emphasized the importance of schoolbased mental health services, which have long been critical resources for children experiencing distress in school settings. The disruption of daily routines as a result of COVID-19-related hybrid and remote learning has disconnected children from trusted school-based resources. This has in turn deepened the profound negative impact of the pandemic on the mental health of this vulnerable population. Staffing of school psychologists is currently insufficient to meet the increased needs resulting from the pandemic. Specifically, Dr. Evans cites data indicate that school psychologists currently serve three times the number of recommended students. Numbers of providers from other specialties who might offset the need, including counselors and social workers, are also in short supply.

Children have struggled to learn and develop on a personal and social level during this period of distancing and isolation; some may have been grappling with the loss of loved ones and navigating grief and personal trauma experienced as a result of the COVID-19 pandemic. Time away from school and structured social activities may have led to increased time spent on social media, which could have in turn exacerbated feelings of isolation, stress, and anxiety and contributed to behavioral issues. Untreated, persistent mental health challenges in children could impact success in academics and completion of educational requirements. In the long term, we may witness profound impacts on employment and socioeconomic stability due to the dual pandemics of COVID-19 and mental health.

Looking forward, and focusing on how we can intervene, Dr. Evans’ testimony advocated for the Increasing Access to Mental Health in Schools Act (H.R.3572), supporting the development of partnerships between institutions of higher education and local agencies, thereby increasing the numbers of mental health professionals in school settings. He also highlighted the Mental Health Professionals Workforce Shortage Loan Repayment Act, (H.R. 3150) authorizing a student loan repayment program to help boost numbers of mental and behavioral health professionals choosing to work in schools and in Community Health Centers. An additional potentially effective program referenced in this testimony is the Comprehensive Mental Health in Schools Pilot Program Act (H.R. 3549). This initiative will seek to positively impact student well-being in poorly resourced schools by investing in a holistic approach to mental health programs, train ing school-based staff and educators to better support students through emotional intelligence training and trauma-informed support.

The APA 2022 Trends Report similarly highlights a variety of ways in which psychologists are working to address this crisis by focusing on schools and communities; advocating for increased school-based mental health resources, training educators to recognize crisis and trauma in children, and promoting resilience training in K-12 educators. The American Rescue Plan Act, which was passed in March 2021, provides $170 billion in school funding, which can be utilized to increase mental health services and staffing in school settings, focusing on prevention in addition to treatment. The APA 2022 Trends report highlighted a number of training programs and formal curricula in mental health that can be provided for school-based staff, to help educators build skills and serve as an additional resource for vulnerable children. Examples referenced include Yale’s RULER program (8) and Mental Health Primers (9), both of which provide curricula for educators, to cultivate emotional intelligence, recognize the warning signs of mental health crises, and help educators identify stressors and navigate the presence of anxiety and uncertainty in the classroom. Ultimately, the goals of these and similar initiatives are to decrease burnout in the K-12 setting, to support children and educators, and to potentially prevent escalation of classroom-based stress and anxiety.

Now, more than ever, in the wake of the COVID-19 pandemic, resources to support our teachers in their support of children is critical. Through the advocacy of organizations committed to the mental well-being of our children, through education and communication to break down barriers and stigma, and through the collaborative support of educators, families, and all healthcare providers, we can ensure that our children will emerge from this pandemic with the resources and support that show them that we care, and that we are invested in their long-term health and well-being, despite these profound challenges. +

Dr. Sonia Chimienti is Senior Associate Dean for Medical Education at the Geisel School of Medicine at Dartmouth, and former Vice Provost for Student Life at the TH Chan School of Medicine at the University of Massachusetts Medical School.

REFERENCES

1. Abramson A, 2022 Trends Report, “Children’s mental health is in crisis”, https://www.apa.org/monitor/2022/ 01/special-childrens-mental–health#:~:text=In a 2020 survey of,to happen to their child. Accessed June 5, 2022.

2. https://www.cdc.gov/childrensmentalhealth/access.html (updated 4/27/22, accessed 6/5/22)

3. Bitsko RH, Claussen AH, Lichtstein J, et al. Surveillance of Children’s Mental Health – United States, 2013 – 2019 MMWR, 2022 / 71(Suppl-2);1–42. https://www.cdc.gov/ mmwr/volumes/71/su/su7102a1.htm

4. https://www.luriechildrens.org/en/blog/childrens-mental-health-pandemic-statistics/

5. Leeb, R. T., et al., Morbidity and Mortality Weekly Report, Vol. 69, No. 45, 2020

6. https://www.usnews.com/news/health-news/articles/ 2022-03-15/suicide-rate-is-spiking-upwards-inpreadolescent-children

7. https://www.apa.org/news/press/releases/2021/09/ covid-19-children-testimony.pdf

8. https://ycei.org/ruler

9. https://www.apa.org/ed/schools/primer