Youth Mental Health in the Wake of the COVID-19 Pandemic

Abstract

Objective

In this article we examine the current state of youth mental health across the United States and in Delaware, and discuss the impact of the COVID-19 pandemic on the mental health and well-being of children and adolescents.

Methods

We review available literature detailing the short- and long-term effects of the COVID-19 pandemic on youth mental health and discuss the resultant programmatic and legislative efforts in Delaware and nationally.

Results

The COVID-19 pandemic had a severe impact on the mental health of young people. The prevalence of depression and anxiety among children and adolescents, which was already increasing pre-pandemic, spiked after the pandemic’s onset. Even as public health precautions have lifted, young people continue to struggle with mental health in conjunction with lower levels of educational achievement, hindered social development, increased screen time, diminished access to effective mental healthcare, and economic instability. The negative impact of the pandemic will continue to have ramifications on the health and wellbeing of young people for years to come.

Conclusions

Compiling evidence examining mental health trends is an important first step to understanding the impact of the pandemic on child and adolescent mental health and developing effective solutions.

Policy Implications

Although the official state of emergency is over, the effects of the COVID-19 pandemic are far-reaching and long-lasting. It is imperative that legislators and program administrators in Delaware and nationally work to ensure that young people and their families have access to affordable, high quality mental healthcare.

Introduction

It has been more than four years since the COVID-19 virus began to spread in the United States and one year since the federal public health emergency expired. Efforts to mitigate the spread of the virus included stay at home orders, school closures, and shutdowns of many public spaces nationwide. In addition to the deleterious impact on physical health, much of the population also experienced negative impacts on mental health. Young people are particularly vulnerable to these disruptions in development and have continued to experience the mental and social ramifications of the pandemic more acutely than older adults.¹

Pre-pandemic, mental health was already declining among young people, with feelings of hopelessness or sadness increasing by 40% among high school students between 2009 and 2019.² The pandemic heightened these issues: according to one survey, 71% of parents reported the pandemic took a mental health toll on at least one of their children, and 64% believed the pandemic will have lasting developmental impacts.³ More than two years into the pandemic, 40% of parents said they were extremely worried about their child struggling with anxiety or depression.⁴

In the months following March of 2020, emergency department visits for mental health reasons and suspected suicide attempts increased among young people nationwide, and these visits remained elevated through the pandemic’s second year.⁵ At Nemours Children’s Hospital in Delaware, the number of patients over 12 reporting suicidal thoughts and requiring observation more than quadrupled during the first year of the pandemic.⁶

As a result of this public health crisis, the American Association of Pediatrics declared a national state of emergency in child and adolescent mental health and the U.S. Surgeon General issued an advisory on protecting youth mental health.^7,8 In May 2022, several government agencies including the Centers for Disease Control and Prevention (CDC), the Centers for Medicare & Medicaid Services (CMS) and the Administration for Children and Families (ACF) released a joint letter on children's mental health encouraging states, tribes, and jurisdictions to prioritize mental well-being of children.⁹

In this paper, we explore how the ramifications of COVID-19 —social isolation, increased screen time, threats to physical health, economic instability, and reduced access to care—impacted the mental health and wellbeing of young people nationwide and in Delaware.

Social Isolation

Many children and young people have networks of friends, classmates, and adults outside of their immediate family that they rely on for socialization and support. Lockdowns, mandatory isolation after exposure to the virus, and fewer activities outside of the home removed children from these extended support networks. Although individuals of any age may experience the harmful effects of social isolation, research suggests that children and adolescents are more susceptible to experiencing depression and anxiety during enforced isolation and after it ends.¹⁰ In one survey, more than half of parents reported that a lack of socialization during the pandemic compromised their child’s mental health.³

Periods of social isolation often go hand in hand with loss of routine and missed milestones by reducing the necessary interactions that form a child’s social development. Incidences such as this may have a major impact on the health-related quality of life (HRQoL) of young people, which involves an individual’s perception of their own mental and physical health functioning.¹¹ When considering interventions to address the mental health challenges faced by young people, it is imperative to consider the ways in which mental and physical health intersect.

Remote Learning and Educational Achievement

To keep students, teachers, and staff safe during the pandemic, school systems in Delaware and nationwide adopted remote or hybrid learning models. In addition to the challenges of a new learning environment, many students struggled with the resultant isolation from their peers and teachers. Although students made overall gains during and after the onset of the pandemic, these gains—and overall achievement levels—have remained lower than expected.¹² Students of color and students at high-poverty schools are disproportionately impacted by this achievement gap. Delaware students in grades 4-8 achieved 56% of expected growth in 2023, with low-income students experiencing the least amount of growth (52%).¹³ Although some recovery has been made, students are still catching up to learning missed during the pandemic.

Remote learning led many students to feel isolated from their school communities. During the 2020-2021 school year, more than one in five students reported feeling disconnected from their classmates and school community, and 29% felt disconnected from school adults.¹⁴ This disconnect can negatively impact mental well-being, as students who feel connected to people at school are less likely to experience poor mental health and persistent feelings of sadness and hopelessness.¹⁵ A survey of parents from October and November 2020 found that children in a virtual learning environment experienced greater negative impacts on physical activity, time outside, time spent with friends in-person, and physical and mental health than children in hybrid or in-person learning environments.¹⁶

Educational staff and administrators had to make many challenging but necessary decisions throughout the pandemic to keep school communities safe. It is necessary to emphasize the importance of remote learning as a public health tool for mitigating the spread of COVID-19, and to note that not all students have negative experiences with remote learning environments.¹⁷ As Delaware moves forward in continued recovery from the COVID-19 pandemic, it’s important for leaders in education to consider the benefits and risks of educational approaches for each student’s individual learning style.

Screen Time

As remote learning and virtual socialization peaked in the early stages of the pandemic, the overall screen time for adolescents, including time spent on computers, phones, televisions, or video games, drastically increased. Children were more likely to experience an increase in screen time than adults, especially children aged 6-10 who had the highest increases in total screen time out of any age group during the pandemic.¹⁸ Older children experienced similar increases in screen time, and data from May 2020 show that 12- and 13-year-old adolescents spent 7.7 hours a day on non-school related screen time, which is more than double the pre-pandemic estimate.¹⁹

Screen time has continued to remain high even as public health precautions have been lifted.²⁰ In 2023, 23% of fifth graders in Delaware spent more than five hours a day in front of a computer, phone, or television screen, not counting screen time needed for school.²¹ These high levels of screen time can have adverse effects on young people. Research has shown that excessive screen time for children and youth is associated with a variety of physical and mental health issues including unhealthy diet, depressive symptoms, and perceived stress.²² These findings emphasize the importance of mitigating unnecessary screen time and encouraging participation in alternative activities, such as in-person socialization and time outdoors. Promisingly, interventions to decrease children’s time spent in front of screens—particularly those involving the components of goal-setting and self-monitoring—have shown effectiveness in screen time reduction.²³

Health and Well-Being Concerns

Children are less likely to become severely ill with COVID-19 than adults, representing just under one in five COVID cases since the beginning of the pandemic.²⁴ However, severe cases are still possible, particularly for children with comorbidities including chronic respiratory and cardiovascular diseases.²⁵ The fear of catching the virus, or dealing with the impact of illness in themselves or family members, can be a stressor for young people. During the pandemic, more than half of adolescents aged 13-19 reported heightened levels of concern about their own or their families physical and mental health.¹⁴ In one survey of public schools, 20% of schools reported that students with, or in families with, a high-risk medical condition were more likely to seek out mental health services.²⁶ Dealing with the anxiety of getting sick, or the loss of a loved one, may critically impact a child’s mental and emotional well-being.

Economic Instability

Many young people have either experienced or witnessed family and friends endure a myriad of economic challenges during the COVID-19 pandemic. Financial instability can have lasting effects, as adolescents from families experiencing greater economic hardship are more likely to suffer from long-term impacts to mental health as a result of the pandemic.¹²

To combat widespread economic hardship during the pandemic, many safety net measures supporting families and children were expanded during the public health emergency. The free school meal program made meals available to all children through the 2023 school year,²⁷ the Supplemental Nutrition Assistance Program (SNAP) provided an emergency allotment to expand families’ food budgets,²⁸ Temporary Assistance for Needy Families (TANF) increased cash benefits,²⁷ and Medicaid expanded eligibility, enabling recipients to stay enrolled even if they did not meet previous guidelines.²⁹ However, all of these increased benefits ended between February and June 2023, leaving many families without supports they had come to depend on. The unwinding of these program expansions may mean that many families are experiencing increasing food and financial insecurity, which can be a major stressor for adults and children alike.

Access to Care

Although mental health issues among young people have risen throughout the course of the pandemic, many parents and children have faced challenges accessing the care they need. As the U.S. healthcare system struggled to meet demand at the start of the pandemic, some services were unavailable or halted completely. Between February and October 2020, the number of child Medicaid/CHIP beneficiaries receiving mental health services dropped by 50%.³⁰

Concerns about access to effective mental healthcare have continued to persist several years into the pandemic. In an April 2022 survey, 70% of public schools stated that the rate of students seeking mental health services has increased during the pandemic, though just 56% agreed that they are able to effectively provide mental health services to all students in need.²⁸ Barriers to access for mental healthcare can include availability to appropriate providers, cost, parental reluctance, long waiting lists, lack of insurance coverage, and cultural stigma.^28,29,31 While telehealth visits may reduce some of these barriers, in-person visits are important for many children who may not have the private space or quality of internet access necessary to have a virtual visit with a mental healthcare provider.

Specifically for youth who identify as LGBTQ+, a 2022 survey by The Trevor Project of young people ages 13 to 24 showed that many desired mental health care but did not access it. Factors limiting access included fear of discussing concerns, worries around obtaining permission to access care, fear they wouldn’t be taken seriously, affordability issues, concern their identity would be misunderstood, and a lack of transportation.³² It is imperative that mental health supports meet the needs of all adolescents, regardless of race, ethnicity, sexual or gender identity, or economic status.

Discussion

As schools have resumed in-person learning, educators and administrators have recognized the need for increased mental health services among school aged children, resulting in programs and legislation to expand existing and new infrastructure. Nationwide, schools are working towards acknowledging and adapting to student challenges. Twelve states currently allow students to take a certain number of mental health days as excused absences.³³ Additionally, teachers across the country are working to better understand the signs of mental distress among their students and establishing regular check-ins as part of their classroom routines.³⁴

Policymakers in Delaware have continued to work towards increasing access to youth mental health services. The state passed House Bill 301, requiring the establishment and implementation of statewide mental health educational programs for each grade, kindergarten through grade 12, in each school district and charter school in this State.³⁵ Moreover, Governor Carney has signed bills expanding access to school counselors.³⁶

While mental health services are vital to ensuring the needs of children and adolescents are met, it is necessary to note the importance of security in all areas of life for young people. For many adolescents, meeting basic needs such as security of family relationships, a safe and stable home environment, the availability of nutritious food, and financial stability, can majorly impact their overall wellbeing.¹³ Children experiencing adverse childhood experiences (ACEs)—which include forms of abuse, neglect, and household instability—at home during the pandemic were significantly more likely to have poor mental health or a suicide attempt in the past year than children without ACEs.³⁷ In order to address the mental health crisis, Delaware must continue to focus on increasing the overall quality of life for children throughout the state.

Conclusion

The ramifications of the COVID-19 pandemic will continue to impact children’s health and development for years to come. With this in mind, is important to have tools in place to track the experiences of families and youth so their needs can be met. Tools such as the Household Pulse Survey³⁸ will continue to collect data to quantify family experiences during the coronavirus pandemic, with data reported close to real-time. The National Survey of Children’s Health³⁹ works to capture detailed health data, with trends to analyze before, during, and throughout recovery from the COVID-19 pandemic, and the Youth Risk Behavior Survey (YRBS) captures a variety of mental and physical health data from students in Delaware and nationally.⁴⁰

The data from these surveys and research tools are vital in order to formulate effective services to aid young people in their continued recovery from the COVID-19 pandemic. Providing children and their families with the mental, physical, and emotional support they need is paramount to ensuring the well-being of Delaware’s children throughout the public health crisis and beyond.