The Impact of the COVID-19 Pandemic on Adolescents: An Opportunity to Build Resilient Systems

Abstract

The impact of the COVID-19 pandemic on adolescents is significant. Educational progress and mental health, in particular, have been negatively affected. Among youth from vulnerable communities, pre-existing academic and health disparities have been exacerbated. Youth outcomes are often attributed to individual resilience – or lack thereof; in this paper, we describe how failure to adapt and effectively cope at the system level (i.e., lack of system resilience) is implicated in the current dual educational and mental crisis. We describe opportunities to make our systems more nimble and better-equipped to support youth moving forward.

Media reports have highlighted the stress, social isolation, school disruptions, and mental health consequences adolescents have experienced due to the COVID-19 pandemic. Those of us who work with adolescents, families, educators, and mental health providers hear about the impact of the pandemic in our day-to-day work, including stories of intense trauma and loss, declining mental health, changes in housing, and economic and family stress. Research echoes personal stories; demonstrating pandemic-related impacts across multiple domains including school, family, activities, peers, physical and mental health.^1–7

As a guiding framework to understand the diverse and broad-reaching impacts of the pandemic on adolescents, we draw on an ecological systems-based conceptualization of resiliency. Resilience is defined as the “capacity of a system to withstand or recover from significant disturbances that threaten its adaptive function, viability, or development;” the definition can be applied to individuals and to larger systems.⁸ Critically, resiliency in youth is not an individual skillset or trait. Rather, adolescent health, wellness, and ability to cope in the face of adversity are predicted not only by individual-level characteristics, but also proximal and distal influences across ecological layers.⁹ These include parental support and guidance, positive peer relationships, school and classroom climate and culture, family economic resources, and a range of community factors such as neighborhood environment, systems of support (e.g., faith communities, sports, social activities), and community resources and services.¹⁰ In the current paper, we apply this resiliency lens to highlight the 1) impact of the pandemic on adolescent well-being, 2) impact of the pandemic on key systems of support (mental health and education), and 3) strategies for creating adaptive systems to more effectively foster resilience in adolescents.

Impact on adolescent well-being: Mental health and educational outcomes

The mental health impact of the COVID-19 pandemic has been widely covered; in particular, increasing rates of depression, anxiety, eating disorders, and suicidal thoughts and behaviors among young people have received broad attention and calls for action.^2,3,11–14 Information on the educational impact of the pandemic is also beginning to emerge; in our work, we have heard school personnel describe students who have reached 11^th grade with no experience taking high school-level tests, wide variability in academic skills among students at the same grade level, an increase in physical fights, and students struggling to maintain daily routines and social norms that previously would have been taken for granted. Student absences nearly doubled during the first part of the pandemic¹⁵, with low-income, minority students most likely to miss school, further exacerbating existing educational disparities.^15,16 Recent reports also highlight significant declines in academic performance in math and in reading, especially among students in high-poverty schools, who were likely to have spent more time in remote learning due to living in communities with high levels of COVID-related risks.^17,18

The factors that contributed to the exacerbation of mental health and educational issues concerns among youth during the pandemic are myriad. For many, social isolation had a significant negative impact. Loneliness has been highlighted as one of the consequences of the pandemic;¹⁹ both the intensity and duration of feelings of loneliness have been associated with more severe symptoms of depression and anxiety.^11,20 Given the developmental importance of peer relationships for adolescents,^21,22 they may be especially susceptible to negative effects.

Without the option for in-person socializing, time spent on social media increased for most youth.²³ Although social media use among youth has received a lot of negative attention, the role of social media is not purely positive or negative for most youth.²⁴ During times of strict quarantine, social media provided a crucial connection and support network. However, social media also creates opportunities for bullying and comparisons with peers that contribute to feelings of inadequacy and even suicidal ideation.^25,26 During the pandemic, aspects of which became highly politicized, online activity also contributed to conflict based on differing beliefs.²⁶

Another consequence of prolonged reduction in-person socialization is that many young people missed out on opportunities to develop important social skills. Research has shown that isolation during the pandemic may have increased the risk of social anxiety¹ and many adolescents expressed fears about returning to in-person activities.²⁷ Related, significant time spent avoiding COVID-19 infection – and with it – other people, has contributed to other anxiety symptoms (e.g., avoiding public places, contamination concerns) which can result in real impairment, including school refusal and ongoing social isolation that requires intervention.³

Youth well-being has also suffered due to lost opportunities to be involved in community activities. ⁴ Most school extracurricular activities and community programs were canceled or moved online early in the pandemic.¹² Some never returned to the pre-pandemic format. These activities are often important sources of self-confidence for young people and aid in identity formation.^28,29 Activities also provide youth with opportunities to socialize with peers who share their interests and – importantly – to develop relationships with adult mentors. For vulnerable young people, especially those from economically-disadvantaged backgrounds, positive role models can protect against potential risk factors.^30–32 Positive role models are associated with higher academic achievement and lower rates of delinquent behavior; loss of these relationships may have contributed to recent increases in school dropout³³ and reckless behaviors.^34,35

Systems-level impacts on adolescent mental health and wellness

The pandemic has also been a test of the resiliency of our child-serving systems, which in turn directly impact on adolescents’ ability to cope and adapt effectively. Schools and mental health providers made remarkable shifts to virtual teaching and service delivery, and many engaged in unprecedented outreach to support families. However, it is also evident that despite these efforts, our systems’ capacity to adapt and respond has been insufficient. Moreover, in both its immediate effects and in our ongoing recovery, the pandemic has disproportionately affected people who were already coping with the consequences of racial and socioeconomic disparities. These communities have experienced higher disease burden and COVID-related stressors,³⁶ unequal access to instruction, internet, and devices,^37–39 greater declines in educational outcomes,¹⁸ and greater difficulty accessing mental health care.⁴⁰

Unfortunately, existing mental health services were already taxed before the pandemic started; a 2021 report from the Surgeon General of the United States noted that, in the decade prior to 2020, rates of hopelessness and suicide increased significantly and that nearly 20% of youth met criteria for a mental health disorder.⁴¹ Among young people affected by a mental health concern prior to the pandemic, a majority did not receive treatment.⁴² There are a number of reasons for low service utilization among this population, including costs and logistical barriers, discomfort accessing and navigating service systems, stigma, and privacy concerns.^42–44 Youth of color are among those least likely to receive mental healthcare.^44,45

During the pandemic, the majority of mental health services moved to virtual formats.⁴⁶ For some patients, virtual care was a poor alternative,⁴⁷ and could be challenging to access for people who may have had limited access to the necessary technology and/or struggled to find privacy.⁴⁸ For others, the move to virtual formats was beneficial, increasing convenience and access to providers outside of one’s immediate area.⁴⁹ Therapists also varied in their response to moving to a virtual format; although some were able to effectively adapt, others felt ill-equipped to maintain the same quality of care virtually.^50,51

As the mental health consequences of the pandemic grew, waitlists ballooned and providers widely reported feeling overworked and burnt out.⁵⁰ More than two years into the pandemic, months-long waiting lists persist, especially for youth.⁵² Even before the pandemic, the number of mental health providers for youth was insufficient and waiting lists were common,^53,54 now it can be impossible to find an opening for outpatient care. Unfortunately, people placed on waiting lists often deteriorate and/or drop off before receiving care.⁵⁵ Increases in the number of psychiatry emergency visits for children⁵⁶ and greater severity of symptoms among youth inpatients² may be direct consequences of the lack of access to quality outpatient mental health care.

In addition, schools, which have long played an important role in providing access to mental health care,^57–59 either by providing direct services or facilitating access to care, were stretched thin trying to provide remote learning and could not offer anything “extra” – like mental health care. Related, schools traditionally provide many other vital services, including access to food, physical education, and an array of other social and community supports for students and their families. As the pandemic has continued, teacher shortages, burnout and secondary traumatic stress, and ongoing disruption due to staff and student illness have plagued districts’ efforts to return to “normal.”^60,61 Sadly, districts serving families most in need of additional supports, are most at risk for these pandemic-related consequences.^62–64 Figure 1 summarizes the multi-level impacts of the COVID-19 pandemic on adolescent well-being.

Figure 1.

The impact of the COVID-19 pandemic on adolescent well-being across ecological levels adapted from Bronfenbrenner (1979)

Building systems to support adolescent resilience

To better support adolescent resilience moving forward, our systems need to be more flexible and grounded in models of public health and educational prevention and intervention science. Predominant models from public health and education call for tiered systems for organizing prevention and intervention efforts.^65,66 These models start with efforts to address broad factors that impact population health (e.g., social determinants of health), universal approaches for creating contexts that promote wellness and educational success (e.g., school climate, community engagement), targeted intervention or prevention efforts (e.g. teacher consultation, support groups), and intensive services (e.g., mental health treatment, special education services). Applied to adolescents, prevention and intervention efforts should be guided by science and solutions should take an ecological (i.e., context-focused) approach. Although individual-level support is necessary, viable solutions must take into account interactions between adolescent-level variables (e.g., skills, symptoms) and environmental variables (e.g., chronic stressors, classroom/school climate), rather than conceiving of the challenges as problems that lie within students themselves.⁶⁷ Effectively shifting away from a focus on resiliency at the individual level to build more flexible and resilient systems will require new research; although we know a lot about how to support youth, a better understanding about how best to implement supports across systems and to address barriers within existing systems is necessary for youth supports to have the intended benefits. While far from comprehensive, examples of practices that could begin to address these issues across levels follow and are summarized in Figure 2.

Figure 2.

Sample practices to support adolescent resilience across tiered systems of prevention and intervention

Universal supports in schools.

An increasing number of schools across the country are using programs and practices that promote social emotional learning (SEL)⁶⁸; SEL programs have been linked to both academic success and mental health promotion.^69–71 Along with SEL skills (e.g., stress management strategies, self-regulation), culturally responsive teaching and educational practices can promote equity and begin to reduce educational disparities.^72,73 In addition, trauma-informed school models that increase focus on the impact of trauma on learning and foster educators’ skills in being responsive to the needs of students exposed to adversity can be especially beneficial in communities with high rates of trauma exposure.^74,75 Together, these approaches can foster resiliency in youth by emphasizing positive teacher-student and peer relationships, creating supportive classroom and school contexts that promote students’ sense of belonging and connection, and enabling students to engage effectively in their academic work.

Support for educators, counselors, and other support staff.

During focus groups conducted in the gulf coast region following Hurricane Katrina, school counselors and mental health staff reported having to take on a wide range of unexpected roles and responsibilities, at a time when they themselves were highly impacted.⁷⁶ Training in evidence-informed approaches to help students who have been traumatized or otherwise negatively impacted by the pandemic is crucial to helping to mitigate feelings of incompetence or being overwhelmed. Teachers, school counselors, clinicians, and other staff also need support services for managing their experiences of trauma and loss, and for processing the secondary traumatic stress that can come from working with children who have experienced trauma.^77,78 In addition, across settings, organizational leadership, guidance for teachers and mental health staff, and organizational support for self-care is critical for reducing burnout and fostering a strong professional community.^79–81 Rather than waiting for the next crisis, communities need to introduce training and support now, so that school personnel feel competent and prepared when next called on to support students in these ways.

Targeted student academic and mental health supports.

For adolescents who are struggling with school engagement, academic progress, anxiety, depression, or behavioral challenges, several models of intervention and targeted support may be helpful. For example, supportive, high frequency, ongoing contact, is a key mechanism in Check and Connect programs to improve school attendance⁸² and caring contact models of suicide prevention. ⁸³ Similar approaches may also be effective at targeting other youth concerns, but have not been tested. Approaches that target teachers and families can also promote academic engagement, address behavioral challenges, and build school connectedness. For example, teacher consultation models help teachers implement classroom and individual supports for students, culturally responsive classroom management strategies, and SEL programming – which, in turn – benefit students.^84–87 In addition, family engagement interventions that seek to build home-school connections and provide parenting strategies for adolescents increase school engagement and emotion regulation skills, while also reducing substance use risk.^88,89

To further support students, schools could screen for mental health symptoms such as anxiety, depression, traumatic stress, and grief. Many youth experiencing mental health symptoms will not seek help on their own,^42–44 but by providing feedback on symptoms (i.e., letting them know the severity of their symptoms based on screening checklist scores) and making referrals to school-based health centers, district mental health staff, or outside agencies, schools can make it easier for youth engage with care.⁹⁰

Innovation in mental health services to increase access and reach.

The mental health workforce is both insufficient in number and inadequately trained.⁹¹ Youth of color and those from economically disadvantaged backgrounds are disproportionately affected by lack of access to high-quality care.⁹² Significant investment to both recruit and train mental professionals to work with youth and families is necessary ensure that all youth in need have the opportunity for evidence-based care. Alternative models of care should also be considered; research on task shifting and community service provision shows that individuals with master’s-level education or even those without an advanced degree can deliver evidence-based assessment and intervention. Crisis call lines, which support people in acute need, are often staffed by well-trained volunteers. Family peer advocates can play an important role for parents in navigating complex systems of care.⁹³ Many people are motivated to help those experiencing mental health concerns – it can be a rewarding line of work – especially if the barriers to entry were reduced. Further, compensation models that fairly pay for these services must be implemented; insurance companies reimburse for psychotherapy and assessment services at a rate that falls well below market value and are less likely to reimburse for therapy/counseling than for psychiatry, despite psychosocial interventions being the recommended frontline approach for post-traumatic stress.⁹⁴ Many competent mental professionals do not accept insurance because they can earn significantly more when patients pay out-of-pocket. This results in a system where the best-trained people are often only available to the wealthy, while those who work in community clinics and other insurance-supported practices are expected to see more patients for smaller fees.

Another way to extend mental health services is to implement more digital tools. The pandemic forced clinicians and patients to gain comfort with telepsychiatry, and many now prefer this option. It also helped introduce patients to the option of receiving services through their devices. Adolescents are especially engaged with technology⁹⁵ and research suggests that digitally-based interventions can be more appealing than in-person services for youth.^96,97 Rather than replacing mental health professionals, these innovative tools are most effective for augmenting and extending services – digital programs that include human support lead to the best engagement and functional outcomes.⁹⁸ Although research on digital psychiatry tools for youth is still somewhat limited, the benefit of those that include evidence-based principles and include human interaction can be on par with in-person services.^99,100 Importantly, digital tools enable asynchronous treatment, which can allow one clinician to treat multiple patients per hour, in contrast to in-person services. Furthermore, digital options can reduce both attitudinal and structural barriers to treatment, such as discomfort accessing services, stigma, and privacy concerns.^42,44,101 This can help increase both treatment initiation and compliance over time, to ensure that youth remain in care long enough to benefit – an issue that often limits symptom improvement.¹⁰²

Conclusion

The evidence – or lack thereof – of youth resilience is a common theme. While many of us can point to ways in which we have seen youth adapt and grow during the pandemic, this resilience does not lie within our youth alone. The COVID-19 pandemic has tested adolescents, families, and the systems intended to support them. It has laid bare inequities that existed long before the pandemic and made clear that many systems are not equipped to offer a nimble, robust response, despite significant effort. Writing about health justice for the children of Flint, Michigan, Mona Hanna-Attisha titled her New York Times opinion piece, “I’m Sick of Asking Children to Be Resilient.”¹⁰³ This sentiment suits our current situation, more than two years into the pandemic, just as well. Rather than relying on a bootstraps-approach to resilience, we need to build systems to support adolescents that are community- and equity-driven, guided by science, and adequately funded. We must also support the educators, mental health providers, and others we are counting on to provide crucial services to youth within these systems. Finally, greater collaboration across systems of care and private-public partnerships are necessary to spark innovation across systems and develop novel ways to support adolescents.