Impact on Child Psychiatry

Abstract

The American pediatric mental health system is in crisis; the COVID-19 pandemic highlighted and exacerbated existing gaps. All youth were affected by the pandemic, an impact medicated by mental illness, the closing of schools, reduced access to mental health services, loss and bereavement, and financial and emotional stress on families. The pandemic's fallout is likely to be felt for years to come as today's youth move through successive developmental stages. Improvements in health care systems for youth, innovations in how care is delivered, and ongoing community support for recovery and resilience are needed moving forward.

Key points

• •The mental health system for youth was already in crisis before the COVID-19 pandemic struck.
• •The pandemic has affected all youth, and its sequelae are expected to play out over time as children move through the developmental stages.
• •Those youth who were most at risk prepandemic (those with preexisting mental health, substance use, and developmental disorders or adverse childhood experiences) are also expected to suffer the greatest fallout from the pandemic.
• •Improvements in the mental health care workforce, financial and technical support for innovations to improve access, and ongoing community recovery and resilience efforts will be vital in mobilizing protective factors and promoting the health and well-being of youth and their families.

Introduction

The mental health of children and adolescents has been a cause for serious concern worldwide even before the start of the COVID-19 pandemic. Pediatric systems of mental health care have long-standing, significant gaps including shortages of inpatient beds and lack of outpatient services covered through insurance plans. Such gaps are even larger for racial and ethnic minorities and rural populations.¹

The global coronavirus pandemic exacerbated the mental health crisis across age-groups. For youth, the pandemic led to an unprecedented and abrupt cessation of structure and normalcy in daily life, a loss compounded by death and bereavement for many. Those with the most risk factors are expected to be disproportionately impacted, including youth with preexisting trauma and mental illness² and those facing health disparities and unmet needs.³

Information on the immediate mental health effects of the pandemic is emerging, but long-term sequelae are also a major concern. The potential negative impacts of adverse childhood experiences across the lifespan have long been recognized, including increased risk of physical and mental health conditions and early death.⁴ Pandemic stressors may change the developmental course of youth and cause epigenetic changes to their DNA that will have ramifications for years to come.⁵

This paper examines emerging data about ways COVID-19 has affected youth mental health and development, mediated in part by such factors as social isolation, school closures, family functioning, and modifications in health care delivery systems. Changes resulting from the pandemic in how child psychiatry is practiced and taught are also addressed. Suggestions for the future for mitigating long-term negative outcomes and optimizing new opportunities are offered.

Impact of the pandemic on youth mental health and development

Social Isolation During the Pandemic and Its Effects on Child Development

The pandemic profoundly altered youth development by dismantling social contact across all ages. Young children learn about themselves, the perspectives of others, and the world around them by engaging in play and exploration with similarly aged peers. Play is the work of the child, offering a training ground for developing skills in fine and gross motor, speech and language, cognition, social-emotional regulation, and moral reasoning. During latency (6–12 years) the growing presence of peer groups and friendships help children further develop their capacities for perspective-taking and resolving conflict. During adolescence, youth naturally turn toward peer relationships to develop a sense of individual and communal identity.

With the abrupt closing of daycare centers and schools and the cessation of playdates and spontaneous social time, the COVID-19 pandemic severely disrupted normal social-emotional learning. Decreased access to safe and trusted adults, such as teachers and extended family, also limited youth’s ability to be closely observed, share their true selves, and receive reflective, positive feedback. For many, the resultant social isolation has led to the experience of high levels of loneliness. Loneliness, especially for long time periods, is associated with future mental health problems in youth, including increased social anxiety and depression,⁶ with children who were quarantined having a higher likelihood of experiencing trauma- and grief-related disorders than those who were not.⁷

Worsened Mental Health for Youth During the Pandemic

The combined stressors of the pandemic have challenged the mental health of youth with and without prior mental health concerns. Although some youth, such as those with social anxiety, may have experienced short-term improvement in mental health symptoms because of a relative reduction in anxiety-provoking interactions with peers,⁸ most of the mounting evidence points to the deleterious cumulative effects of the pandemic on mental health across ages.

In a Canadian study, two-thirds of youth reported worsening mental health several months after enforced lockdown, even in the absence of significant COVID-19 disease exposure or economic concerns.⁹ Youth without prior mental health concerns reported increased rates of anxiety-related symptoms.¹⁰ In the adolescent age group, health insurance claims during 2020 for generalized anxiety disorder, major depressive disorder, and adjustment disorder all increased by about 90% as a percentage of all medical claims compared with similar months during 2019.¹¹ With emphasis in the media around the importance of handwashing and respiratory spread of the virus, youth with obsessive-compulsive disorder perceived even more threat from contamination, and studies noted an increase in obsessions about contamination, cleaning-centered compulsions, and avoidance behaviors.¹²

Behavioral problems also increased in children. Abrupt cessation of supports, such as in-home behavioral and therapeutic services, and the closure of schools and residential placements resulted in less structure to help children regulate their behaviors. Children with autism spectrum disorder and their families suffered from sudden reduction in occupational, speech, and behavioral therapy services and respite care. Many families of children with autism spectrum disorder noted an increase in behavioral problems, adding more challenges to already stressed family systems.¹³

Eating disorders also rose during the pandemic. With disruption of routine activities, and an increase in sedentary behaviors, screen time, and social media use,¹⁴ clinic visits and hospitalizations for eating disorders and calls to the National Eating Disorder Association’s hotline surged across all age groups. Delays in diagnosis caused by reduced pediatric checkups may have resulted in a more serious course of illness.

Although research has suggested that the pandemic’s stressors have increased many forms of substance use in adults, the data for youth may be more positive. Reduced peer interactions and disruptions in supply from commercial sources of drugs may be a mitigating factor in youth. A national survey of more than 2000 teenagers and young adults found that nearly 70% noted that they had reduced or quit their use of e-cigarettes, in part because of inability to purchase products.¹⁵

Influence of Social Media on Mental Health of Youth During the Pandemic

In a world where youth already heavily relied on screens and smart phones for communication, the pandemic was associated with a spike in social media use. Technology may have helped mitigate feelings of isolation and loneliness through use of online apps and “face-to-face” interactions across the screen.¹⁶ In a nationally representative survey of teenagers and young adults conducted nearly a year into the pandemic, most noted that social media played an important and positive role in helping them stay connected with family and friends, and several used health-specific apps meant to promote positive coping skills.¹⁷

However, recent research has also suggested harmful effects of social media on mental health including depression, self-harm, negative body image, and self-esteem.^{18 , 19} These negative sequelae of social media use may have been exacerbated by the pandemic, and several groups have reported an increase in cyberbullying and use of online pornography among youth during this time.²⁰

Impact of the pandemic on schools and education

In response to the public health emergency of the COVID-19 pandemic, communities across the world rapidly closed schools and shifted to home-based distance-learning models. In the United States, almost all 55 million students from kindergarten through twelfth grade were affected by these closures starting in March 2020. In addition to academics, American schools provide physical education and sports, nutrition, mental health services, monitoring for abuse and neglect, and a social focal point for communities. The full impact of these closures and the resulting loss of resources is yet to be learned; however, early data are concerning.

School Lunch/Food Insecurity

Schools provide lunches for more than 30 million students in the United States, where 35 million children live in poverty.²¹ Although schools tried creative ways to continue providing children with food during the pandemic’s school closures, this effort met with limited success. Within months, the pandemic brought increased reports of food insecurity.²²

Learning: Access and Other Inequities

School closures resulted in a massive shift to digital platforms for learning, which presented significant challenges and resulting inequities.²³ Families faced digital obstacles, such as doing schoolwork on cell phones, relying on public Wi-Fi to complete schoolwork because of unreliable Internet connection at home, and being unable to fully participate in their work and learning because of lack of computer access at home.²⁴ Lower income parents and those from minority communities reported a higher likelihood of these obstacles. Even before the pandemic, 25% of Black students reported struggling to complete schoolwork because they lacked a computer at home.²⁵ Non-English speakers found attempts to assist their children’s remote learning and communicate with teachers to be particularly challenging.²⁶

Educational Achievement

Educational achievement and growth have also been impacted by school closures and remote learning. Multiple surveys document that most teachers were unprepared to teach virtually and taught less new material, particularly in lower-income communities. Many students did not consistently log on for virtual classes and the summer 2020 makeup time was variably used, exacerbating the problem of “summer learning loss.”²⁷ Studies documented declines in educational achievement, particularly in mathematics.²⁸ The loss of services provided through individualized education plans was particularly challenging, and students with neurodevelopmental, sensory, and learning disorders seem to be at increased risk for the pandemic’s negative impacts on learning.²⁹ The poorest performing students prepandemic also had the largest declines in academic achievement and school attendance during 2020.²⁸

School Mental Health Services

Schools are also a critical site for mental health evaluation and treatment of youth.³⁰ Approximately 35% of adolescents who receive any mental health services receive them only in school settings. This percentage disproportionately includes youth from racial and ethnic minorities, lower family income, and those with public health insurance.³¹ With the rapid institution of fully remote and later hybrid models of schooling during the pandemic, the ability of teachers and school counselors to provide therapeutic interventions or meet regularly with students was limited. Therapeutic schools that relied on the entire school milieu as being part of a child’s treatment plan were handicapped by the virtual modality, leaving parents with the challenge of structuring a child’s day or managing significant behavioral outbursts.^{32 , 33}

Impact of the pandemic on parents and families

The COVID-19 pandemic impacted families directly through illness and bereavement, and through detrimental effects on mental health, financial and employment uncertainty, and increased pressures on work-life balance.

Parental Mental Health Effects

Parents’ mental health is a key determinant of the mental health of their children. Although some families reported more positive effects of pandemic-induced changes in family life, such as increased time spent with children,³⁴ most evidence suggests a decline in parental and family mental health during the pandemic. Young children, who are particularly vulnerable to distress in their caregivers, displayed increased clinginess, worrying, inattention, restlessness, and irritability.³⁵ A survey of economically vulnerable families of preschool children found a strong association between parental job and income loss with a parent’s symptoms of depression, stress, decreased sense of hope, and negative parent-child interactions; families who experienced several simultaneous hardships during the pandemic reported a worsened mental health than those who experienced fewer.³⁶

Shifting Landscape of Work and Childcare

As the pandemic continued, families experienced a significant reshifting in their work and childcare responsibilities. With abrupt closures of schools, businesses, and childcare services at the start of the pandemic, many Americans, especially low-wage workers in the service industry, experienced a drastic reduction in work hours and an increase in layoffs, resulting in increased financial stress.

Parents were often unable to work because of the lack of childcare. In a June 2020 national survey, 48% of those families who reported worsening mental health early in the pandemic noted that they had lost childcare. The mental health effects were noted to be greater in mothers and single parents.²² Stress and difficulty balancing work and family responsibilities ensued, with most changes seeming to fall on mothers.³⁷ Latina and Black mothers, who are more likely to be single or have a partner working outside the home, were twice as likely to take on all childcare and housework once COVID-19 struck.³⁸

Parental Stress and Child Maltreatment

Classic risk factors for childhood maltreatment, including poverty, economic instability, and employment insecurity, were exacerbated by the COVID-19 crisis, increasing concerns about the safety of children. In general, levels of cumulative parental stress, such as those experienced during the pandemic, have been linked to increased likelihood of engaging in harsh parenting practices and increased risk of childhood maltreatment and intimate partner violence.³⁹ Data from previous pandemics suggest that risk of violence for children increases with school closure associated with public health emergencies.⁴⁰ Rising rates of parental substance abuse and job loss during the pandemic are believed to be associated with this phenomenon.³⁹ In families where parents worked out of the home, sparse childcare options may have also resulted in less than ideal caretaking arrangements.

Despite these, risks, official reports to child protective agencies and total number of emergency room visits related to suspected child abuse and neglect decreased starting in March 2020 when compared with the corresponding times from the previous year.⁴¹ This decrease is thought to be caused by the markedly limited interaction of children with mandated reporters, such as physicians, teachers, and childcare workers. This concern was one of the key factors leading national organizations, such as the American Academy of Pediatrics, to support returning to in-person schooling.⁴²

Impact of the pandemic on mental health service delivery for youth

The implementation of the public health emergency in March 2020 led to a rapid transformation of the mental health delivery system and unanticipated changes that have affected virtually all service domains. Simultaneously, the pandemic’s negative impact on parent and child mental health described previously led to an increase in demand for mental health services in an already underresourced system. In the May 2021 American Psychiatric Association survey, 26% of parents reported seeking professional mental health help for their children and nearly half of parents reported seeking such help for themselves. However, with waitlists increasing, more than one in five parents reported having difficulty scheduling an appointment for their child with a mental health professional.⁴³

Wraparound Services

Therapists in community agencies before the pandemic were often able to achieve rapport and buy-in for treatment through their ability to meet patients and families in their homes and offer in-the-moment parenting guidance and in vivo crisis stabilization. This home-based care, a critical element of “wraparound services,” often mitigated the need for acute levels of care. With the pandemic, most of these services either ceased or converted to telephone and/or video platforms, which diminished their in-person benefits.

Emergency Room Visits

Although the child mental health system of care in the United States was already in crisis before the pandemic, COVID-19 exacerbated the problem of children “boarding” in emergency rooms awaiting psychiatric beds.⁴⁴ Early in the pandemic, all pediatric emergency room visits decreased largely because of fear of contracting the virus; however, the proportion of total emergency room visits for mental health concerns simultaneously rose. According to data from the Centers for Disease Control and Prevention, the proportion of children’s mental health–related visits to emergency rooms across the country between April 2020 and October 2020 increased by between 24% and 31% for children aged 5 to 17 when compared with data from the same months in 2019.⁴⁵ Several studies noted a relative increase in the number of emergency room presentations related to self-harm and suicidal ideation.^{46 , 47} Some evidence indicates that the height of these visits corresponded with times of peak community concern and efforts to curb the spread of the virus through increased restrictions and lock-downs. This suggests that youth may have experienced heightened levels of distress during this time related to stressors in their home environment and increased isolation from peers and supports.⁴⁶ Across the country, news reports documented the experience of children spending days to weeks in emergency rooms waiting for psychiatric admission.⁴⁸ As of the writing of this paper, this crisis is still ongoing.

Inpatient Hospitalizations

On inpatient units, the pandemic required implementation of infection control measures, such as mask-wearing and remote-contact mobile devices, a reduction or cessation in milieu-based treatment approaches, and reduced family and social visits.49, 50, 51 Family-based and parent-centered treatment became more challenging to provide. The loss of therapeutic groups and alteration in the therapeutic milieu may have made the provision of care less optimal.^{50 , 51} Children and adolescents on inpatient units who required discharge to other treatment programs, such as residential facilities or partial hospitalization, may have had their stays extended or, alternatively, their discharge to home hastened because of the limitations on availability and quality of services. These care facilities were subject to the same requirements in securing personal protective equipment and preventing outbreaks as all other health care facilities, with often less access to supplies and experience in these procedures, meaning that many of them were unable to accommodate the number of patients needing that level of care.⁵²

Outpatient Services

Outpatient clinicians also had to adjust the treatment they offered. To continue providing outpatient care safely, health care systems rushed to implement telepsychiatry platforms that yielded benefits and concerns for the provision of health care for children and families. A major benefit was increased access to services and decrease in no-show rates because of elimination of barriers, such as long commute times, parking fees, and patient preference for virtual care.52, 53, 54 However, many believe that the rapid reliance on telepsychiatry may have also inadvertently worsened mental health disparities for families with limited English proficiency and without Internet or computer access.⁵⁵

Televisits in people’s homes afforded clinicians unprecedented and valuable glimpses into a child’s environment and family functioning.⁵⁶ However, they also required clinicians and patients to adapt their interactions to the virtual space. Clinicians had to be more intentional about addressing aspects of an evaluation often taken for granted during in-person visits, such as assessing a child’s play or ensuring privacy for sensitive conversations.⁵⁶ In situations of safety concern, clinicians had to preemptively consider the best way to access emergency services for patients in the virtual context. Trauma-focused therapy, psychological first aid,⁵⁷ and disaster response strategies became more salient⁵² modes of treatment. The rapid rise in anxiety and depression symptoms required a more nuanced distinction between a “normal” reaction to pandemic stress and pathologic anxiety.⁵⁸ The frame of the encounter also shifted, with the adolescent or family having far more control over where the appointment took place and how engaged they chose to be during a visit. Appointments regularly occurred while patients were driving in cars; shopping in stores; or otherwise distracted by video games, television, or social media.⁵⁶ Professional organizations rapidly promulgated new and existing guidelines on telepsychiatry professionalism, billing, and technological concerns to help anticipate and navigate potential challenges.^{59 , 60}

Training Considerations

Child and adolescent psychiatry fellowship training directors also had to strike a balance between safety of their fellows and providing high-quality training. Learning to provide telepsychiatry became an unanticipated focus of training programs. A 2020 national survey of child psychiatry training directors found an increase from 12% to 90% in reported “direct-to-consumer” visits in outpatient training services when contrasting pre-COVID-onset and post-COVID-onset telehealth services.⁶¹ More care was delivered to patients via telepsychiatry in their homes and much more teaching, training, and supervising was done virtually. Educators are concerned that certain learning objectives, such as those significantly benefitting from in-person interaction (eg, play therapy), have suffered because of virtual care. To get around difficulties in assessing younger patients, some institutions asked parents to video their young children playing or interacting in their natural setting.⁶² The extent to which the state of emergency waivers continue or are modified as the pandemic progresses is likely to affect mental health care for children and families and, secondarily, how fellows are trained.

Summary

The COVID-19 pandemic’s impact on the mental health and development of children and adolescents will be a topic of study for years to come. As the pandemic evolved, child psychiatry experts formulated a research agenda to better understand the short- and long-term effects of the pandemic on the mental health of children, families, and society.⁶³ The loss of social contact and schooling and effects of illness and bereavement will continue to have lasting foreseen and unforeseen consequences. The impact is expected to be greatest on those youth already at risk because of such factors as economic hardship, unsafe neighborhoods, poor educational and health care services, prepandemic mental illness or neurodevelopmental disorders, and family dysfunction including abuse and neglect. Minority groups, disproportionately affected by COVID-19 through social determinants of health and the effects of systemic racism,⁶⁴ may suffer more from the travesties of the pandemic. Those youth with protective factors, such as sufficient resources for daily needs, community connections, academic competence, strong self-regulation skills, and close relationships with caretaking adults, may prove most resilient against the fallout.

As the pandemic evolves and society builds a “new normal,” the needs of those most vulnerable must be kept at the forefront, although all youth will be processing this experience over and over as they move through each developmental stage. Despite overall improvements in society’s response to the pandemic, the reality remains that the mental health needs of youth are still at a crisis point, as emphasized in a joint statement of the American Academy of Child and Adolescent Psychiatrists, the American Academy of Pediatrics, and the Children’s Hospital Association released in October 2021 that declared a National State of Emergency in Children’s Mental Health and called on policymakers to do the same. Among other recommendations, the organizations called for increased funding for the mental health needs of youth to support initiatives that address regulatory challenges, expand on sustainable models of school-based and integrated care, and address ongoing challenges of acute care needs.⁶⁵

To serve the needs of youth in the postpandemic world, the prepandemic health, socioeconomic, and racial inequities in systems and institutions that the pandemic highlighted must be addressed. For children and families, this means addressing:

• •The well-established shortage of child/adolescent psychiatrists, psychologists, social workers, school counselors and other mental health professionals trained to address the complex mental health needs of children and families
• •Financial and technical support for innovations that helped promote mental health access during the pandemic, such as telepsychiatry
• •Social determinants of health and structural inequities, such as through efforts to promote housing security, end systemic forms of racism, and close the “digital divide”

Proposed improvements include comprehensive screening for social determinants of health; flexible, inclusive, and coproduced models of care; potential redefinition of what constitutes an “essential” service, such as in-person provision of care in some situations; and fostering community-led initiatives, which may promote resilience through positive and protective experiences.⁶⁶

In shaping the future of youth mental health care, pandemic “lessons” include the need for increased emphasis on community engagement, empowerment of patients and families in their own treatment,^{2 , 67} and adaptation of existing services to include a trauma-informed approach. Child psychiatry training needs to address what may have been lost during the pandemic (eg, training in dynamic play therapy) and embrace positive changes (eg, increased telepsychiatry experience). The pandemic-induced rapid adoption of digital technology and videoconferencing may lead to positive innovations in personal-professional balance for working parents, hybrid educational models that better meet the individual needs of students, and health care services that improve the lack of access to pediatric mental health care across the country and even the world. It is hoped that vulnerable youth, who were so adversely impacted by the pandemic, will be in a position to gain from such improvements in the future.

Clinics care points

• •The mental health system for youth was already in crisis before the COVID-19 pandemic struck.
• •The pandemic has affected all youth, and its sequelae are expected to play out over time as children move through the developmental stages.
• •Those youth who were most at risk prepandemic are also expected to suffer the greatest fallout from the pandemic. These include youth with preexisting mental health, substance use, and neurodevelopmental problems and those facing social determinants that adversely affect mental health: poverty, racism, health inequities, poor education, and lack of a close relationship with a caretaking adult.
• •Improvements in the mental health care workforce, financial and technical support for innovations to improve access, and ongoing community recovery and resilience efforts will be vital in mobilizing protective factors and promoting the health and well-being of youth and their families.