As children across the U.S. return to school campuses this month and next, education officials worry about their capacity to handle the increased mental health needs of students brought on or exacerbated by the pandemic.
“Nearly all students have experienced some challenges to their mental health and well-being during the pandemic,” the U.S. Department of Education writes in a report released in June. The agency suggests some groups of children have been impacted more than others.
During the pandemic, girls were more likely than boys to say they felt anxious and depressed, according to a study of children in multiple regions of the world. Meanwhile, another study spotlights a growing number of U.S. kids aged 12-17 years going to hospital emergency rooms for suspected suicide attempts.
High school athletes in the U.S. differed in their responses to COVID-19 and the resulting school closures, with students who played team sports such as soccer and softball reporting higher rates of moderate-to-severe anxiety than students who played individual sports such as running and tennis, a study published earlier this year shows.
We elaborate on those and other findings below.
Even before the pandemic, many elementary, middle and high schools lacked the mental health professionals they needed, as organizations such as the National Association of School Psychologists and American School Counselor Association have pointed out for years.
The National Association of School Psychologists recommends a ratio of one school psychologist for every 500 students in kindergarten through twelfth grade. But education officials generally do not follow that guidance.
Across the country, the average ratio is one school psychologist per 1,211 kids, according to an analysis the association released earlier this year. Preliminary data for the 2019-2020 school year indicate the number varies considerably across states, with some states reporting an average student-to-school psychologist ratio exceeding 10,000:1.
Schools also fall far short of the student-to-school counselor ratio of 250:1 recommended by the American School Counselor Association. During the 2019-20 academic year, the nationwide average was one counselor per 424 students, an analysis from that organization shows.
Education officials have spoken out about the need for additional resources to help students. Almost 70% of the school administrators the National Association of Elementary School Principals surveyed in December said they do not have sufficient staff to meet the demand for mental health-related services.
Some states have decided to use part of their federal COVID-19 relief funding to hire additional mental health professionals. For example, the Oklahoma State Department of Education recently awarded almost $36 million in grants to allow 181 school districts to hire school counselors, licensed social workers and other mental health professionals.
Nevada set aside $7.5 million to hire 100 school-based mental health professionals, reports The 74, a news outlet that covers education issues nationwide. Connecticut also will “expand mental health supports” for students with a portion of its relief funds, the Hartford Courant reports.
To help journalists investigate the pandemic’s impact on child health, we’ve gathered and summarized several studies published in 2021 or 2020. Most look at the prevalence of mental health issues such as depression, suicidal thoughts, eating disorders and obsessive-compulsive disorder in kids amid the pandemic. We also included papers examining COVID-19’s impact on the mental health of specific groups of students, including high school athletes.
The prevalence of mental health issues
Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19: A Meta-analysis
Nicole Racine, et al. JAMA Pediatrics, August 2021.
To get a clearer understanding of how common depression and anxiety were among children during the first year of the coronavirus pandemic, researchers analyzed data they collected from 29 studies conducted in various parts of the world. A key takeaway: Of the combined 80,879 kids who participated in the studies, about 1 in 4 had symptoms of depression and about 1 in 5 had symptoms of anxiety.
The researchers suggest those rates are higher than before the pandemic. They point to a 2019 study of U.S. adolescents that finds 12.9% had major depression at that time and a 2019 study of Finnish adolescents that finds 11.6% had moderate symptoms of anxiety.
“Depressive symptoms, which include feelings of sadness, loss of interest and pleasure in activities, as well as disruption to regulatory functions such as sleep and appetite, could be elevated during the pandemic as a result of social isolation due to school closures and physical distancing requirements,” researchers write in the journal JAMA Pediatrics. “Generalized anxiety symptoms in youth manifest as uncontrollable worry, fear, and hyperarousal. Uncertainty, disruptions in daily routines, and concerns for the health and well-being of family and loved ones during the COVID-19 pandemic are likely associated with increases in generalized anxiety in youth.”
The study indicates some groups of children were more likely than others to develop symptoms of depression and anxiety.
The researchers learned that “the prevalence of clinically elevated depression and anxiety symptoms were higher in studies collected later in the pandemic and in girls.” They write that older children also were more likely to exhibit symptoms than younger ones, a trend that “may be due to puberty and hormonal changes in addition to the added effects of social isolation and physical distancing on older children who particularly rely on socialization with peers.”
It’s worth noting that 16 of the 29 studies included focused on eastern Asia. Six were from North America, four were from Europe and two were from Central America and South America. The remaining study focused on kids in the Middle East.
Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1-October 17, 2020
Rebecca T. Leeb; et al. Morbidity and Mortality Weekly Report, November 2020.
This report from the U.S. Centers for Disease Control and Prevention looks at how often children went to hospital emergency rooms for mental health-related issues from Jan. 1, 2020 to Oct. 17, 2020.
Researchers discovered that the number of times children went to emergency rooms for mental health-related issues fell from mid-March 2020 through early April 2020, when shelter-in-place orders were in effect. The number then rose steadily through October 2020.
Even though the number of mental health-related visits initially dropped, the proportion of all child emergency room visits that were for mental health-related issues rose sharply beginning in the spring of 2020.
From mid-March into October, the proportion increased 24% among children aged 5-11 years and 31% among those aged 12-17 years, compared with the same period in 2019. For children aged 4 years and younger, the proportion of mental health-related visits remained similar both years.
“Emergency departments (EDs) are often the first point of care for children experiencing mental health emergencies, particularly when other services are inaccessible or unavailable,” the authors of the paper write.
The authors examined emergency room data from a subset of hospitals in 47 states representing nearly three-quarters of emergency room visits nationwide. They find that although the number of mental health-related visits to emergency rooms dropped, the proportion of pediatric emergency room visits that were for mental health-related reasons rose, especially among kids aged 12-17 years.
Kids in that age group accounted for the biggest share of children’s mental health-related visits in both 2019 and 2020. For them, the highest rate of emergency room visits for mental health occurred in April 2020. In one week in April, hospitals recorded 4,758 visits for mental health reasons for every 100,000 total pediatric emergency room visits.
For children aged 5-11 years, the rate was highest in October 2020, when emergency rooms recorded 1,177 mental health-related visits for every 100,000 total pediatric visits.
Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12-25 Years Before and During the COVID-19 Pandemic — United States, January 2019-May 2021
Ellen Yard; et al. Morbidity and Mortality Weekly Report, June 2021.
This report from the U.S. Centers for Disease Control and Preventi on examines trends in emergency room visits for suspected suicide attempts among people aged 12-25 years at three distinct phases of the pandemic — spring 2020, summer 2020 and winter 2021.
Researchers discovered that people aged 12-25 years made fewer trips to the emergency room for suspected suicide attempts in the spring of 2020 than they had during the same period in 2019. In May 2020, however, the number of visits for suspected suicide attempts began to rise among kids aged 12-17 years, especially girls.
In the summer of 2020 — defined as July 26, 2020 to Aug. 22, 2020 for the purposes of this study — the weekly average for girls aged 12-17 years was 26.2% higher than it had been during the same period in 2019. For boys in that age group, such visits increased 10.8%.
In the winter of 2021 — defined as Feb. 21, 2021 to March 20, 2021 — the weekly average for girls aged 12-17 years was 50.6% higher than the prior year. It was 3.7% higher for boys of the same age.
The researchers indicate they are unsure how much of the increase is due to parents and guardians being more aware of the mental health of kids in their household.
“By spending more time at home together with young persons, adults might have become more aware of suicidal thoughts and behaviors, and thus been more likely to take their children to the ED [emergency department],” they write.
The researchers note the study has multiple limitations, including the fact that the data analyzed is not nationally representative. They obtained information from the CDC’s National Syndromic Surveillance Program, which collects data from about 71% of U.S. emergency rooms in 49 states.
The researchers also point out the data likely do not capture all suspected suicide attempts. They “likely underrepresent the true prevalence of suspected suicide attempts because persons with less severe injuries might be less likely to seek emergency care during the pandemic when many persons avoided medical settings to reduce the risk for contracting COVID-19.”
The Impact of the COVID-19 Pandemic on the Number of Adolescents/Young Adults Seeking Eating Disorder-Related Care
Jessica A. Lin; et al. Journal of Adolescent Health, forthcoming.
To better understand eating disorders among adolescents and young adults during the pandemic, the authors examine data from an eating disorders program generally serving patients aged 8 to 26 years at Boston Children’s Hospital.
The authors note that social isolation and disruptions in routines and medical treatment — all of which have been common during the pandemic — can contribute to eating disorders among people in this age group. They find that after the onset of COVID-19, inpatient admissions increased at the eating disorders program as did patient and parent inquiries. Prior to the pandemic, patient volume had remained stable.
“Anecdotally, the multiple hospitals that provide inpatient ED [eating disorder] care in our area also reported increased admissions,” write the authors, led by Jessica A. Lin, a physician and assistant professor at Harvard Medical School.
They add that an Australian study published earlier this year finds a similar increase in hospital admissions for anorexia nervosa among patients under age 16 amid COVID-19.
“In our clinical experience,” Lin and her colleagues write, “many patients report that their ED symptoms began or worsened soon after the pandemic started, consistent with growing literature describing worsening ED symptomatology during this time. Our findings may represent increased incidence, prevalence, and/or acuity of EDs during the COVID-19 pandemic.”
The COVID-19 Pandemic and Obsessive-Compulsive Disorder in Young People: Systematic Review
Catherine Cunning and Matthew Hodes. Clinical Child Psychology and Psychiatry, June 2021.
In this paper, researchers review six studies that explore the link between COVID-19 and symptoms of Obsessive-Compulsive Disorder in children and young adults under the age of 21.
All but one of the studies indicate COVID-19 prompted an increase in symptoms in young people. The remaining study indicates an improvement in symptoms, but is based on a sample of just 29 children and adolescents in Israel.
Obsessive-Compulsive Disorder, commonly referred to as OCD, “is a common, chronic, and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and/or behaviors (compulsions) that he or she feels the urge to repeat over and over,” according to the National Institute of Mental Health. Common obsessions and compulsions include fear of germs, excessive cleaning and repeatedly checking and counting.
The researchers explain there are several hypotheses as to why COVID-19 might worsen OCD symptoms. For example, they write that the “emphasis on handwashing and the cleaning of surfaces in government guidelines, the media and in day-to-day life may have increased perceptions of threat and responsibility in people with OCD, therefore exacerbating cleaning compulsions and fear of contamination.”
They note stress also can exacerbate symptoms.
“Considering the stress and fear associated with the pandemic, it seems clear that the level of distress in society would impact on young people’s mental health,” they explain. “If anxiety and distress increase across the population of young people, they will also increase in those with OCD. OCD symptoms in particular would appear likely to be affected by this increased stress partially because there is evidence that stress can play a significant role in both aetiology and maintenance of OCD symptoms.”
Impacts on student groups
Mental Health, Physical Activity, and Quality of Life of US Adolescent Athletes During COVID-19–Related School Closures and Sport Cancellations: A Study of 13 000 Athletes
Timothy A. McGuine; et al. Journal of Athletic Training, January 2021.
The authors of this paper assert it is the first to assess the mental and physical health of high school athletes after the coronavirus outbreak, which forced many U.S. schools to close and cancel interscholastic sports. A national survey reveals that student athletes’ mental and physical health differed substantially depending on factors such as their sex, the sport they played, their grade level in school and the poverty level of the county where they lived.
In all, 13,002 high school athletes completed the anonymous online survey, conducted in May 2020. Of them, 52.9% were male, 70.2% lived in states in the Midwest and 87.2% attended public schools.
Among the main takeaways:
- High school seniors were more likely to indicate they exhibited symptoms of moderate-to-severe anxiety and moderate-to-severe depression than athletes in grades 9, 10 and 11. The authors offer a possible explanation: “Although we cannot definitively identify the specific underlying mechanism for this finding, it is possible that the loss of social connections due to school and sport cancellations were felt the most by older adolescent athletes,” they write. “Whereas younger student-athletes may be able to envision continuing their careers in upcoming school years, seniors were confronted with the fact that their high school and scholastic sport experiences had suddenly ended.”
- Students who played team sports such as soccer and softball reported a higher prevalence of moderate-to-severe anxiety than did athletes who played individual sports such as running and tennis. It’s possible, the authors write, that individual sport athletes were able to keep playing when social distancing restrictions were put in place and, therefore, the pandemic might have affected them to a lesser extent.
- Athletes from counties with the highest poverty levels reported the highest prevalence of moderate-to-severe anxiety and moderate-to-severe depression. They also reported lower levels of physical activity. The authors point out that cancelling school sports “may have a differential effect on the health of athletes depending on their level of poverty. Whereas the mechanisms are speculative, our results nonetheless suggest that moving forward, we should prioritize increased access to physical activity and sports for these adolescents.”
Impact of COVID-19 Pandemic on the Mental Health of Students From 2 Semi-Rural High Schools in Georgia
Julie Gazmararian; et al. Journal of School Health, May 2021.
This paper provides insights into how COVID-19 affected teen mental health in one part of Georgia and the strategies kids used to cope with their feelings after local public schools closed in March 2020.
The researchers surveyed students at two high schools in northcentral Georgia where almost half of students were racial or ethnic minorities and more than 40% of students qualified to receive free or reduced-price meals at school based on their household incomes. A combined 761 students completed the online survey, which ran from March 30, 2020 to May 8, 2020.
Many students — 47% — said they were worried they or someone in their family would get COVID-19 and 16% indicated a family member or close friend already had been infected. But minority students were more likely than white students to express serious worries about the pandemic.
Girls were more likely than boys to say they worried about the pandemic and felt depressed, lonely or stressed.
Students indicated they dealt with their feelings in various ways. Nearly 70% said listening to music was their go-to means of coping with pandemic-related stress, fear and anxiety. Meanwhile, 60% said watching TV and movies helps. Other common strategies: talking to friends and family members, sleeping and using social media.
About 48% of Black teens said they eat to cope, compared with 40.4% of white teens and 45.2% of Hispanic teens. Black students also were most likely to say they meditate or practice mindfulness — 16% named it as a coping mechanism, compared with 11.1% of white students and 12.3% of Hispanic students.