Sounding the Alarm for Children’s Mental Health During the COVID-19 Pandemic

Increasingly, research confirms the negative effects of COVID-19 safety measures on the mental health of children and adolescents.1-5 Saunders and colleagues6 call for an urgent response to the increasing sustained demand for mental health services inclusive of substance use and developmental disorders. The authors’ population-based cross-sectional study used linked administrative and health data to examine changes in utilization of physician-provided mental health services for 2.5 million children and adolescents aged 3 to 17 years in Ontario, Canada. From March 2020 through February 2021, the authors found a rapid and sustained 10% increase in outpatient mental health service utilization by children and adolescents compared with prior rates. Similar trends were not observed for acute mental health service utilization for the same period, except for girls. The current study found striking sex differences with substantially higher rates of utilization observed for acute inpatient psychiatric hospitalization and outpatient mental health services for school-aged and adolescent girls.

The authors hypothesized that there would be a large, rapid shift toward virtual care that would be sustained throughout the COVID-19 pandemic and that utilization would vary by diagnostic groups and age. Thus, they examined variations in utilization of virtual care by diagnostic groups and adoption of telehealth as a modality for treatment. Rapid major shifts in utilization of virtual visits occurred very early during the COVID-19 pandemic and were sustained at approximately 70% of treatment.6 Increased rates of substance use disorders and psychotic disorders occurred early and were sustained at levels higher than expected, although they represent a small proportion of visits. The largest increases were noted for mood and anxiety disorders (74.7%), psychosis (73.2%), substance use (83.6%), social problems (64.6%), and neurodevelopmental disorders (69.8%).

Saunders and colleagues6 join the growing number of investigators confirming the substantial mental health outcomes associated with the COVID-19 pandemic in youth and a need to respond to the increasing demand for services. The authors highlight the need for a systematic response to address increasing mental health needs, including variations in demand by age and sex differences noted across studies.6-8 The results of this population-based study suggest that youth in Ontario are experiencing increasing psychological distress that underlies the 10% greater utilization of physician-provided outpatient mental health services.

Although this study highlighted increasing mental health service needs for children and adolescents during the COVID-19 pandemic, the authors noted several limitations. The administrative and health data for mental health services provided by physicians were not linked with the data for services provided by psychologists, social workers, and other therapists, who provide a significant proportion of mental health care in Canada, nor did the data set allow for measurement of unmet need.6 Classification of diagnostic groups by physician billing codes, rather than clinical diagnostic criteria, complicated assessing prevalence of diagnosis, illness severity, or family contexts that might influence care seeking. Furthermore, billing codes did not differentiate virtual visits by telephone or video, nor could they account for the outcomes of variations in reimbursement that affect utilization, thus limiting generalizability. Moreover, digital equity and disparities among Asian, Black, Indigenous (Inuit and Métis), and Latin American people; rural and urban communities; and access and utilization were not addressed.

The findings of a sustained 10% increase in mental health service utilization are far-reaching with both short- and long-term consequences. Since the start of the COVID-19 pandemic, survey data for children and adolescents reported higher rates of anxiety and depressive symptoms and parental concerns about their children’s mental health.1,4,5 A 2021 meta-analysis7 found a 2-fold increase in the global prevalence of depression and anxiety for children and adolescents, with higher rates for adolescents and girls. Other studies have found increasing rates of anxiety, depression, and suicidal behaviors among school-aged children and adolescents (especially for girls8); increasing emergency visits9 and hospitalizations8,10; and long waits for acute psychiatric care.8,10 The adverse effects of lockdowns, social isolation, educational adaptations, and loss of moderating community supports are significant contributors. The COVID-19 pandemic has further highlighted disparities in mental health burden for girls; lesbian, gay, bisexual, transgender, queer or questioning, asexual or allied, and intersex youth; and racially and ethnically minoritized youth.11-13

Despite these limitations, the authors’ call for a systematic approach to increasing access to mental health services is well founded.6 Accessing mental health treatment for children and adolescents was challenging before the COVID-19 pandemic. In response to the alarming mental health crisis within the US, leading pediatric and mental health professional organizations have declared “a national state of emergency in child and adolescent mental health,”14(p1) urging a national response to address these needs.

Saunders and colleagues6 further add to increasing data showing greater illness burden for girls,7,8 adding to what is known regarding racially and ethnically minoritized populations’ disproportionate illness burden.15,16 Hillis and colleagues13 studied the burden and rates of caregiver loss and orphanhood in the US in addition to known risk factors for poor mental health outcomes by race, ethnicity, and state; they found that risk of loss was 1.1 to 4.5 times higher among racially and ethnically minoritized youth than among non-Hispanic White children. Black and Indigenous youth had risk of loss that was 2.4 and 4.5 times higher, respectively, than that of non-Hispanic White children. Racially and ethnically minoritized populations in Canada also experience substantial barriers in accessing mental health treatment, despite having universal health care.17 A systematic response must consider how historically marginalized populations are psychologically affected by the COVID-19 pandemic, and existing disparities in virtual care must be carefully considered when planning interventions and eliminating barriers to care.18

The good news is that we do have effective treatments for pediatric mental health conditions. The challenge is ensuring that all children and adolescents who need them have access. This study6 adds support for virtual visits as one potential part of the solution. Virtual visit utilization transformed mental health care during the COVID-19 pandemic, with more than two-thirds of visits moving to virtual visits in Ontario. Similar transitions occurred in other countries.19,20 Virtual visits allowed children and families to continue their mental health care while adhering to safety precautions. Studies of virtual visits have been shown to have equivalent outcomes in patient adherence, satisfaction, and symptom reduction when compared with in-person visits.21,22

Interventions for common mental health, substance use, and developmental disorders can be delivered in community schools and primary care practices to address mild to moderate symptoms before they worsen. Training non–mental health clinicians to assess and treat common mental health conditions virtually is critical for expanding access to services,23 thereby creating collaborative-care models to address children’s mental health needs in settings with fewer resources. Studies to determine which populations or diagnostic groups will benefit most from virtual or hybrid (virtual and in-person) visits and measurement of quality and outcomes will inform future directions.

The immediate effect of the COVID-19 pandemic on children and adolescents has been significant, but the long-term effect will be more devastating without urgent action. Globally, 2.2 billion children have been or will be directly or indirectly affected by the COVID-19 pandemic and its sequelae. Saunders and colleagues6 and other researchers have sounded the alarm. We cannot wait to respond to the distress and escalating mental health and suicide crisis. Prioritizing children’s and adolescents’ mental health demands a transformational societal and systems solution that protects their future.

Corresponding Author: Tami Benton, MD, The Children’s Hospital of Philadelphia, 3440 Market St, Ste 400, Philadelphia, PA 19104 (bentont@email.chop.edu).

Published Online: February 7, 2022. doi:10.1001/jamapediatrics.2021.6295

Conflict of Interest Disclosures: None reported.

3.Zhou  SJ, Zhang  LG, Wang  LL,  et al.  Prevalence and socio-demographic correlates of psychological health problems in Chinese adolescents during the outbreak of COVID-19.   Eur Child Adolesc Psychiatry. 2020;29(6):749-758. doi:10.1007/s00787-020-01541-4 PubMedGoogle ScholarCrossref 5.Patrick  SW, Henkhaus  LE, Zickafoose  JS,  et al.  Well-being of parents and children during the COVID-19 pandemic: a national survey.   Pediatrics. 2020;146(4):e2020016824. doi:10.1542/peds.2020-016824 PubMedGoogle Scholar6.Saunders  NR, Kurdyak  P, Stukel  TA,  et al.  Utilization of physician-based mental health care services among children and adolescents before and during the COVID-19 pandemic in Ontario, Canada.   JAMA Pediatr. Published online February 7, 2022. doi:10.1001/jamapediatrics.2021.6298PubMedGoogle Scholar7.Racine  N, McArthur  BA, Cooke  JE, Eirich  R, Zhu  J, Madigan  S.  Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a meta-analysis.   JAMA Pediatr. 2021;175(11):1142-1150. doi:10.1001/jamapediatrics.2021.2482 PubMedGoogle ScholarCrossref 8.Yard  E, Radhakrishnan  L, Ballesteros  MF,  et al.  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.   MMWR Morb Mortal Wkly Rep. 2021;70(24):888-894. doi:10.15585/mmwr.mm7024e1 PubMedGoogle ScholarCrossref 9.Leeb  RT, Bitsko  RH, Radhakrishnan  L, Martinez  P, Njai  R, Holland  KM.  Mental health–related emergency department visits among children aged  MMWR Morb Mortal Wkly Rep. 2020;69(45):1675-1680. doi:10.15585/mmwr.mm6945a3 PubMedGoogle ScholarCrossref 12.Hawke  LD, Hayes  E, Darnay  K, Henderson  J.  Mental health among transgender and gender diverse youth: an exploration of effects during the COVID-19 pandemic.   Psychol Sex Orientat Gend Divers. 2021;8(2):180-187. doi:10.1037/sgd0000467 Google ScholarCrossref 13.Hillis  SD, Blenkinsop  A, Villaveces  A, et al.  COVID-19–associated orphanhood and caregiver death in the United States.   Pediatrics. 2021;e2021053760. doi:10.1542/peds.2021-053760 Google Scholar15.White  A, Liburd  LC, Coronado  F.  Addressing racial and ethnic disparities in COVID-19 among school-aged children: are we doing enough?   Prev Chronic Dis. 2021;18:E55. doi:10.5888/pcd18.210084 PubMedGoogle Scholar18.Dawson  AZ, Walker  RJ, Campbell  JA, Davidson  TM, Egede  LE.  Telehealth and indigenous populations around the world: a systematic review on current modalities for physical and mental health.   Mhealth. 2020;6(6):30. doi:10.21037/mhealth.2019.12.03 PubMedGoogle Scholar19.Wong  MYZ, Gunasekeran  DV, Nusinovici  S,  et al.  Telehealth demand trends during the COVID-19 pandemic in the top 50 most affected countries: infodemiological evaluation.   JMIR Public Health Surveill. 2021;7(2):e24445. doi:10.2196/24445 PubMedGoogle Scholar20.Srinivasan  R, Wallis  KE, Soares  N.  Global trends in telehealth among clinicians in developmental-behavioral pediatric practice: a COVID-19 snapshot.   J Dev Behav Pediatr. Published online May 12, 2021. doi:10.1097/DBP.0000000000000963 PubMedGoogle Scholar21.Hilty  DM, Ferrer  DC, Parish  MB, Johnston  B, Callahan  EJ, Yellowlees  PM.  The effectiveness of telemental health: a 2013 review.   Telemed J E Health. 2013;19(6):444-454. doi:10.1089/tmj.2013.0075 PubMedGoogle ScholarCrossref

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