Globally, the coronavirus disease 2019 (COVID-19) pandemic has had an extraordinary effect on young people’s mental health.1 In the United States, before the pandemic, the prevalence of mental health disorders among youth was high.2 Over the course of the pandemic, the rates have soared even higher. Data from the 2021 Adolescent Behaviors and Experiences Survey indicate that 37.1% of US high school students reported poor mental health during the COVID-19 pandemic, with 19.9% considering and 9.0% attempting suicide in the preceding year.3 Because of the intensification of the crisis, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association issued a joint declaration of a national emergency in child and adolescent mental health.4
The stress brought on by COVID-19 generally can be grouped under the umbrella of adverse childhood experiences (ACEs).5 ACEs are adverse events that occur in childhood (0–17 years of age), such as neglect, experiencing or witnessing violence, or having a family member attempt or die by suicide. Also included are aspects of a child’s environment that can undermine their sense of safety, stability, and bonding. During the COVID-19 pandemic, nearly 3 of every 4 US high school students reported at least 1 ACE, and 1 in 13 (7.8%) reported 4 or more ACEs.5 Comparable prepandemic estimates of cumulative ACE exposure among US adolescents are limited. Nevertheless, the literature is consistent that emotional abuse is the most strongly associated with poor mental health and suicidal behaviors after considering demographic characteristics and the specific types of ACEs (eg, child abuse and neglect, sexual violence, teen dating violence, bullying, and family economic pressures). Other manifestations of mental health problems in youth during COVID-19 include an increased risk of drug use, higher-risk sexual behaviors, experiencing violence, and eating disorders.6
COVID-19 Mental Health Disparities in Minoritized Youth
Many minoritized adolescents displayed positive adaptability to COVID-19-induced changes.7 For example, Black and Native American youth displayed tremendous resilience during the COVID-19 pandemic despite experiencing greater rates of COVID-19 infection in their communities, deaths of family members and close friends, and psychosocial hardship. However, like their nonminoritized peers, they struggled with being physically out of the school environment, with more intimate observations of family hardships and separation from peers and other school resources. A survey of 547 LatinX youth examining the impacts of COVID-19 revealed that increases in adolescent childcare responsibility were associated with negative internal and external behaviors and a decline in school performance.8 Asian-American adolescents experienced increased racial discrimination during the COVID-19 pandemic, impacting socioemotional and academic outcomes. Black and other adolescents faced the syndemic of racialized violence in their communities as COVID-19 surged.9 As youth emerge from the pandemic with experiences of disconnection, discrimination, and family hardship, increasing the quality of care; improving access to clinical, financial, and social supports; and finding ways to creatively blend standardized services with more genuine connections to the patients and their families are recommended strategies to improve adolescent mental health and mental health service utilization for both minoritized and nonminoritized youth.6,10
Take Home Messages for Pediatricians and Mental Health Providers
Committed understanding that mental health is essential to overall health and that youth mental health conditions, which were rising before COVID-19, are common and treatable.
Those who experience mental health challenges warrant support, grace, compassion, and care instead of stigma, bias, and shame.
COVID-19 added to preexisting mental challenges that youth faced. Unfortunately, the pandemic has had the greatest effects on those who were already vulnerable, including youth with disabilities, racial and ethnic minorities, LBGTQ+ youth, and other marginalized communities.
Recognizing that the prevention of mental health challenges is paramount. Prevention strategies must be in place for all youth, especially those with a history of adversity. Prevention services/scaffolding can be implemented in schools, childcare, justice, social services, economic support centers, school enrichment programs, and legal structures.
Routine screening for mental health challenges and risk factors, including ACEs, should occur during each health care appointment, including annual physical or routine vaccination visits using principles of trauma-informed approach to care.
Accessible on-line and in-person mental health resources for families in need should be available at all appointments because mental health screening of parents, caregivers, and other family members for depression, violence, substance use disorder, food insecurity, housing instability, and other social determinants of health significantly influence the health and wellbeing of children and adolescents.
Combine the efforts of clinical staff with those of community partners, and child-serving systems (eg, child welfare, juvenile justice) should work with pediatric and mental health providers. Inclusive payment and delivery models, such as the Centers for Medicare & Medicaid Services Innovation Center’s Integrated Care for Kids Model, can be used to support the mental health-related needs of youth in all areas in which youth receive care.
Create interdisciplinary teams to forge viable and sustainable services for our youth and their families. These teams must include the theme “not for us, without us.” Youth and families should be involved in all decision-making stages, from screening to treatment, with culturally appropriate services offered in multiple languages and delivered by a diverse mental health workforce.
Support the mental health and wellbeing of mental health providers and community partners, building their capacity to support youth and their families (from Call to Action: The Surgeon General’s Advisory).
All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
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