Abrams, Z. (2023, January 1). Kids’ mental health is in crisis. Here’s what psychologists are doing to help. Monitor on Psychology, 54(1). https://www.apa.org/monitor/2023/01/trends-improving-youth-mental-health
The Covid -19 pandemic era ushered in a new set of challenges for youth in the United States, leading to a mental health crisis as declared by the United States surgeon general just over a year ago. But U.S. children and teens have been suffering for far longer.
In the 10 years leading up to the pandemic, feelings of persistent sadness and hopelessness—as well as suicidal thoughts and behaviors—increased by about 40% among young people, according to the Centers for Disease Control and Prevention’s (CDC) Youth Risk Behavior Surveillance System.
“We’re seeing really high rates of suicide and depression, and this has been going on for a while,” said psychologist Kimberly Hoagwood, PhD, a professor of child and adolescent psychiatry at New York University’s Grossman School of Medicine. “It certainly got worse during the pandemic.”
In addition to the social isolation and academic disruption nearly all children and teens faced, many also lost caregivers to Covid -19, had a parent lose their job, or were victims of physical or emotional abuse at home.
All these difficulties, on top of growing concerns about social media, mass violence, natural disasters, climate change, and political polarization—not to mention the normal ups and downs of childhood and adolescence—can feel insurmountable for those who work with kids.
ADVERTISEMENT“The idea of a ‘mental health crisis’ is really broad. For providers and parents, the term can be anxiety-provoking,” said Melissa Brymer, PhD, who directs terrorism and disaster programs at the UCLA–Duke University National Center for Child Traumatic Stress. “Part of our role is to highlight specific areas that are critical in this discussion.”
Across the field, psychologists are doing just that. In addition to studying the biological, social, and structural contributors to the current situation, they are developing and disseminating solutions to families, in schools, and at the state level. They’re exploring ways to improve clinical training and capacity and working to restructure policies to support the most vulnerable children and teens.
Psychologists were also behind new mental health recommendations from the U.S. Preventive Services Task Force, a group of volunteer health professionals who evaluate evidence on various preventive health services. The task force now recommends regular anxiety screenings for youth ages 8 to 18 and regular depression screenings for adolescents ages 12 to 18.
“I see these trends in children’s mental health problems as being critical, but there are solutions,” Hoagwood said. “If we refocus our efforts toward those solutions, we could see some of these tides turn.”
Across the United States, more than 200,000 children lost a parent or primary caregiver to Covid -19 (“ Covid -19 Orphanhood,” Imperial College London, 2022). In the face of those losses, families had to curtail mourning rituals and goodbye traditions because of social distancing requirements and other public health measures, Brymer said. Many children are still grieving, sometimes while facing added challenges such as moving to a different home or transferring to a new school with unfamiliar peers.
The CDC also reports that during the pandemic, 29% of U.S. high school students had a parent or caregiver who lost their job, 55% were emotionally abused by a parent or caregiver, and 11% were physically abused (Adolescent Behaviors and Experiences Survey—United States, January–June 2021, CDC).
“Schools are crucial for keeping kids safe and connecting them with services, but the pandemic completely disrupted those kinds of supports,” Brymer said.
Those extreme disruptions didn’t affect all young people equally. Echoing pre- Covid -19 trends, the CDC also found that girls, LGBTQ+ youth, and those who have experienced racism were more likely to have poor mental health during the pandemic, said social psychologist Kathleen Ethier, PhD, director of the CDC’s Division of Adolescent and School Health.
Contributing factors likely include stigma, discrimination, and online bullying, Ethier said. Female students also report much higher levels of sexual violence than their male peers, which can further harm mental health.
As much hardship as Covid -19 wrought, it’s far from the only factor contributing to the current crisis. Biology also appears to play a role. The age of puberty has been dropping for decades, especially in girls, likely leading to difficulty processing complex feelings and knowing what to do about them (Eckert-Lind, C., et al., JAMA Pediatrics, Vol. 174, No. 4, 2020). In early puberty, regions of the brain linked to emotions and social behavior are developing more quickly than regions responsible for the cognitive control of behavior, such as the prefrontal cortex, Ethier said.
Those developmental changes drive young people to seek attention and approval from their peers. For some, using social media fulfills that need in a healthy way, providing opportunities for connection and validation to youth who may be isolated from peers, geographically or otherwise.
For others, negative messages—including online bullying and unrealistic standards around physical appearance—appear to have a detrimental effect, but more research is needed to understand who is most at risk.
“There is clearly some aspect of young people’s online life that’s contributing [to the mental health crisis], we just don’t know exactly what that is,” said Ethier.
Finally, structural factors that affect millions of U.S. children, including poverty, food insecurity, homelessness, and lack of access to health care and educational opportunities, can lead to stress-response patterns that are known to underlie mental health challenges.
“Even in very young children, prolonged stress can trigger a cycle of emotion-regulation problems, which can in turn lead to anxiety, depression, and behavioral difficulties,” Hoagwood said. “These things are well established, but we’re not doing enough as a field to address them.”
The biggest challenge facing mental health care providers right now, experts say, is a shortage of providers trained to meet the mounting needs of children and adolescents.
“There’s a growing recognition that mental health is just as important as physical health in young people’s development, but that’s happening just as mental health services are under extreme strain,” said clinical psychologist Robin Gurwitch, PhD, a professor in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center.
Schools, for example, are a key way to reach and help children—but a 2022 Pew Research Center survey found that only about half of U.S. public schools offer mental health assessments and even fewer offer treatment services. Psychologists are now ramping up efforts to better equip schools to support student well-being onsite.
Much of that work involves changing policies at the school or district level to provide more support for all students. For example, school connectedness—the degree to which young people feel that adults and peers at school care about them and are invested in their success—is a key contributor to mental health. Youth who felt connected during middle and high school have fewer problems with substance use, mental health, suicidality, and risky sexual behavior as adults (Steiner, R. J., et al., Pediatrics, Vol. 144, No. 1, 2019).
Through its What Works in Schools program, the CDC funds school districts to make changes that research shows foster school connectedness. Those include improving classroom management, implementing service-learning programs for students in their communities, bringing mentors from the community into schools, and making schools safer and more supportive for LGBTQ+ students.
Psychologists are also building training programs to help teachers and other school staff create supportive classrooms and aid students who are in distress. Classroom Wise (Well-Being Information and Strategies for Educators), developed by the Mental Health Technology Transfer Center Network and the University of Maryland’s National Center for School Mental Health (NCSMH), is a free, flexible online course and resource library that draws on psychological research on social-emotional learning, behavioral regulation, mental health literacy, trauma, and more (Evidence-Based Components of Classroom Wise (PDF, 205KB), NCSMH, 2021).
“We’re using evidence-based practices from child and adolescent mental health but making these strategies readily available for teachers to apply in the classroom,” said clinical psychologist Nancy Lever, PhD, codirector of NCSMH, who helped develop Classroom Wise .
The course incorporates the voices of students and educators and teaches actionable strategies such as how to create rules and routines that make classrooms feel safe and how to model emotional self-regulation. The strategies can be used by anyone who interacts with students, from teachers and administrators to school nurses, coaches, and bus drivers.
“What we need is to build capacity through all of the systems that are part of children’s lives—in families, in schools, in the education of everybody who interacts with children,” said psychologist Ann Masten, PhD, a professor of child development at the University of Minnesota.
Other training efforts focus on the students themselves. Given that preteens and teenagers tend to seek support from their peers before turning to adults, the National Child Traumatic Stress Network (NCTSN) created conversation cards to equip kids with basic skills for talking about suicide. The advice, available in English and Spanish, includes how to ask about suicidal thoughts, how to listen without judgment, and when to seek guidance from an adult (Talking About Suicide With Friends and Peers, NCTSN, 2021).
While training people across the school population to spot and address mental health concerns can help reduce the strain on mental health professionals, there will always be a subset of students who need more specialized support.
Telehealth, nearly ubiquitous these days, is one of the best ways to do that. In South Carolina, psychologist Regan Stewart, PhD, and her colleagues colaunched the Telehealth Outreach Program at the Medical University of South Carolina in 2015. Today, nearly every school in the state has telehealth equipment (Wi-Fi and tablets or laptops that kids can use at school or take home) and access to providers (psychology and social work graduate students and clinicians trained in trauma-focused cognitive behavioral therapy). Students who need services, which are free thanks to grant funding or covered by Medicaid, meet one-on-one with their clinician during the school day or after hours (American Psychologist, Vol. 75, No. 8, 2020).
“We learned a lot about the use of technology during the pandemic,” Ethier said. “At this point, it’s very much a matter of having sufficient resources so more school districts can access those sources of care.”
Limited resources are leaving families low on options, with some young people making multiple trips to the emergency room for mental health-related concerns or spending more than six months on a waiting list for mental health support. That points to a need for more trained emergency responders and psychiatric beds, psychologists say, but also for better upstream screening and prevention to reduce the need for intensive care.
“Just as we need more capacity for psychiatric emergencies in kids, we also need an infusion of knowledge and ordinary strategies to support mental health on the positive side,” Masten said.
In New York, Hoagwood helped launch the state-funded Evidence Based Treatment Dissemination Center in 2006, which offers free training on evidence-based practices for trauma, behavioral and attention problems, anxiety, depression, and more to all mental health professionals who work with children in state-licensed programs, which include foster care, juvenile justice, and school settings, among others. The center provides training on a core set of tools known as PracticeWise (Chorpita, B. F., & Daleiden E. L., Journal of Consulting and Clinical Psychology, Vol. 77, No. 3, 2009). It also offers tailored training based on requests from community agency leaders and clinicians who provide services to children and their families.
Hoagwood, in collaboration with a consortium of family advocates, state officials, and researchers, also helped build and test a state-approved training model and credentialing program for family and youth peer advocates. The peer advocate programs help expand the mental health workforce while giving families access to peers who have similar lived experience (Psychiatric Services, Vol. 71, No. 5, 2020).
Youth peer advocates are young adults who have personal experience with systems such as foster care, juvenile justice, or state psychiatric care. They work within care teams to provide basic education and emotional support to other youth, such as giving advice on what questions to ask a new mental health practitioner and explaining the differences between psychologists, psychiatrists, and social workers. Youth peer advocates in New York can now receive college credit for their training in peer specialist work.
“Making community health work into a viable career can also increase diversity among mental health workers and help us address structural racism,” Hoagwood said.
Pediatricians are another group that can provide a first line of defense, drawing on their relationships with parents to destigmatize mental health care.
“Pediatricians are in many ways uniquely positioned to help address the mental health crisis in youth,” said Janine A. Rethy, MD, MPH, division chief of community pediatrics at MedStar Georgetown University Hospital and an associate professor of pediatrics at Georgetown University School of Medicine. “We have the privilege of building long-term relationships with children and their families over many years,” with at least 12 well-child checkups in just the first three years of a child’s life, followed by annual visits.
During these visits, they can watch for warning signs of social and behavioral problems and screen for maternal depression and other issues in parents, which is now recommended by the American Academy of Pediatrics (PDF, 660KB). Several new resources provide guidance for integrating mental health care into pediatric practices, including the Behavioral Health Integration Compendium (PDF, 4.1MB) and the Healthy Steps program. But most pediatricians need more education on mental health issues in order to effectively respond, Rethy said—yet another area where psychologists may be able to help. Psychologists can provide direct consultations and training to pediatricians through the Pediatric Mental Health Care Access program.
“The more we can weave mental health knowledge, capacity, and checkpoints into places where parents feel comfortable—like the doctor’s office and at school—the better,” Masten said. “All professionals who work with young people really need the knowledge that’s being generated by psychologists.”