We have seen this coming. We know that early childhood trauma can confer lifelong vulnerability to physical and mental health problems.
Today’s middle-schoolers were born during the Great Recession as foreclosure and unemployment rates soared, and parents worried about keeping their children housed and fed. Even before that, income inequality—also strongly associated with worsening health—grew from historically low levels in the mid-20th century to levels not seen since the Gilded Age. Opiate deaths and family disruption spiked as these children were in their school years.
Youth suicide rates have been trending up since 2007. The COVID-19 pandemic represents a “second hit” to a population already at risk. We might have been fooled as children’s healthcare utilization of all kinds fell with the first lockdowns. Some children found relief staying home—away from bullying, curricula that failed to support a diversity of learning styles and abilities, and a system biased toward those with the means to access its standardized testing gateways.
Now we also see the impact of the prolonged lack of formal and informal supports for children and youth with a wide variety of vulnerabilities. Both parents and children are finding out how important it had been to live in dense social networks of friends and activities in school and out. Around the country, hospitals report increases in the severity of suicide attempts and families struggling to care for children without the benefit of school and community-based programs. At Seattle Children’s, we’ve seen a 37% increase in the percentage of emergency visits associated with mental health since the pandemic began.
Though vaccines and now massive financial support from the federal government are promising a return to normal, experience with prior prolonged trauma (most specifically the aftermath of Hurricane Katrina) suggests it will take years for the emotional and behavioral impact of the pandemic to ease. In the next decade, our children’s mental health system will have to look profoundly different than it does now.
First and foremost, it will have to be invested in prevention and early intervention. Addressing parents’ own mental health problems is critical to preventing and treating children’s problems; child mental health systems can no longer assume someone else will do that. Housing and food insecurity are enormous threats to child mental health; if we can’t incorporate these “social determinants” into our treatment plans, much of what we do will be futile. Supporting effective parenting is among the most potent preventive interventions known for children’s health; we have to make this support more universally available and incorporate it into our other treatments.
Second, we have to come to terms with the inadequacy of our workforce. Yes, we need more psychologists and psychiatrists, and more ways to spread their expertise geographically. But the pipeline producing these professionals was already too long, too expensive, and insufficiently diverse to meet pre-COVID needs; now it is utterly inadequate.
In the same way that the country mobilized to create a COVID vaccine it now needs to mobilize to create a new child/youth mental health workforce. Medical providers who have historically felt that mental health was “not what I trained for” need training to deliver first-line mental health interventions. We can re-import programs from less-resourced countries where community health workers and peer navigators effectively reach and treat diverse populations in languages and cultural frames that they understand. We can utilize technology to ensure that once a child or youth has come into contact with the mental health system, they never again feel that help is out of reach or that they are forgotten.
The biggest barriers to making these changes come from within our systems. Doubling down on care models that were inadequate before COVID will not meet new needs. Clinicians of all kinds will have to step up to new roles, and systems that have based success on providing medical and surgical services will have to understand how providing mental healthcare can be similar—and very different—from that sort of work. A generation of children needs us to respond as quickly as we can.