The pandemic has exposed many teens to trauma and tested their fragile resilience. What can you, as a clinician, do to help?
While teenagers have been largely spared the ravages of COVID-19, the full picture of their experience is just beginning to emerge. The pandemic has exposed many teens to trauma and tested their fragile resilience. The school closures, canceled proms, and separation from friends seemed a small price to pay to save the lives of thousands. But in exchange, the 14- to 18-year-olds who represent the younger side of Generation Z were robbed of the capstone of their formative years. It created an atmosphere of uncertainty and anxiety among some teens, about both the future and their place in it.
As if the pandemic was not enough, teens watched as police violence and racial tensions reached breaking points. They saw angry mobs take over cities and storm the Capitol. Then Mother Nature swept in with deadly wildfires and other natural disasters that underscored the threat of climate change.
Throughout COVID-19, the physical health needs of the most vulnerable often took priority over the mental health needs of others. But as the pandemic dragged on, health care providers expressed concern over its long-term mental effects on youth and teens. Against expectations, suicide rates for all ages dropped by 5.6% in 2020 compared to 2019.1 But this is not entirely unusual. Known as the “pulling together” effect, suicide rates tend to dip during shared experiences of catastrophe. Despite this decline, there are indications that the pandemic has triggered a ripple of mental health concerns across all age groups.
When the shelter-in-place measures went into effect in late March 2020, trips to the emergency department (ED) for anything other than COVID-19 plummeted by 42% across all ages.2 Yet, while these non-COVID trips declined, the proportion of ED trips for psychosocial issues actually increased by 69%.2 Children and teens experienced increases of about 24% and 31%, respectively.2 Further, there were troubling indications that suicide-related ED visits by girls were significantly higher than boys.3 In summer 2020, these visits for attempted suicide rose 26% among girls aged 12 to 17 compared to 2019.4
As COVID-19 rolls through 2021, clinicians are in desperate need of a comprehensive public health strategy to manage the anticipated increase in demand for treatment. This will be particularly important when working with teens. Many are dealing with multiple issues, including trauma, the effects of isolation, and a shattered sense of security and safety. COVID-19’s unique conditions may have created a new kind of posttraumatic stress disorder (PTSD), one rooted in fear of what might happen instead of what has happened. As a result, how PTSD is defined and diagnosed in the DSM-5 will likely need to change.
Until then, clinicians would do well to use a trauma-informed approach to care—one that considers and addresses the causes of traumatic stress. This may help stave off future conditions and nurture a resilience that will serve teens a lifetime.
Adapting to the “New Normal”
When the pandemic shuttered classrooms across the country, everyone scrambled to pivot. Schools were pressured to build remote-learning solutions from scratch. Families had to adjust their homes to create space and time for work and school. Kids and teenagers did their best to stay focused, engaged, and connected despite the uncertainty.
A September 2020 poll found that 59% of teenagers considered online school worse than in-person instruction, with 19% describing it as “much worse.”5 One national survey found that half of the teenagers were experiencing anxiety, trouble concentrating, and social isolation/loneliness during remote learning.6 Also in the survey, 31% of parents reported their child’s emotional health was worse than before the pandemic. About 53% worried their children would contract COVID-19 if they went back to school the following fall. Another 36% worried their mental health would suffer if they did not.6
In 2019, almost 19% of high school students in the United States had seriously considered suicide, 15.7% made an attempt plan, and 8.9% reported attempting suicide at least once.
Interestingly, parents were more likely to notice new or worsening symptoms of depression and anxiety in teen girls.6 In July/August 2020, the number of girls admitted to the ED for suspected suicide attempts had increased 26.2% over a year prior.4 In February/March 2021, this rate was now 50.6% higher.4 Among boys, this rate had increased only 3.7%.4 These were troubling statistics, especially since suicide is the second-leading cause of death among youths aged 10 to 17.7 In 2019, almost 19% of high school students in the United States had seriously considered suicide, 15.7% made an attempt plan, and 8.9% reported attempting suicide at least once.3
Mental health care providers scrambled to set up telehealth options in order to treat patients from afar. For many teens, COVID-19 took away coping strategies like going on a hike or visiting friends—things that have always had a positive impact on depression, anxiety, and chronic health conditions.8 Ironically, remote learning did provide some protections for teens, namely against bullying, which is more commonly done in person. One study noticed online searches for “school bullying” and “cyberbullying” dropped by 30% to 40% in spring 2020 and maintained this level through the following winter.9 As students gradually returned to school, however, internet searches about bullying increased.9
Alcohol and marijuana consumption among 12th graders remained stable during 2020.10 This indicated that even though the pandemic created perceived barriers to access, teenagers could still acquire these substances.10 Nicotine vaping, however, declined from 24% before the pandemic compared to 17%.10
Effects on Minority Youths
A Centers for Disease Control and Prevention (CDC) report in October 2020 acknowledged that virtual education presented more risks to the mental and emotional wellbeing of both parents and children.8 Children spent less time outside, less time with friends, and less time exercising because of it.8
Children in Black, Latino, and multiracial families were particularly impacted, as they were more likely to receive virtual instruction compared to White children.8 Parents of these remote-learning children were also more likely to report loss of work, job stability concerns, child care challenges, emotional distress, and difficulty sleeping.8
Among Latino families, adults reported a higher prevalence of stress in relation to food, housing, and job insecurity.11 Racial tension, protests, and riots added another layer of stress within Black, Indigenous, and people of color communities, where more than half of teens worried about dealing with racial justice issues at school.12
Asian Americans and Pacific Islanders were experiencing their own version of racism, as many held them responsible for the spread of COVID-19.13 No less than 81% of Asian Americans and Pacific Islanders felt violence against them was increasing in 2020.13
36% of teenagers found social media helped them cope with the pandemic.
The pandemic has affected just about every teenager in some way. Cut off from their peers, there was little opportunity to socialize and commiserate in person. It is only natural that young people turned to social media to connect with others. In fact, 36% of teenagers found social media helped them cope with the pandemic.12
The Influence of Social Media
Prior to March 2020, 26% of students spent 4 to 8 hours a day on social media.12 That shot up to 39% during the brunt of the pandemic.12 Aware that it was one of the few available ways to connect, many families relaxed their rules on screen time, with 81% saying it helped their children.14 Social media provided kids with comfort, inspiration, and something to do. Kids learned the latest TikTok dance, perfected making whipped coffee, and collectively laughed as school pranks easily transitioned to online platforms.
Among 14- to 22-year-olds, 43% said social media helped them feel better when they were depressed, stressed, or anxious—up from 27% in 2018.
A survey of teens from September to November 2020 revealed that 53% credited social media as “very important” to keeping them connected to friends and family.15 Among 14- to 22-year-olds, 43% said social media helped them feel better when they were depressed, stressed, or anxious—up from 27% in 2018.15 It was also where most of them got their news. A 2019 survey discovered that 54% of teens relied on social media and 50% on YouTube for information.16 When the murder of George Floyd and the killing of Breonna Taylor by police ignited racial unrest, teens turned to their phones to keep up to date.
But there was also a dark side to social media. A month after police Floyd’s death, the “George Floyd Challenge” encouraged some teens to recreate scenes of the crime and post them on social media. For BIPOC youth, it was a stark reminder of how powerful and hurtful social media can be. According to a survey, 69% of Black youth and 67% of Hispanic youths reported encountering racist content online.15 They were not the only ones.
About 74% of youth who identified as lesbian, gay, bisexual, transgender, and queer (LGBTQ) said they encountered homophobic content on social media. Gender and sexual identity were major topics of discussion in 2020, with almost a quarter of youths identifying themselves as some form of nonbinary gender.15 At 65%, LGBTQ youth were twice as likely to report symptoms of moderate to severe depression than non-LGBTQ youth.15 When 92% of them searched for health information online, the most common topics were COVID-19 and anxiety.15
Girls continued to be exposed to the harsh side of social media. Body dissatisfaction and body shaming played online, with 53% of girls exposed to at least 1 form of weight stigmatization.17 Eating disorders were also on the rise. The number of 12- to 18-year-olds admitted to a hospital for an eating disorder increased by 25% from March 2020. This was mainly attributed to girls, who experienced a 30% increase, compared to boys at 4%.18
By fall 2021, the prevalence of depression and anxiety in children and adolescents around the world had doubled from pre-pandemic levels to 25.2% and 20.5%, respectively.19 Symptoms were noted at higher levels later in the pandemic, especially in girls and older teens.19
With COVID-19 infection rates constantly fluctuating, schools and communities debated, hesitated, and grappled with the decision to reopen schools for in-person learning. The city of San Francisco had to sue its own school district in March 2021 to force it to open its doors to students, citing a loss in learning and mental health concerns.20
When students returned to school earlier this fall, only 31% felt emotionally prepared to socialize in person, 20% felt they would succeed in school, and 28% felt they would be able to focus on learning.12 Adding to the back-to-school jitters, 1 survey found that 3 in 4 teens were worried about contracting COVID-19 during in-person school.21
At least now, schools could fulfill their role identifying kids with mental health conditions as well as other situations, such as abuse and homelessness. In the meantime, federal and state governments are directing funds to provide training to schools and doctors to identify, treat, and refer children in need of mental health services.
Anxiety and depression continue to be the most common conditions among teens, with 1 in 3 adolescents meeting the criteria for anxiety by age 18.22 But there is growing discussion over whether the COVID-19 pandemic qualifies as a traumatic event. If so, this will affect how clinicians approach and treat patients.
The Case for PTSD
PTSD can occur when people have experienced or witnessed a traumatic event where lives and personal safety have been threatened. It involves 4 categories of symptoms (Table).
Currently, the pandemic does not quite fit the criteria set within DSM-5. Qualifying traumatic events are generally direct events that happened in the past. Yet, much of the trauma experienced during the pandemic has been the result of indirect reactions to what might happen in the future.23 For instance, there were teens who lost family members to COVID-19, an event that could meet the standards for PTSD. But what about waking up every day to news that thousands of people were dying from a ruthless virus and that you could be next?24
The sheer number of COVID-19 deaths was 4 times the amount of those killed in the Vietnam War.24 In the news constantly, it dominated our lives and conversations. Teens and adults alike worried that they would either contract the disease or inadvertently infect someone else. Surely this heightened—and prolonged—fear could qualify as a traumatic event.24
PTSD’s symptoms of intrusive thoughts and heightened arousal were certainly present.23 One June 2020 survey by the CDC indicated that 26.3% of respondents had symptoms of trauma and stressor-related disorders related to the pandemic.25 Another study found 13.2% of participants had PTSD symptoms even though their events, such as being in lockdown, did not technically fit the description of trauma.23 Through it all, teens endured the fear, uncertainty, and suffering largely alone, isolated from friends and loved ones. In fact, during the pandemic, loneliness was the strongest predictor of symptoms of PTSD, depression, and anxiety.26
The pandemic has been a true test of their resilience—the ability to develop inner strength despite traumatic events. Research on resilience plays a huge role in how PTSD is treated, and it holds promise for all those affected by COVID-19.
Resilience and Trauma-Informed Care
In its simplest terms, trauma is what happens when an event challenges a person’s ability to cope. Resilience serves as a buffer—a mental fortitude that allows people to bounce back from life’s challenges. It develops over time and is largely modeled and nurtured at a young age by parents and primary caregivers. Resilience involves a number of genetic components and can even be passed onto future generations with an inheritance range of 33% to 53%.27 Research even suggests that maternal resilience can provide protective factors to children after birth.27
During childhood, parents and caregivers can help build this resilience by reassuring that kids are safe, establishing healthy routines, and regulating their own emotions so they can help their children do the same.28 This reflecting or leading by example was understandably difficult for many families during COVID-19. No one knew what to expect, and the shifting sands of the pandemic created feelings of panic that were hard to control.
Children and adolescents who experience stress early in life are particularly susceptible to psychiatric vulnerability.27 This refers to the cognitive structures that can make people more fragile to stress.27 It is also why 75% of all mental illnesses are established by 24 years of age.29
How Parents Can Help Teens Build Resilience
- Make sure to attend to your own stress and self-care needs. Keeping reactions in check will not only reassure kids, but allow you to notice any emotional cues of distress your child may be expressing.
- Open the door to communication by asking questions that encourage them to express their feelings. Even a simple, “how does that make you feel?” can release a flood of emotions.
- Listen to your teens, and do not automatically offer solutions. Sometimes teens just want to be heard.
- Limit their exposure (and yours) to news and social media, as this can increase stress.
- Consistency is key. Make sure kids are sticking to a healthy routine that ensures they are eating well and getting plenty of rest.
One 2020 study compared brain scans and surveys of teenagers before and after the pandemic. It found that a teen’s ability to manage the pandemic’s challenges depends on the fortitude of their executive functions, the skills used to navigate life on a daily basis. Increased connectivity in the brain’s frontal lobe indicated greater resilience.30 As youth experience challenges, the love, reassurance, and support they receive from families, friends, and social networks can provide a protective factor that can build resilience. Higher socioeconomic status and education also provide protections.27 Creativity, humor, and altruism are also powerful tools that can buffer against the effects of stress and even trauma.27 Knowing that we are not alone can provide the comfort we need to build resilience. See the Sidebar for more suggestions.
After the 9/11 terrorist attacks, for example, suicide rates in New York declined “significantly” during the 180 days after.31 But the pulling-together effect can also exert itself in more subtle ways. One study noticed how fewer suicides occurred on Super Bowl Sunday, an indication that the “need to belong is so powerful that, when satisfied, it can prevent suicide.”32
Ultimately, understanding resilience holds the key to understanding the pathology behind mental health conditions. Adopting a trauma-informed approach to care gives clinicians a broader picture of what is going on so they can treat the totality of a problem, not just the symptoms. Rather than focus on what is wrong with a person, a trauma-informed approach asks, “what happened to you?” In this way, clinicians can build a relationship of trust with patients. Patients, in turn, are more actively engaged in their treatment, and together they can avoid retraumatization and identify healthy paths toward recovery.
In many ways, today’s teenagers are vastly different from who they were before the pandemic. The best years of their lives were thrown into chaos, and it is going to take some time to recover. For some, their sense of safety has been threatened. Others lost their momentum and motivation to do well in school or engage in their lives. Still others are recovering from grief associated with the death of a parent, friend, or loved one due to COVID-19.
Together, they have collectively shared a major life event—one that is sure to impact how their resilience evolves. On the cusp of adulthood, these teens still need lots of love, reassurance, patience, and positive examples. Parents can provide this by checking in with their teens, listening more, and acknowledging that even grownups get overwhelmed. Maintaining connections with others and sharing their thoughts is often the best way to diffuse pent-up feelings. By being open and honest, they can teach resilience to their children.
Clinicians can help by acknowledging that patients likely experienced the pandemic as a traumatic event ranging from large to small. Assuming trauma has occurred is often the best way to get to the heart of what led to their mental health challenges.
COVID-19 continues to exert a powerful influence on the lives of everyone, and time will tell how today’s teenagers will fare from this experience. It is up to us to help them reset and take action in their lives.
View the full article in Psychiatric Times.