November-December 2021 | Parenting

Are the kids all right?

The isolation, grief and uncertainty of the pandemic have led to a mental health crisis in children and teens

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Illustration by Hannah Agosta

The volleyball never talked back. But amid the loneliness of the pandemic, 13-year-old Malia could confide in it—how she wanted to emulate the “glow up” videos on TikTok that encouraged girls to use the lockdown to reinvent themselves and improve their looks. How she was angry at the friends she saw on social media, gathering despite COVID-19 restrictions. How she was unhappy with who she was, something she discovered only after the many activities of her busy life were stripped away.

Before the pandemic, she played multiple sports. She took the hardest classes available, including honors geometry as an eighth-grader, and participated in clubs at her public middle school in Montgomery County. “I just tried to keep myself busy, just go to the next thing, go to the next thing,” says Malia, now a high school volleyball player.

But none of that was happening as Malia hunkered down with her younger brother and her parents, who were tracking the latest news about the virus. (She and her parents requested that their actual names not be used to protect their privacy.) Malia was so scared of contracting COVID and giving it to her parents that she locked herself away, she says, and rarely reached out to friends. Playing volleyball had been a huge part of her identity, and “for it to just be gone, it was heartbreaking,” Malia recalls.

“When COVID started, I was like, oh my gosh, I don’t have all these things to keep me busy,” she says. “I didn’t have the distractions I needed to distract myself from the fact that I wasn’t happy with who I was.”

As the weeks passed, she became “really anxious,” unable to sit and watch a movie, unable to tolerate going on a drive with her parents just to get out of the house. Checking social media didn’t help—she’d only get angry when she saw photos of people hanging out when everyone was supposed to be social distancing and feel awful when she saw people posting on Instagram “how perfect their life was.” And then there were all those posts about how girls and women should use the lockdown to change their style, transforming themselves mentally, physically and emotionally.

Practicing outside with her volleyball, she’d tell herself that she needed to restructure her life, to get better at things she didn’t do well enough, to create a more perfect version of herself. An athlete her whole life, she decided to use the summer after eighth grade to get really fit.

So she started running, clocking mile after mile, day after day.

By September 2020, Malia’s parents were noticing that her weight had dropped significantly. At first, it seemed that Malia’s running was just a way to stay active. She “enjoyed being busy” and was “never the kind of kid to just sit around,” her mom says. They’d noticed that she was eating less food, but she was also choosing healthier options. “It took us awhile to realize there was a problem.”

Malia says she knew she’d lost a lot of weight and needed help, but she couldn’t stop running. “If I didn’t run, I would feel, oh my gosh, I’m a mess. This is not productive. This is not good,” she says. “I would beat myself up if I didn’t do it.”

Malia says she wanted someone to tell her that she had to stop because she knew her physical and mental health were suffering, even though a halt to running would keep her from finishing what she now understands was an irrational “journey” to achieve her perfect self. “I looked completely different. My dad said I lost my spark,” she says. “And I was so unhappy with myself.”

Her parents took her to the family’s pediatrician, who diagnosed Malia with an eating disorder and recommended an outpatient treatment program through Children’s National Hospital in Washington, D.C., that focused on mental health and medical and nutrition issues. “We were glad we did, because we were told that we got her in at a good time,” her mom says, explaining that Malia was in the early stages of her disorder, diagnosed as anorexia. “It really did help, but it took months and months—and it was very hard.”

Both parents worried whether they were providing the kind of support their daughter needed throughout the continuing isolation caused by the pandemic. “We didn’t know if we were doing the right thing through any of it,” her mom says.

In December 2020, Malia was also diagnosed with anxiety and depression. She began taking an antidepressant, which, along with therapy, marked “a turning point” in her recovery as the new year began, her parents say. “I noticed her starting to feel better about herself after that point,” Malia’s mom says.

Talking to a therapist during her treatment helped Malia realize that “there’s no such thing” as a perfect version of herself and that she should embrace who she is. “I needed someone to tell me that ‘what you were doing is not right and you know that, and I know that, and so now we’re going to fix that.’ It was, like, someone who actually listened to me,” she says. “Not that my parents didn’t listen to me, but they didn’t understand what I was going through.”

Even before the pandemic, experts had long warned of a mental health crisis among the nation’s children. Studies have found that one in five suffers from a diagnosable mental health disorder. Loneliness, depression and self-harm “increased sharply” over the past decade among U.S. adolescents, especially girls, according to The Journal of Adolescence. As the pandemic continued, experts predicted that the crisis would worsen because of the depression, anxiety and uncertainty that kids were experiencing due to school closures, isolation and family trauma caused by COVID.

“Before the pandemic, it’s not like our kids were doing great,” says psychologist Lisa Sanchez, whose Chevy Chase practice serves children, adolescents and adults. “Whatever was present before the pandemic—for example, if your kid had a tendency to be kind of anxious, if your kid had a tendency to be irritable, even if your kid had [obsessive compulsive disorder] or something more significant than that—once the pandemic hit, the severity and intensity of all of that got worse. Whatever was there before just kind of took a nosedive.”

Children’s mental health-related visits to hospital emergency rooms started increasing in April 2020 and remained elevated through that October, according to a November 2020 CDC report. “Compared with 2019, the proportion of mental health-related visits for children aged 5 to 11 and 12 to 17 years increased approximately 24% and 31%, respectively,” the report says.

This past June, the Centers for Disease Control and Prevention disclosed that between Feb. 21 and March 20 of 2021, visits related to suicide attempts were nearly 51% higher among girls than during the same period in 2019, while the number of visits among boys increased by less than 4%, according to the report.

Adolescent girls and young women are more likely to attempt suicide, while adolescent boys and young men are more likely to die by suicide, according to a 2019 report in the International Journal of Public Health. A September article in the Journal of the American Academy of Child and Adolescent Psychiatry also showed a sharply rising suicide rate among Black girls between 2003 and 2017.

Psychologist Mary Alvord is the director of Alvord, Baker & Associates, which has offices in Chevy Chase and Rockville. She says “girls probably do more self-harm,” but boys choose more lethal means.

“When we first had to shut down, there was so much anxiety and so much sadness because kids went into virtual school, parents had to work at home, everyone was sort of frantic with trying to negotiate this new way. It happened so quickly,” says Alvord, who also is an adjunct associate professor of psychiatry and behavioral sciences at The George Washington University School of Medicine and Health Sciences. “I saw a lot of sadness, you know, loss of friendships, loss of activity, loss of the rites of passages, graduations, moving on to the next level.”

In June 2020, Montgomery County Public Schools (MCPS) confirmed that three students killed themselves in a two-week period. Though the deaths of a high schooler and two middle schoolers weren’t publicly linked to the pandemic, the suicides led officials to call for more mental health resources and services for children.

Therapists say the overuse of technology proved to be a big trigger for depression and self-harm ideation for children, who may have been spending hours alone on their devices, especially if their parents were essential workers. Viviana Azar, a therapist and manager of Montgomery County’s Child and Adolescent Behavioral Health Services, says of those seeking help, girls were more likely to be spending a lot of time on social media, leading to eating disorders and self-harming behavior, while boys tended to spend time alone playing video games, leading to interrupted sleep cycles, lack of interest in everyday activities and self-neglect. The department serves children ages 5 to 18 and their families who receive Medicaid, don’t have health insurance, or are undocumented. Families contact the county’s treatment centers in Rockville and Silver Spring for help, but the agency also receives referrals from pediatricians, MCPS and Child Welfare Services, Azar says.

The disruption of routines, lack of structure and far greater exposure to news—including the coverage of the pandemic and the violence leading to the racial justice movement—all created more stress for kids and contributed to their feelings of anxiety, anger and fear, says therapist Jonah Green, whose Kensington practice works with children and families in the Bethesda area. Being stuck at home meant children were more exposed to conflicts in their families—such as sibling discord around favoritism and extramarital liaisons—because everyone was spending so much time together. Family conflict also erupted over differences with parents, or even between parents, about how to stay safe from the coronavirus, Green says.

Some of the anxiety and sadness lifted during the summer of 2020, therapists say. But those feelings intensified again in the fall with the continuing isolation connected to virtual learning, grief over the loss of relatives, family financial stress, and other issues caused by the virus in the time before vaccines became available and hopes began to lift. Now, after a summer of feeling like life was returning to normal, families are again seeking help as anxiety has resurfaced amid the surge of the delta variant.

A survey of Montgomery Blair High School students in late October 2020, which garnered more than 700 responses, showed a decline in student motivation. Just under 25% of students responded that their academic motivation was fairly strong during remote learning, compared with 72% who had previously felt that way about in-person classes. “There were definitely feelings of helplessness and it’s not worth it. They didn’t connect as well, not being able to see friends,” says Xander Toti, a 2021 Blair graduate who for two years led the Student Government Association’s Student Wellness Committee, which conducted the survey. “Personally myself, I dealt with that, too.”

At Suburban Hospital in Bethesda, the number of kids, particularly teens, with mental health crises who were coming to the Shaw Family Pediatric Emergency Center remained consistent with pre-pandemic numbers, while the number of those with more common pediatric health issues “just precipitously fell off,” says Dr. Dominique Foulkes, the center’s medical director. While the number of kids experiencing mental health crises did not increase, more of those who came were suicidal or a danger to themselves, “so we had more kids needing to be admitted,” she says.

More families with tweens and teens also came to the center seeking therapy on an outpatient basis, including “a lot of kids who were stable, they’re on their medications, they had their outpatient providers in place” before the pandemic, but their conditions worsened because of the stress and because they couldn’t meet in person with their therapists, Foulkes says.
Jenny, a Silver Spring mother of three boys who didn’t want to use her full name, says the closure of the local elementary school in the spring of 2020 proved disastrous for her youngest son, who had been “highly anxious” even before the pandemic. Unlike his two brothers, who could use their cellphones to stay in touch with friends, the boy was cut off from his social circle and “sort of left to his own devices a lot of the time” as Jenny worked full time at home.

Jenny says her son, now 10, became “very aggressive and angry,” and his schoolwork started to suffer. “He would swear at me and he would just yell and he was extremely unpleasant,” she says.

Looking for help, Jenny contacted the office of a therapist in Friendship Heights who had successfully counseled her 13-year-old middle son years earlier on his own anxiety. But the office was offering only virtual visits, and Jenny and her ex-husband decided their son wouldn’t benefit enough to justify the $300 per-session cost before they met their deductible. “So we just sort of had to muddle through it, and it was unpleasant for the whole family because he was just very disruptive,” she says. “It was also very hard on me and my ex-husband because we knew in normal times we could help him, and we really felt powerless to help him.”

During the pandemic, families seeking help for their children often have confronted the cost of treatment as well as the sharp disparity between the number of mental health professionals and the demand for help. Under the Affordable Care Act, most insurance plans are required to cover mental health care. But co-pays and qualifying criteria may vary, according to GoodTherapy, a website dedicated to making it easier for people to access mental health services. A therapy session can cost from $65 to $250 per hour, the website says.

“We’ve always had a wait list, and now we have a very long wait list,” says Alvord, a strong proponent of telehealth. Now that children are back in school, families are competing for the limited number of therapy sessions that can be scheduled after school, she says.

Green says his practice has accepted “very few” new patients since last winter. “People come back; people use mental health services longer,” he says. “It’s just overwhelming.”

As of mid-September, 35 children were waiting for services provided by the county, Azar says. If families have been waiting more than a month, she says, the program’s therapists will check in and possibly refer them to other services, including the National Alliance on Mental Illness, which holds support groups locally in English and Spanish.

Malia’s parents consider themselves fortunate that they were able to secure outpatient treatment at Children’s National. “We were very happy with the doctors,” her dad says. “That really made a difference. Getting help and getting help early and getting the right people was critical.”

In late August, Amy Dawson Taggart watched her visibly agitated son Vincent pace around their Silver Spring home, concentrating on making sure he had everything he needed before they left for his first day of fourth grade. Though he’d done well with virtual learning and had attended in-person classes at Sligo Creek Elementary School last spring, Vincent was feeling anxious because he didn’t know what to expect now that everyone was returning to school full time.

Once they were in the car, Taggart says, she was surprised to notice that Vincent was sitting up straight with his eyes closed, breathing deeply. His palms were turned upward in a traditional meditation pose, with the thumb and middle finger of each hand touching, as he recited a mantra: “I’m good. I only have to focus on today. The only thing I need to focus on is this moment, this day. I don’t need to worry about future days. Only today. Everything will be OK today.”

Taggart says she realized that Vincent was using the mindfulness meditation skills that he’d been taught in class as far back as first grade to calm his anxieties about returning to school. “There’s no question that was the single most powerful demonstration of it,” Taggart says. “And it worked.”

While being back in school is a positive step for many students, the readjustment isn’t necessarily easy, therapists and doctors say. “It’s almost like everybody has been deconditioned,” says Dr. Sarah Edwards, director of the new Children & Adolescent Psychiatric Unit at the University of Maryland Children’s Hospital in Baltimore and an assistant professor of psychiatry at the University of Maryland School of Medicine. “We have muscles that are a little bit weak. So for our youth, they have been deconditioned from tolerating periods without social media and electronic devices. Focusing and concentrating for a longer period of time is another thing [where] they need to kind of build up the brain muscle, and just having to be out of the house for that eight-hour day at school.”

For some kids like Jenny’s son, being back in school is the perfect antidote. “Getting him out of the house and getting him back with his peers, it was almost as good as therapy,” says Jenny, whose son also attended class in-person in the spring and summer. “He’s like a different kid again, and he’s back to himself.” The school also offers a support system beyond academics that “I just can’t do at home by myself,” she says. “I mean, we’ve learned that over the last 18 months.”

Teaching mindfulness and other types of social-emotional learning skills is a big part of the MCPS playbook this year, officials say, as schools focus on helping students return to classrooms. Students also will be learning life skills through “Leader in Me,” a newly purchased social-emotional learning curriculum by FranklinCovey Education that’s based on Stephen Covey’s 1989 book The 7 Habits of Highly Effective People.

School counselors, who are expected to play a key role, spent the summer preparing to help students as they unpack their “emotional backpacks” throughout the school year, says Lindsay Cao, MCPS’ coordinator of school counseling. “Counselors have a variety of things they do—it’s not just the mental health component—so we’ve made it very clear that that needs to be their main focus,” Cao says.

Counselors and school psychologists received training—including sessions provided by the Center for Anxiety and Behavioral Change in Rockville—on helping students deal with their anxieties about returning to school and their grief over losing loved ones, according to Cao. MCPS has partnered with Caring Matters in Gaithersburg to hold sessions for students impacted by grief. Counselors also received training on making sure social-emotional lessons were culturally responsive, Cao says.

Counselors are continuing to meet virtually with students and families, who also can attend Mental Health Mondays, a weekly virtual workshop that began last spring and provides tips and advice. Student well-being teams, created during the pandemic to develop resources for students and families, will continue reaching out to students identified as needing help, Cao says.

This school year also marks the first time that students can cite their mental health or “well-being” as a valid reason, with a parent’s note, for missing school. The county school board approved the idea last spring.

Student activists who pushed for the change also have focused on raising awareness about mental health issues and how they can help their classmates readjust to school. They’re calling for more counselors and school psychologists, and access to services outside of schools, says Hana O’Looney, the student member of the county school board. Addressing mental health in health classes is another way to reduce the stigma so students aren’t afraid to ask for help, she says. “If we want to make sure that kids are actually using and taking advantage of the mental health days, we need to make sure they feel comfortable talking about it with their parents and teachers,” she says.

At Blair High School, student government leaders have worked on helping students return by advocating for better teacher-student communication, including clear direction regarding when assignments are due and consequences for late work, and for teachers to provide more breaks for students during the day. Other initiatives call for the scheduling of a monthly homework-free weekend, the designation of relaxation spaces during lunch where students can catch up on sleep, and the creation of study groups so “students can help one another really catch up on content,” SGA President Salma Chicas says.

By last spring, Malia was feeling “so much happier” than she’d been earlier in the pandemic. She was soon back in school and playing volleyball again. Through therapy, she’d learned to find ways to connect with those she loved, and she had grown closer to her younger brother. Over the summer, she and her family traveled to see relatives, and she went to sleepaway camp. “Being able to spend time with people has been just amazing. It also has been a really big part of how I got better, realizing there are people there for me,” says Malia, who still takes medication and checks in with her pediatrician and psychiatrist.

If a silver lining has emerged from the pandemic, therapists say, it’s more families, educators and society at large grasping the importance of caring for children’s mental health. “The good part is: It did normalize mental health for a lot of families. It becomes more routine to have a conversation—whereas they were doing that with physical health before, maybe they weren’t doing that as much for mental health,” says Niki Picogna of the Bethesda Play Therapy & Healing Center. “I think it could be a positive thing. We’re taking care of our feelings, too. We’re learning how to manage it together and being honest and having these conversations.”

Once Malia began reconnecting with friends, she realized that she wasn’t the only one with mental health issues during the pandemic. Two of her friends also had been diagnosed with eating disorders; one spent several months in a residential treatment center.

“I wish I had reached out to them when I was struggling because we could have helped each other,” Malia says. “I saw everyone on social media and I thought, wow, no one else is struggling. But that was wrong. Everyone else had their own thing about COVID, whether they struggled how I did or they struggled completely different than I did.”

Contributing editor Julie Rasicot lives in Silver Spring.


Resources

Here are a few of the resources available in the Washington, D.C., region for families seeking children’s mental health services:

  • For Montgomery County’s Child and Adolescent Behavioral Health Services, contact 240-777-1450. The Rockville treatment center can be reached at 240-777-1432, and the Silver Spring center at 240-777-1450.
  • To contact the Rockville offices of the National Alliance on Mental Illness, call 301-949-5852 or visit namimc.org.
  • The American Psychiatric Association in Washington, D.C., provides information and a directory of doctors at psychiatry.org.