SAN DIEGO — Since the COVID-19 pandemic struck last March, psychiatric emergency visits at Rady Children’s Hospital near San Diego have crept up as youths and teens struggle with virtual learning, social isolation and unstable home lives.
“March through May, we had a spike, about a 5 percent to 7 percent increase in the kids coming to our emergency room,” said Sandy Mueller, senior director of behavioral health services for Rady Children’s Hospital. “That dipped down in May to June, when school let out. And then we saw a 7 percent increase to the present.”
In similar findings, a report released by the Centers for Disease Control in November showed that mental health visits comprised a greater percentage of pediatric emergency room visits during the pandemic in 2020, compared to the same months of the previous year. From mid-March 2020 through October, the report stated, “the proportion of mental health–related (emergency department) visits increased sharply,” rising 24 percent among children ages 5 to 11, and 31 percent among adolescents ages 12 to 17, over the same period in 2019.
Moreover, many of the patients at Rady have more severe and complex problems than the hospital typically sees, Mueller said.
“Those kids have higher acuity, higher levels of anxiety and depression,” she said, including “social isolation, food insecurity, family stressors at home. There’s a stronger overlay of child abuse issues. Those kids aren’t able to be in school, so they’re enduring more abuse at home.”
The problems facing families may have deeper, more enduring effects on children, who don’t have the perspective to see the pandemic as a temporary circumstance.
“COVID, job loss, social isolation, that’s a global issue for adults and kids,” Mueller said. “But the complexity of that for kids with underlying mental health issues is higher.... They don’t have free meals. Their social network, after-school programs, those are severed.”
The increased mental health visits at Rady, however, aren’t consistent with the trend in San Diego, where countywide mental health emergency room visits for youth have declined, said Luke Bergmann, director of behavioral health services for the County of San Diego. Data from 12 local hospitals show that psychiatric-related visits for youth declined 27 percent from February 2020 to January 2021, compared to the same period from 2019 to 2020.
That’s probably not a good sign, as the drop likely represents mental health problems that aren’t getting treated.
“It’s not necessarily telling us that the need for crisis care is down, but it’s telling us that people are accessing crisis care at much lower rates,” Bergmann said.
Parents may be taking children for emergency care at Rady because of its specialty in pediatrics, he said, but could be reluctant to seek care at other hospitals during the pandemic, or unable to navigate mental health systems.
Substance abuse treatment for all age groups including young people is also down, while overdose deaths have risen, he said. The deferred treatment for mental health disorders will likely have costs down the line, Bergmann cautioned. Mental wellness is a “lagging indicator,” in which the effects of trauma today can show up months or years later, he said.
“We know that mental trauma experienced among young people has impacts on their lives that can last many, many years,” he said. “We know this through ACEs data (adverse childhood experiences) when young people experience trauma, we can see the impact in both their mental health and their physical health even decades later.”
From frustration with virtual learning and anxiety about grades, to the loss of normal social life, students now face a variety of stresses that can seem insurmountable, even for those without underlying mental health problems, said Kristine Brady, a psychologist in private practice in Encinitas.
“There’s just so much hopelessness, and teenagers have a hard time understanding just how temporary this is,” she said. “They are 13 years old, so this feels like a lot of their life. Kids are just missing out on these milestones. There’s a lot of losses: no prom, no yearbook signing, no graduation. Kids who used to complain about school are now saying, ‘I’m missing school.’”
Struggles with virtual education affect students across the academic spectrum. High-achieving perfectionists fear not getting good grades or getting into the college of their choice, while those with learning disabilities, attention deficit hyperactivity disorder and other challenges worry they might not graduate at all.
“That high-functioning, high-academic kid is cutting, wanting to kill themselves, and has so much anxiety because they feel they’re not going to succeed in life, and it’s very fatalistic. They feel it’s ruined their life,” Mueller said. “Then you have kids who are academically struggling who are failing even more, who feel like this is hopeless, and why bother, so they’re withdrawing.”
Virtual learning platforms themselves create stress, as students scramble to master content while learning all the apps and systems used to deliver it, Brady said.
“They have a really hard time navigating the system,” she said. “The teacher may say turn on the whiteboard, share your screen. They have to shift from three different apps on whiteboard, which may be slow. If they’re called on to answer, and they’re locked, that brings on huge anxiety. Especially if you have ADHD, those kids are really struggling and they already have trouble with organization. To have to organize something on a screen you can’t even see is setting them up for failure.”
Her own son Ryan Kies, 16, a student at San Dieguito Academy, said online learning can be confusing and frustrating, even for students without academic obstacles.
“Not having classmates nearby is a big part,” he said. “Usually, if you have just a small question you could ask the person sitting next to you, but now that’s not an option. If you miss just a small bit of information that the teacher says, you have to stop the whole class.”
Students are self-conscious about participating on Zoom, and worried about being called to answer questions online, Brady said. Without friends and classmates for support, they’re less able to cope with those stresses.
“Teenagers need to be around other teens, their job right now is to get out there and explore with other kids, and that’s not possible right now for many,” she said.
Parents can help by expressing empathy, backing off from strict academic expectations, and taking time for fun, safe family outings, or allowing students to take part in socially distanced activities with friends, she said.
For students from troubled families, the setbacks of the pandemic are even greater, and potentially life-threatening, Mueller said.
“We’ve had a lot more kids who have been significantly abused,” she said. “Parents are losing jobs, stressed, and drinking more, and they’re all home. The environment is intensified, so we’re seeing a lot more injuries to kids.”
For younger children, that often shows up as skull fractures, while adolescents suffer bruising or broken bones from physical abuse. Mental and physical health crises often overlap, she said.
“Older kids coming in saying they’re suicidal, but when we assess we find out they’re abused in home and have acute injuries,” Mueller said.
Job loss and other financial pressures cause family conflict to escalate, and isolation obscures its consequences. Child sexual abuse is both worsened and hidden under the cloud of the pandemic, she said.
“Children being sexually abused in home had hours of reprieve (during the school day) and now they’re with their perpetrator 24-7 and have no way to escape,” she said. “For our kids that have child abuse issues, there’s a higher chance for their parents to reoffend or abuse, because those kids can’t get a break from them.”
School closures also confound efforts to identify those threats. Teachers are mandated reporters, who must notify public safety and health authorities of suspected child abuse. They are often the first line of defense, and sometimes the only trusted adult whom abused children can turn to for help. With schools out of session and students’ cameras often turned off during class Zoom sessions, teachers might not see the danger signs, Mueller said.
“School is a safety net for kids, and we took that safety net away, and we don’t know what’s going on in the homes and what their needs are,” she said.