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When Millis Public Schools opened their doors at the beginning of the 2021/22 school year, teachers and staff looked forward to seeing their students in real classrooms again.
“We were so excited we were all coming back to start the school year,” said Bob Mullaney, the Boston District Headmaster.
But the transition was more difficult than expected.
“Right from the start, we’ve seen high levels of stress, anxiety, and various behavioral problems in students,” says Mullaney.
Schools across the country are overwhelmed with K-12 students struggling with mental health problems, according to school staff, pediatricians and mental health workers. This surge has not only made it difficult for educators to return to the classroom, but has also weighed on an already strained healthcare system.
Of course, the rise in mental symptoms in children did not start this school year. Recent studies show that the pandemic exacerbated an already growing mental health crisis in young people. CDC data shows that the percentage of emergency visits for children’s mental health increased at the start of the pandemic. In the fall of 2020, the American Academy of Pediatrics, Children’s Hospital Association, and American Academy of Child & Adolescent Psychiatry declared a child and adolescent mental health emergency.
The US Surgeon General also drew attention to the crisis in a December 2020 report on the mental health of young people.
The rise in symptoms continued through 2021. According to the Children’s Hospital Association, there were more than 47,000 psychiatric emergency rooms in 38 children’s hospitals across the country in the first three quarters of 2021 – nearly 40% more than in the same period in 2020.
And the situation has worsened over the past few months.
Stressed students hurt others – and themselves
Schools see a lot of children younger than their age, says Dr. Vera Feuer, assistant vice president of mental health in schools at Cohen’s Children’s Medical Center in Long Island. For example, high school students act more like middle school students and often push and push each other in the hallways, she says. Some children who are having difficulty often display their emotions with more aggression and violence.
“In some counties, the numbers of student fighting are really alarming,” says Mullaney.
In addition, Mullaney said, there have been recent reports of violence against authorities: a school principal in Massachusetts was attacked by a student and in other schools staff members were attacked by students.
And many students get injured. There has been an increase in the number of students in his district who have reported self-harm, suicidal ideation, and attempted suicide, Mullaney said. His school district has referred more children for mental health treatment than ever before, he added.
Based on data from nearly 40 children’s hospitals across the country, there were 14,630 emergency rooms for children aged 5 to 18 between January and September last year.
“And unfortunately, younger children are experiencing higher rates than in the past,” said Amy Knight, president of the Children’s Hospital Association (CHA), which hosted a congressional briefing on the mental health crisis of young people.
In fact, health care providers across the country are seeing more referrals with cases beyond the capacity of schools.
“In any case, we see schools referring children with more behavioral problems and aggression,” says Feuer. She and her colleagues also see children with symptoms of depression and those who refuse to go to school who need to be screened for suicide risk. According to CDC data, the number of emergency room visits for suspected suicide attempts by people ages 12-25 increased through May 2020, and that number has continued to increase in children’s hospitals across the country.
The psychological costs of a year without face-to-face school
Much of this surge in reports of mental health problems is due to the stress of returning to school, says Dr. Tami Benton, chief psychiatrist at Children’s Hospital of Philadelphia, citing the observations made by her and her colleagues while working with patients and schools.
“The year they didn’t go to school was a year they didn’t have the opportunity to develop the social skills that normally appear during their developmental phase,” she says. “And all of this is somehow made up for under exceptional circumstances.”
Atlanta high school junior Francesca Henderson says that after a year in isolation, many of her friends were scared of finding their way around the social landscape. While Henderson herself was able to maintain her friendships through the pandemic, she initially found it difficult to interact with people at close range again.
“My biggest problem was getting used to personal life again,” says the 17-year-old.
Academics were stressful too. “You made a lot of things easier [last year], “says Henderson.” We had no exams; we had projects and almost all of our reviews were open. So you didn’t have to learn that much. “
Henderson and her colleagues have had to relearn skills like time management and are focused on dealing with this year’s tougher academic pressures.
Some children found it particularly difficult to catch up, says Benton.
Children with special needs who were in need of personal support at school lagged far behind their peers, both academically and developmentally, in the final year of school, as did children diagnosed with mental illness prior to the pandemic.
“A lot of people were late in performing so they actually felt worse when they went to psychiatric treatment,” says Benton. “For some of these children, who actually had pretty strong self-help groups before the pandemic, [they] had to restore it [relationships] when they got back to school. “
Henderson has seen this in some of her friends, whose pre-pandemic emotional well-being benefited greatly from social interactions at school. “So you take away the cold turkey, it was kind of harmful.”
Then there are children who mourn the loss of loved ones to COVID-19. An estimated 175,000 lost a parent or caregiver, according to a CDC study. Colored children are disproportionately affected by these losses as long-standing inequalities have resulted in higher death rates in their communities. The CDC study showed that Asian children were 4.5 times more likely to lose a parent or other caregiver to COVID-19 compared to white children, black children 2.4 times more likely, and Hispanic children twice as likely.
“And this trauma alone is very significant,” says Dr. Nicole Christian-Brathwaite, child and adolescent psychiatrist and chief medical officer at Array Behavioral Health, a telepsychiatry company. It is especially strong “when there are some children who have lost generations of family members and then go to school and face that stress without necessarily having a therapist or school counselor or nurse on hand.”
There is also not always enough help for these children. Schools in many underserved communities lack psychological support, she adds. “Some schools have an advisor who is spread across an entire district.”
And many children who developed symptoms of mental health problems in the first year of the pandemic did not get immediate help because they were not from school staff who may have discovered symptoms early.
Before the pandemic, schools were “a sort of first responder,” said Mullaney, the superintendent of Massachusetts, when it comes to student mental health problems. Teachers and other school staff would identify changes in behavior or symptoms of mental illness and connect these children to help. But that proved more difficult in a virtual learning environment.
A perfect storm: more need for help, harder to come by
With an already saturated health system, children and families have difficulty getting help in a timely manner.
“You only see this perfect storm out of increased need [and] Difficulties in accessing medical care, “says psychiatrist Feuer, pointing out the need for psychologists.” All of them have booked or are not accepting new patients or are planning very far in advance. But in many cases, not even when scheduling, just because they are so full.
As a result, families have no choice but to take their child to a hospital emergency room for diagnosis and treatment of any mental health problem, especially if the child is in crisis.
Emergency room visits at Colorado Children’s Hospital for Child and Adolescent Mental Health have increased 75% in the past few months, Heidi Baskfield, vice president of community health and advocacy at Children’s Hospital Colorado, said at a virtual congressional briefing last month. She called the situation “untenable” for providers and communities.
“Every day between 15 and 40 children with mental health problems seek help in our emergency rooms,” she says. “We are constantly busy with all of our psychiatric departments. Our outpatient visits lasted from three weeks to sometimes over nine months, going back a year. ‘ “
The sharp rise in demand has prompted schools and healthcare providers to find spontaneous solutions. Overworked school staff has turned to psychologists in many places for advice on how to better recognize symptoms of mental and behavioral problems so that they can help children earlier. In some well-resourced communities, schools and providers work together to provide care for children before things escalate.
At the federal level, to some extent, the problem was recognized and there were some resources to address it. The CARES Act and American Rescue Act have helped many schools hire more counselors and social workers to meet the increased demand.
But Mullaney is still concerned about what will happen when the money from the COVID relief plans runs out.
“We have to find a way to continue these services,” he says. “The need will remain in the years to come.”