[Skip to Navigation]
Sign In
Editorial
August 9, 2021

Addressing the Global Crisis of Child and Adolescent Mental Health

Author Affiliations
  • 1Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 2University of Pennsylvania, Philadelphia
JAMA Pediatr. 2021;175(11):1108-1110. doi:10.1001/jamapediatrics.2021.2479

Over the course of the past year of the global COVID-19 pandemic, growing attention has focused on the mental health and well-being of children and adolescents. The study by Racine and colleagues1 calls attention to a critical need that must be addressed to respond to the global mental health effects of COVID-19 on the world’s children and adolescents. This meta-analysis consisting of 29 studies totaling 80 879 youth globally found prevalence estimates of clinically significant depression and anxiety symptoms to be significantly higher than the estimates reported prior to the onset of COVID-19 and subsequent lockdowns. Of added concern, throughout the past year, the authors found that prevalence rates for depression and anxiety increased as the pandemic progressed.1 Notably, differences were found in rates of depression and anxiety symptoms for older adolescents and girls, with both groups expressing higher rates compared with younger children and boys, respectively. Likely, these findings may not be surprising in the context of the extraordinary changes faced by youth including social isolation, loss of peer interactions, and other lost supports no longer accessible through schools and communities. Racine and colleagues1 highlight concerning escalations in the mental health needs of children and adolescents, including important sex differences. This meta-analysis suggests that globally, children and adolescents may experience increased rates of psychological distress requiring clinical attention and emphasize the importance of continued ongoing longitudinal research to fully understand whether clinically significant symptoms are sustained, exacerbated, or resolved over time. This level of inquiry will ensure the ability to understand and respond to future mental health needs of children when these crises arise.

Prior to COVID-19, global estimates for depression and anxiety, 2 of the most common mental health conditions of childhood, were estimated to be 8.5% for depression2 and 11.6% for anxiety.3 The meta-analysis by Racine and colleagues1 suggests significantly higher rates for clinically significant depression (23.8%) and anxiety (19%) for children and adolescents, a more than 2-fold increase in prevalence rates compared with those reported prior to the pandemic.

While this meta-analysis is significant in aggregating the highest-quality published and unpublished studies to estimate increasing rates of depression and anxiety for youth, the authors appropriately note several limitations of their study. Although the mental health effects of COVID-19 on children and adolescents have been of important interest, mitigation strategies have resulted in most of the mental health diagnostic data being gathered using parent- and self-report instruments.

Another important limitation is that the study’s findings represent North America, Europe, and Asia with 14 of the 29 studies specific to China, limiting generalizability of these findings, which is especially relevant because 90% of the world’s children live in low- or middle-income countries.4 A prior meta-analysis estimating global prevalence rates for psychiatric disorders among children and adolescents from 27 countries representing every world region found that 2.6% of youth had any depressive disorder and 6.5% had any anxiety disorder.5 Finally, few studies included youth from racial, ethnic, or gender minority groups, who are more likely to experience mental health effects of COVID-19.6 Despite these limitations, Racine and colleagues1 add to our knowledge of what must be addressed now and for the future.

The data are sobering but not surprising considering the effect that COVID-19 has had on the lives of children and families across the world. We know that the mental health of youth has been negatively affected by the COVID-19 pandemic globally7 and that safety measures, adaptations to schooling, and contraction of buffering community supports and services are significant contributors. Concurrently, many countries report that youth are seeking short-term mental health treatment in emergency settings.8,9 In some nations, children seeking care for emergency mental health services has increased with more children presenting with severe symptoms requiring hospital level care,8,10 and significant disparities have been noted for youth from minority groups.11 What is true worldwide is that needed mental health services are largely unavailable and children are waiting for care.12,13

The authors suggest urgent action to address the increasing mental health needs of youth, and fortunately, we have effective interventions to address depression and anxiety. What we do not have are easy solutions for increasing mental health access.

It is well known that access to evidence-based treatments for depression and anxiety are effective and that outcomes are poor without treatment. Kapur and colleagues14 demonstrated decreased regional suicide rates when clinicians adhered to national treatment guidelines for depression. Understanding levels of impairment among those identified with depression and anxiety symptoms will assist in targeting appropriate interventions. For example, in the meta-analysis by Polanczyk and colleagues,5 an increase in diagnostic prevalence rates for all mental health conditions increased when youth with symptoms but not impairment were considered. This is important because youth with subthreshold symptoms are less likely to require intensive interventions than youth who have functional impairment, highlighting the importance of understanding severity when providing interventions. In the study by Racine et al,1 the inclusion of studies using self-report instruments with well-validated severity scales could guide us when planning treatments. For example, identifying youth with severe symptoms can facilitate planning for closer monitoring and follow-up for adherence to appointments and treatment guidelines to assure safe and effective care.

Most importantly, understanding the effect of COVID-19 across all nations will be essential to effective creation and implementation of interventions. COVID-19 has had a disproportionate effect on disadvantaged and marginalized families, highlighting disparities for youth linked to discrimination, racism, preexisting inequities, poorer access to care, increased exposure to risk, underrecognizing of illness, poor-quality treatment, limited economic resources, crowded living conditions, and the like. Also, widely seen across the globe, youth from marginalized and minority groups are also more likely to experience grief and loss of family members to COVID-19 secondary to overrepresentation of the virus in communities that have been historically marginalized.15 As noted by the authors, future studies must include low- and middle-income countries. How minority populations are psychologically affected by COVID-19, as well as access to mental health care, must be thoughtfully considered. For example, Black youth in Canada experience significant barriers in accessing mental health treatment, despite having universal health care.12 Aboriginal youth in Australia also experience significant disparities in access to mental health care.13

The increased mental health needs identified in the meta-analysis call for immediate action for every country. Our responses must consider the range of child mental health infrastructures available, which vary across countries, with some having well-developed and coordinated mental health services, while others have informal, limited, underfunded, or fragmented systems of care.13 It is critical to identify intervention strategies that are empirically supported and culturally appropriate in countries and communities for children and families.

The authors’ call for urgent action is well founded. Each country has learned lessons during COVID-19, and that knowledge should be leveraged, personalized, and shared to respond to this crisis. We have learned throughout the pandemic that universal and indicated interventions for anxiety and depressive symptoms can be delivered in communities, schools, primary care practices, or online to address symptoms of psychological distress before they become severe. Collaborative care models can be used to address children’s health care needs in low-resource settings. Interventions may include the transfer of essential skills for mental health assessment and treatments to nonpsychiatric personnel by developing partnerships between psychiatrists and primary care clinicians and other health care workers. Task shifting can be effective for increasing access to care provided by individuals available to provide needed services despite differences in level of training. For countries with any telehealth capacity, services via text, telephone, or video can expand access to a spectrum of services for individuals and expert consultation for partners in low-resource communities. Telehealth has demonstrated effectiveness for lowering the barriers to seeking treatment for those with suicidality, depression, and anxiety.16

Strengthening these accessible mental health resources in communities for children and families would decrease use of high-acuity emergency psychiatric services, which are limited in most countries.13

The COVID-19 pandemic is a global call to action. We are experiencing a global public health crisis in youth mental health that began long before the pandemic, and we must advocate for implementation of evidence-supported practices that are scalable, expands access to care, and eliminates disparities worldwide. We must lead the charge for equitable mental health care for all children across the world.

Back to top
Article Information

Corresponding Author: Tami D. Benton, MD, Children’s Hospital of Philadelphia, 3440 Market St, Ste 410, Philadelphia, PA 19104 (bentont@email.chop.edu).

Published Online: August 9, 2021. doi:10.1001/jamapediatrics.2021.2479

Conflict of Interest Disclosures: None reported.

References
1.
Racine  N, McArthur  BA, Cooke  JE, Eirich  R, Zhu  J, Madigan  S.  Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a meta-analysis.   JAMA Pediatr. Published online August 9, 2021. doi:10.1001/jamapediatrics.2021.2482Google Scholar
2.
Burdzovic Andreas  J, Brunborg  GS.  Depressive symptomatology among Norwegian adolescent boys and girls: the Patient Health Questionnaire-9 (PHQ-9) psychometric properties and correlates.   Front Psychol. 2017;8:887. doi:10.3389/fpsyg.2017.00887PubMedGoogle ScholarCrossref
3.
Tiirikainen  K, Haravuori  H, Ranta  K, Kaltiala-Heino  R, Marttunen  M.  Psychometric properties of the 7-item Generalized Anxiety Disorder Scale (GAD-7) in a large representative sample of Finnish adolescents.   Psychiatry Res. 2019;272:30-35. doi:10.1016/j.psychres.2018.12.004PubMedGoogle ScholarCrossref
4.
The World Bank. Population ages 0-14, total: lower middle income. Accessed July 12, 2021. https://data.worldbank.org/indicator/SP.POP.0014.TO?view=chart&locations=XN
5.
Polanczyk  GV, Salum  GA, Sugaya  LS, Caye  A, Rohde  LA.  Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents.   J Child Psychol Psychiatry. 2015;56(3):345-365. doi:10.1111/jcpp.12381PubMedGoogle ScholarCrossref
6.
Hawke  LD, Hayes  E, Darnay  K, Henderson  J.  Mental health among transgender and gender diverse youth: an exploration of effects during the COVID-19 pandemic.   Psychol Sex Orientat Gend Divers. Published 2021. doi:10.1037/sgd0000467Google Scholar
7.
Lee  J.  Mental health effects of school closures during COVID-19.   Lancet Child Adolesc Health. 2020;4(6):421. doi:10.1016/S2352-4642(20)30109-7PubMedGoogle ScholarCrossref
8.
Krass  P, Dalton  E, Doupnik  SK, Esposito  J.  US pediatric emergency department visits for mental health conditions during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(4):e218533-e218533. doi:10.1001/jamanetworkopen.2021.8533PubMedGoogle ScholarCrossref
9.
Marques de Miranda  D, da Silva Athanasio  B, Sena Oliveira  AC, Simoes-E-Silva  AC.  How is COVID-19 pandemic impacting mental health of children and adolescents?   Int J Disaster Risk Reduct. 2020;51:101845. doi:10.1016/j.ijdrr.2020.101845PubMedGoogle Scholar
10.
Gómez-Ramiro  M, Fico  G, Anmella  G,  et al.  Changing trends in psychiatric emergency service admissions during the COVID-19 outbreak: report from a worldwide epicentre.   J Affect Disord. 2021;282:26-32. doi:10.1016/j.jad.2020.12.057PubMedGoogle ScholarCrossref
11.
Craig  S, Ames  ME, Bondi  BC, Pepler  DJ.  Canadian adolescents’ mental health and substance use during the COVID-19 pandemic: associations with COVID-19 stressors.  PsyArXiv. Posted September 9, 2020. doi:10.31234/osf.io/kprd9
12.
Fante-Coleman  T, Jackson-Best  F.  Barriers and facilitators to accessing mental healthcare in Canada for black youth: a scoping review.   Adolesc Res Rev. 2020;5(2):115-136. doi:10.1007/s40894-020-00133-2Google ScholarCrossref
13.
Remschmidt  H, Belfer  M.  Mental health care for children and adolescents worldwide: a review.   World Psychiatry. 2005;4(3):147-153.PubMedGoogle Scholar
14.
Kapur  N, Ibrahim  S, While  D,  et al.  Mental health service changes, organisational factors, and patient suicide in England in 1997-2012: a before-and-after study.   Lancet Psychiatry. 2016;3(6):526-534. doi:10.1016/S2215-0366(16)00063-8PubMedGoogle ScholarCrossref
15.
Webb Hooper  M, Nápoles  AM, Pérez-Stable  EJ.  No populations left behind: vaccine hesitancy and equitable diffusion of effective COVID-19 vaccines.   J Gen Intern Med. 2021. doi:10.1007/s11606-021-06698-5PubMedGoogle Scholar
16.
Fairchild  RM, Ferng-Kuo  S-F, Rahmouni  H, Hardesty  D.  Telehealth increases access to care for children dealing with suicidality, depression, and anxiety in rural emergency departments.   Telemed J E Health. 2020;26(11):1353-1362. doi:10.1089/tmj.2019.0253PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    2 Comments for this article
    EXPAND ALL
    Supporting young people’s mental health through the COVID-19 crisis: call for actions
    Federico Marchetti, Director | Department of Pediatrics, Santa Maria delle Croci Hospital, 48121, Ravenna, AUSL della Romagna, Italy
    Supporting young people’s mental health through the COVID-19 crisis: call for actions

    Dear Editor,

    underestimating the impact of Covid-19 among the youngest, in an already very critical situation in terms of personnel, services and care organization for the neuropsychiatric problems of childhood and adolescence, risks transforming a health emergency such as what we are living in a crisis of the rights of children and young people. The dramatic picture that is underlined in the Editorial comment (1) of the lack of services and planning of interventions is common to several countries (2).

    In England, before the
    pandemic period, it has been estimated that one in six children have a probable mental health problem and the number of children referred for assistance is increasing. In 2019-20 this rose to 538,564, an increase of 35% from 2018-19 and 60% from 2017-18 (3). However, the number of children accessing care is not growing fast enough to meet the demand. In 2019-20 only 391,940 children had a care (a quarter of those estimated to need it) (3). Those who accessed the Services often had to wait weeks or months for treatment, and only 20% of children started within four weeks of requesting. The situation described and common to many countries (including Italy) has dramatically worsened with the pandemic, as reported in the meta-analysis by Racine N et al (4).

    Much must be done to refocus the services on the mental health needs of young people. Services that today are characterized by a high level of fragmentation in methods, places, interaction, which often also entails a failure to request help, which appears paradoxical in relation to the effectiveness of the possible results.
    The global crisis of child and adolescent mental health requires a redefinition of what are the priorities of primary and secondary care, when we put ourselves in the perspective of health to be guaranteed for our generational future.
    Access to integrated mental health and employment support for young people experiencing mental health issues must be urgently expanded within public employment services. It is a matter of learning the "alphabet" with which the new forms of adolescent discomfort is expressed, and to forge tools to act in a view that involves, in addition to the adolescents themselves, families, school and community all.
    But at the moment we are far from having achieved these goals.

    References

    1. Benton TD, Boyd RC, Njoroge WF. Addressing the Global Crisis of Child and Adolescent Mental Health. JAMA Pediatr. Published online August 09, 2021. doi:10.1001/jamapediatrics.2021.2479

    2. OECD Policy Responses to Coronavirus (COVID-19) Supporting young people’s mental health through the COVID-19 crisis. 12 May 2021. https://www.oecd.org/coronavirus/policy-responses/supporting-young-people-s-mental-health-through-the-covid-19-crisis-84e143e5/

    3. Children’s Commissioner. The state of children’s mental health services 2020-21. Jan 2021.
    https://www.childrenscommissioner.gov.uk/wp-content/uploads/2021/01/cco-the-state-of-childrens-mental-health-services-2020-21.pdf.

    4. Racine N, McArthur BA, Cooke JE, Eirich R, Zhu J, Madigan S. Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19: A Meta-analysis. JAMA Pediatr. Published online August 09, 2021. doi:10.1001/jamapediatrics.2021.2482
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Elephants that can't be ignored: militarism by the US, American imperialism, bipartisan quest for global dominance
    Vivek Jain, MD | Hospital
    Even with the relatively recent phraseology eg "social determinants of health", "structural violence" etc, the majority of medical journals, academic researchers, clinicians, and so-called professional organizations (AACAP, AMA, APA, etc) continue to ignore the global impact of warmongering by the US empire, especially the impact on children within the US and beyond. These well educated people don't talk about imperialism or what empires do. Seldom is class warfare acknowledged. The ruling class hasn't given up its ambitions to dominate the planet, but reading these prestigious journals, one wouldn't know how the struggles of the bottom "99%" to survive are in any way linked to the Owning class' exploitation of workers and the upward transfer of and accumulation of wealth. Why is that? How many trillions of public dollars has the US government mis-spent on weapons and warmongering? How many dozens of countries have the US imperialists burned, dismembered, destabilized, plundered, left in ruin (resulting in "failed states")? How does the problem of racism -- which so many well-meaning academics profess concern for -- relate to imperialist violence and the capitalist economic order? Why don't investigators cite social scientists such as Michael Parenti, whose 1995 work "Against Empire" clearly articulated how imperialism works and for whom, and at whose expense? Why isn't POWER--class power-- a topic of discussion-- or propaganda, or corporate power--as these relate to democracy, information technology, the press, transparency and accountability, human rights?

    - Vivek Jain
    CONFLICT OF INTEREST: None Reported
    READ MORE
    ×