Dr Dominique Thompson Provides Top Tips about Supporting the Mental Health and Wellbeing of Children, Adolescents, and Young Adults During the COVID-19 Pandemic
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The COVID-19 pandemic has rightly directed attention to the physical and public health needs of the population, with most concern being focused on elderly and vulnerable people. However, there is another population group for whom the pandemic, and a likely subsequent recession, will have a significant negative impact, even if they are considered to be less susceptible to the worst excesses of coronavirus. That group is children and young people.1
Children, teenagers, and young adults may not be facing the physical ravages of COVID-19 in the same way as older people, but some have been experiencing emotional and psychological consequences of lockdown and societal disruption.2 This article describes what impact COVID-19 is having on this age group, what to watch for in primary care, and how best to support them and their carers.
1. Remember that Mental Ill Health was Already on the Rise
It is important to bear in mind that, even before COVID-19 came along, ‘the kids were not alright’ (to misquote The Who). There has been a steady rise in demand for mental health support for young people over the last few years. Child and adolescent mental health services have often struggled to keep up with demand;3 consequently, primary care may be expected to support more complex and challenging casework. The reasons behind this increase in mental health concerns among young people are complicated,4 but the key point is that anxiety, self-harm, and eating disorders were already rising.5–7 Then along came a pandemic, lockdown, and a titanic rise in uncertainty, which breeds anxiety. Lockdown led to changes in living circumstances, disruption to education, and restricted access to healthcare services, all of which have impacted the mental health of young people.8,9
2. Acknowledge the Losses Experienced by Young People Because of COVID-19
Looking more closely at the specific impact of lockdown and the pandemic on teenagers and young adults reveals the loss of important life and academic rituals, such as proms, graduations, and gap years. They have missed out on exams (which, although stressful, can bring closure), end-of-year activities and trips, festivals, and a ‘summer of fun’. And while it may be easy for adults to say ‘there will be other opportunities’, this loss impacts a generation of young people in the UK who are among the unhappiest of their peers worldwide. According to the triennial Programme for International Student Assessment study, the UK’s 15-year-olds are some of the least satisfied with life in the world (69th out of 74 countries), so losing their fun and festive rituals seems particularly unfortunate.10 In addition, missing out on end-of-school education may lead to a bigger disconnect for those moving from primary to secondary, or from secondary to tertiary education, and may cause an associated rise in transitional anxiety. It is also likely that the uncertainty around exam results this summer will have exacerbated the stress for many school leavers and Year 11 pupils.
A recent study reported that 13–14-year-olds have felt less anxious during the pandemic, possibly as a result of factors such as reduced academic and school social pressure, and better sleep;11 however, many others will have struggled.
3. Consider the Greater Negative Impact of Loneliness on Adolescents
One of the key findings of an investigation into the effects of lockdown on the adult population has been that young adults aged 18–29 years are the most likely to feel lonely, and this is much more likely if they have a known mental health diagnosis.12 In addition to this, evidence published prior to the pandemic reported that the 16–24 year age group is the most lonely of all age groups.13 For many teens and young adults, lockdown represents a period of disruptive isolation at a delicate time in brain development,14 and there are concerns that this may have longer-term impacts on their wellbeing.15 Studies have shown that isolation increases the risk of depression in previously well adolescents up to 9 years later.16 The negative impacts of 2020 may be seen for years to come.
4. Recognise that Certain Young People are at Increased Risk of Mental Ill Health
Most lifetime mental health disorders start by the mid-twenties.17 GPs should be aware of trends in the demographics of young people who are most affected by the pandemic. These include young people who have been bereaved or sick themselves, those who are carers or in care, those who have long-term physical or mental health conditions, and those whose healthcare has been disrupted. It’s also important to remember healthcare students, who may have been at the COVID-19 ‘frontline’.18,19 All of these groups will need additional support from primary care as they cope with psychological distress or reconnect with health services.
5. Be Alert to New Risk Factors for Mental Health Issues
It isn’t just the at-risk groups of young people who need support now, but also those who have recently been exposed to risk factors for poorer mental health. Children, adolescents, or young adults living in violent homes, where poverty is rife, or where studying has been impossible because of lack of technology or parental engagement, will be more at risk of mental health issues.18,20 Young people who have struggled to stay in contact with friends, or whose social networks have been disrupted as a consequence of school or university closures, and for whom communicating remotely has not been an option, may have suffered at a time when building social connections and the associated brain development is key.14 The teenage brain is particularly focused on the development of social and life skills, so a paucity of contact may have negative repercussions.
6. Identify Pre-existing and New Mental Health Conditions
Young people who already have mental health conditions seem to have been further disadvantaged by delayed or fragmented care.20 Those with:
- eating disorders may have experienced further food anxiety (driven by ‘panic buying’ and lack of ‘safe food’ availability in the early stages of the pandemic)21
- obsessive compulsive disorders may have experienced worsened or new obsessions, such as repeated hand washing or other hygiene behaviours22
- general anxiety (among others) may have experienced poor sleep23 and heightened distress.20
Young people who had not previously experienced mental health issues may have also struggled with disrupted sleep and anxiety about their future or health. Some may have been misusing substances to cope, or developing addictions such as to gaming and gambling with so much time spent indoors or isolated.20 Having fallen into complex situations, many young people are going to need considerable support to steer them back to good health and positive behaviours.
7. Watch out for Red Flags
A study carried out during lockdown has shown that young adults aged 18–29 years have been the most likely of all adult age groups to feel depressed or anxious, to have had thoughts about death or self-harm, or to be at risk of abuse and violence.12 This group has also reported the lowest life satisfaction.12 There is no evidence that the incidence of suicide is rising in the younger population, but with this documented increase in thoughts of death and self-harm, GPs should be sensitive to the issue of suicidality, and enquire gently about distressing thoughts where appropriate. Uncertainty leads to anxiety, and it has been suggested that this can lead to a rise in self-harmful behaviours.24 If a young person’s behaviour is escalating, or they feel increasingly unsafe, then it is important to seek additional support and refer them to secondary care for additional expert review and advice.25
8. Pay Attention to New Emotions and Behaviours that May Indicate Mental Distress
As well as being attuned to the usual symptoms of anxiety or low mood, it is important to be aware that young people may suffer from other, less common symptoms or emotions, or that their behaviour may change in new ways. They may suffer from feelings of guilt (for example, they couldn’t do more to help/weren’t able to see a relative before they died—survivor guilt),26 helplessness in the face of overwhelming events, or powerlessness.20 They may feel traumatised by their experiences, or fear others—for example, worrying that they may become infected by them, or feeling at greater risk of abuse from them. Being aware of these recent emotional and behavioural changes will help GPs to ask the right questions, and hear the hidden cues.
9. Accept that a Recession will Significantly Impact the Younger Generation
It may not be a priority while we cope with the pandemic itself, but the impact of a likely recession on young people’s mental and physical health will be significant, if past experience is indicative. Studies from the USA have examined the long-term health of students who graduated in a recession since the 1980s, and the results are not good.27 These graduates had a roughly 6% increase in their generation’s age-specific mortality rate. This excess mortality was driven by heart disease, lung cancer, and liver disease, as well as substance misuse. ‘Recession graduates’ in these studies were also less likely to be married, more likely to be divorced, and more likely to be childless. Therefore, supporting and improving the health of young people now may have a positive and mitigating impact for years to come.
10. Understand how to Support Young People and their Families
The past few months have been incredibly stressful for families for multiple reasons, including disruptions to income, work, study, and family relationships. It is likely that young people and their families will need support to move towards recovery. Public Health England (PHE) has created a useful resource for parents and carers (see Box 1) that covers caring for children with a variety of issues, including autism, eating disorders, and bereavement, and this is well worth sharing with patients.28 Support for young people must be built on a trusting relationship, and this may take time to develop. To do this, it is vital to acknowledge their reality, avoid dismissing anything as ‘a phase’, and validate their feelings.
One of the most helpful ways to improve wellbeing is to build social connections, so this may be one of the most important approaches to focus on—encourage young people to talk to others, reconnect with friends and family, and discover new supportive relationships (for example, with therapists, school counsellors, or faith leaders).29 Discuss with them the importance of connecting with people, exercise, getting outside every day, and trying to learn and develop new skills so that they can maintain purpose in their daily lives.30 They may need referral for therapy for persistent and distressing symptoms, such as panic disorder, low mood, hopelessness, or self-harm. Early intervention is better for outcomes,31 and they may require medication, if appropriate, to alleviate depression or severe anxiety.
Coping with the COVID-19 pandemic has been an extraordinary, and occasionally overwhelming, experience for many adults, but it is vital to remember that young generations have also struggled, and to consider the incalculable impact it may have had on their health, wellbeing, brain development, and life skills. There may be positives for some children—those who were bullied at school and found respite in home schooling, for example—but for many, COVID-19 and lockdown will have added significant challenges to what was an already stressful existence. GPs are going to need to reach out and talk to this younger generation, engage with them, and actively check in on them, to make sure that ‘the kids are alright’.
Dr Dominique Thompson
Mental health author and former GP, Bristol
|Box 1: Guidance and Resources|
Student Minds website: www.studentminds.org.uk
Students Against Depression website: www.studentsagainstdepression.org
Young Minds website: youngminds.org.uk
Beat website: www.beateatingdisorders.org.uk
Charlie Waller Memorial Trust: www.cwmt.org.uk
Further Reading from the Author
Anxiety @ University by Dominique Thompson
Depression @ University by Dominique Thompson
NHS App Library (mental health section)—for example, distrACT app for self-harm support