The past 2 years have been traumatic. COVID-19 has affected us all far more extensively than we could have imagined before the pandemic hit. It has had a general negative effect on mental health in both adults (Office for National Statistics, 2021) and teenagers (Ford et al, 2021; Hawes et al, 2021).
The negative impact of the pandemic on the mental health of young people is not surprising. It was anticipated by experts (Douglas et al, 2009; Fegert et al, 2020; John, 2020). Even in normal times, adolescence is a particularly vulnerable period of life, for many reasons (Larsen and Luma, 2018). The pandemic has presented many new challenges to this age group, from the disruption of everyday life and education, the social dislocation of lockdowns, to the long-term fears and uncertainties about the future (exacerbated by the contemporaneous escalation of the climate change crisis).
Exactly what proportion of young people have suffered mental health problems as a result of the pandemic is unclear. Almost all will likely have experienced some degree of anxiety and depression – and in many senses, of course, this is a normal reaction to such events, rather than a mental health problem. But whatever the challenge, individuals vary in their resilience in the face of adversity (Ellis et al, 2017). Some young people will cope with the current situation fairly robustly, where others will be more vulnerable, and fare badly.
Data from previous disasters show that quite a high percentage of young people suffer a variety of mental health problems during disasters: chiefly anxiety and depression, but also post-traumatic stress disorder (PTSD) (Yule et al, 2000; Kar and Bastia, 2006; Douglas et al, 2009). It is early days yet, so there is relatively little research specifically focusing on the effects of the current pandemic on youth mental health, but what there is, is worrying. For example, a study of 12–18-year-olds in the Chinese lockdown reports depression in 43% of participants, anxiety in 37%, and a combination of both in 31% (Zhou et al, 2020). We may expect similar impact on mental health in other parts of the world (Fegert et al, 2020; John, 2020).
Interestingly, PTSD studies report lower levels (5–7%) in Chinese teenagers in the current pandemic (Liu et al, 2020; Sun et al, 2020) than were reported in a study of American families quarantined after exposure to H1N1 or Sars-CoV, where 30% of the children were identified as suffering PTSD (Sprang and Silman, 2013). The reasons for this difference are unclear (Culture? Circumstances? Differing diagnostic criteria?). A key factor is likely to be the directness of the impact on individuals: studies of PTSD following 9/11 found that fairly indirect exposure (e.g. media reports) triggered a rise in PTSD in about 5% of young people (Otto et al, 2007), whereas between 30% and 60% of those in closer proximity to the disaster experienced PTSD (Whalley and Brewin, 2007). The problem may be immediate, or develop over time: a recent long-term follow-up study suggests that 25% of children and teenagers exposed to trauma will develop PTSD by age 18 (Danese et al, 2020).
Risk factors for mental health problems
Three factors have been identified as increasing risk for mental health problems in young people in situations such as the current pandemic: being female is more highly associated with anxiety and depression (Warheit et al, 1996; Zhou et al, 2020), and with PTSD (Liu et al, 2020; Sun et al, 2020); socio-economic or other family difficulties are also risk factors for various mental health issues (Warheit et al, 1996; Zhou et al, 2020), with children in deprived areas or with ineffective or abusive parenting faring worst; and mental health problems pre-dating the pandemic put young people at particular risk – a survey in UK found that 83% of those with such pre-existing problems said that their mental health had deteriorated through the pandemic (YoungMinds, 2020). In part this may be because access to mental health support is reduced by lockdowns and social restrictions. But there is also evidence that individuals with certain pre-existing conditions (e.g. autism [Smile, 2020] and obsessive compulsive disorder [Nissen et al, 2020]) are particularly badly affected.
‘Almost all [young people] will likely have experienced some degree of anxiety and depression – and in many senses, of course, this is a normal reaction to such events, rather than a mental health problem. But whatever the challenge, individuals vary in their resilience in the face of adversity…’
‘It is too early to know how persistent PTSD may be after the long-drawn-out trauma of the pandemic, or how damaging. Recent research has found that PTSD in young people is associated with changes in brain development…’
Severe depression or anxiety are noxious and debilitating, and certainly warrant serious concern, but it is PTSD that concerns many experts the most. The symptoms of PTSD are particularly challenging, as will be discussed below. Though for some, the effects of PTSD are transitory, for others they can be very long-lasting, persisting for many years after the trauma. For example, PTSD may last years in teenagers directly experiencing a major trauma (Holbrook et al, 2005). It is too early to know how persistent PTSD may be after the long-drawn-out trauma of the pandemic, or how damaging. Recent research has found that PTSD in young people is associated with changes in brain development (Herringa, 2017). Specifically with alterations in the fronto-limbic system, which are likely to undermine the development of emotional regulation, already an issue in adolescence (Blakemore, 2018). Such effects may prolong and deepen the impact of PTSD.
Identifying PTSD
Supporting young people suffering from PTSD triggered by the pandemic is important. But how best to do it, when few working in schools have much training in this area, and access to expert interventions is hard?
The first challenge is to identify PTSD. There is a tendency, in some parts of the media, to assume that any severe mental distress in face of traumatic events is sufficient to qualify as PTSD. PTSD is indeed highly associated with anxiety and depression, but much more specific symptoms have to be present for a clinical diagnosis. These are listed in detail in the DSM-V (https://www.ncbi.nlm.nih.gov/books/NBK207191/box/part1_ch3.box16/). Diagnosis requires the presence of one or more symptoms that, for example, include (among other things) recurrent nightmares about the trauma, or flashbacks, intense distress or a physiological reaction at exposure to reminders of the trauma.
In reality, specific diagnosis of PTSD requires detailed expert evaluation. Without specifically relevant training, all we can do is identify suspicion of PTSD. This may be difficult. Children and teenagers may not tell us about their reactions; for example, not volunteering that they are having recurrent nightmares about the pandemic. Common signs we might observe in young people include either shying away from, or conversely obsessing about the experience of the pandemic; increased aggression, impulsiveness or emotional numbness; or a falling off of academic work, a lack of focus in school.
Responding to a suspicion of PTSD
Where there is suspicion that a child or teenager has a diagnosable PTSD, the first step is to seek expert assessment, and urgent referral for treatment. It is thought that PTSD responds best to various forms of talking therapy, such as CBT, but these require a trained practitioner (Clinical Partners, no date). Otherwise, expert advice on supporting sufferers while waiting for expert help includes:
- ‘A trouble shared is a trouble halved’: there is much truth in this traditional proverb: simply talking about woes can reduce stress. Children and teenagers overwhelmed by stress may feel very alone. Offering a safe, non-judgmental place where they can discuss their troubles offers social support, and can make a big difference. There is no need to try to solve their problems – sympathetic listening is a strong support in itself.
- Counter the physiology of stress: individuals with PTSD are, almost by definition, overwhelmed by their stress. Talking therapy, when expert help arrives, can counter the conceptual processes driving that stress. In the meanwhile, we can help young people to counter the physiological reactions that fuel and maintain stress. For example, both muscle relaxation and aerobic exercise can help to relieve PTSD (Newman and Motta, 2007). More powerful still is teaching the practice of deep, slow breathing (Zaccaro et al, 2018).