Last week, the U.S. Surgeon General issued a rare public advisory warning of a widespread increase in mental health issues among children and adolescents. His report pointed to an alarming rise in youth suicide attempts and emergency visits for mental health concerns, particularly since the pandemic began. Meanwhile, three leading groups of pediatric health professionals have declared a national emergency in youth mental health and called for sweeping changes in psychiatric care systems.
Child psychiatrist John Sargent spoke with Tufts Now about what’s behind the emergency and what parents need to know. Sargent, a professor of psychiatry and pediatrics at Tufts University School of Medicine, is director and vice chair of the division of child and adolescent psychiatry at Tufts Children’s Hospital.
Tufts Now: These public health advisories make clear that the nation is facing an acute mental health crisis, and our children are bearing the brunt of it. How did we get to this point?
John Sargent: The first thing is to acknowledge that life has been really hard. All of a sudden, social interaction and physical closeness went from being comforting to being dangerous. Day-to-day life, which for kids is mostly school and activities, became risky and inaccessible.
Add to that the expectation that families would be okay with everyone being at home—that parents would be able to work from home, monitor their kids’ academic lives, and occupy their kids’ social lives. I would call that unrealistic. Then, add the fact that the pandemic had a much greater effect on certain groups of people—those who were already stressed or experiencing hardship, people who are racially discriminated against, people who were more likely to experience disability or job disruptions, and families who didn’t have the necessary technology for their kids to go to school remotely. All of that became very disruptive to our usual ways of living.
I don’t think that we’ve really appreciated what the negative effects have been, as a society or as a community. And we’re not totally out of it even now, two years later.
You point out the pandemic has not affected everyone equally. How does that play out on the mental health spectrum?
What I’ve seen as a child psychiatrist is that the mental health crisis is actually two different crises. People who have psychological, emotional, or developmental differences, who have high-risk jobs, or who are impoverished or homeless have been much more disadvantaged and much more endangered by the pandemic than people who have more resources. People who were barely getting by are now lower on the ladder, essentially. Then there are people who were doing okay but have seen significant disruptions and are plagued with the kinds of worries that accentuate anxiety and can lead to increased family and work difficulties.
The two crises are occurring at exactly the same time. The result is two sets of needs. For those at highest risk, the needs are for intensive services such as in-person therapy, hospitalization, and day-treatment programs. More routine mental health care such as outpatient counseling is needed for people whose lives are disrupted but perhaps are not in immediate danger. Both sets of needs are increasing dramatically.
All the experts saw this coming, this tsunami of pandemic-fueled mental health challenges. Why couldn’t we avert it?
There have never been adequate resources for child mental health. Basically, the entire mental health care system was set up to respond only to the tip of the iceberg on a national basis. This is certainly true in child psychiatry and child mental health.
Before the pandemic, somewhere around a fifth to a quarter of people who needed help got it. The others didn’t—just by virtue of inadequate resources and the stigma that keeps people from seeking out mental health care. Even if they do, services are often less than they need them to be, because they may need a type of therapy the provider doesn’t offer.
With the pandemic, the already under-resourced and overburdened system is absolutely slammed with need. It seems as though stigma has significantly declined, so that people are more willing to say that they’re experiencing mental health challenges, anxiety, or mood problems, and are more willing to seek help. Exactly when the demand increases, the supply doesn’t respond. A lot of reasons are behind that, including the length of training to become a child psychiatrist, which hampers recruitment to the field; inadequate reimbursement to providers of mental health care, and inadequate community-based resources for mental health.
What’s your advice for parents who see their kids struggling?
I often hear this when I talk to a neighbor or a friend: “My kid is having trouble; what should I do?” I say be caring, be warm, be supportive, be understanding. Try to figure out what you need to do to help them change their lives in a successful and confident way. Make sure you pay attention to what your kid is doing. Make sure you help your kid understand that negative emotions are part of life, and that some negative emotions they can deal with and some they may need help dealing with. It’s all of that, together with trying to stay as happy as you can as a family.
The best antidepressants are competence—the sense that one can do something effectively—and connections—the sense that one is loved and cared about. The best ways to approach anxiety are through thoughtful attention to how risky something really is and helping people through periods of worrying and concern so they can realize that in fact things will be okay, and that they can make them okay. You allow people to express their negative feelings, to complain about the pandemic, to say that virtual school isn’t any fun or isn’t helping them. You want to help your children build a sense of resilience and a sense of well-being in the face of challenges.
How does a parent discern when a child needs professional help, and what happens then?
If you’re doing all of those things and your child is not responding to your attention and your support, then seek outside help. The important thing to remember is that kids who don’t feel like doing anything—such as kids who are depressed—aren’t going to feel like pursuing treatment. The kid is going to say don’t bother me with that. The parent needs to say it’s not acceptable for you to be spending all your time in your room, or not doing as well academically, or not being as engaged in your life as you used to be and can be. They need to say it’s not okay, and we have to do something about it, together.
We cannot be laissez-faire about this.
The problem is that it can be hard to find a therapist, and there is often a wait. During the wait, the important thing is to make sure you’re paying attention to your child. Make sure that your child knows you are there for them, that the school is welcoming them as they come back, that people are being as warm and supportive as they can be. You also don’t want to decrease all demands. You want to make sure that kids feel like they’re being challenged, and they are being helped to do what their school or activity or family needs them to do.
The pandemic shows no signs of ending anytime soon. What do you expect for the long-term?
I expect continued distress. And what I hope for is a period of healing and a period of enhanced community. America has always had trouble figuring out how charitable to be for people who have trouble looking after themselves. We have what I call a safety net with holes in it.
One of the messages of the pandemic is that we need to pay attention to each other’s emotional well-being and to our own well-being. We need to take that into account in our daily lives. If we don’t, illnesses can be more severe, recovery from illness can take longer, relationships are problematic, communication with the next generation breaks down…it interferes with having a civil society.
All of a sudden, we’re recognizing that mental health care is a necessary part of day-to-day life. With stigma going away, there’s a possibility that there will be increased valuing of mental health care and increased recognition that it saves people’s lives and helps people live the best life they can live.
Are you suggesting that we all be our own—and each other’s—therapists for the foreseeable future?
It’s not only self-care; it’s mutual care. It’s being in a workplace and if someone’s having trouble, instead of firing them or disciplining them, you help them get help. In the school environment, it’s paying attention to the kid who’s withdrawn in the back, not attending class, or not participating. You say, how can I help you?
This pandemic has been a challenge to ourselves, our families, our survival, our communities, and our governments. And we’re not out of it yet. We can meet this challenge, I believe, by coming together as a community of people who are interested in helping each other.