Myths about the Pandemic and Adolescent Mental Health
A Comment on The crisis of student mental health is much vaster than we realize (The Washington Post)
The Washington Post recently published a report titled The crisis of student mental health is much vaster than we realize (Donna St. George & Valerie Strauss) about the numerous difficulties facing schools in their attempts to deal with various mental health issues of its students.
Unfortunately this otherwise praiseworthy article may be considerably misleading at times, especially due to omission, misdirection and ambiguity, in its handling of statistical data and scientific evidence regarding the effects of the pandemic in general and school closings in particular on the mental health of adolescents.
Depression and Anxiety
The Washington Post paints a picture of the pandemic being a major cause of broad and alarming increases in the prevalence of mental health disorders among adolescents:
Nationally, adolescent depression and anxiety — already at crisis levels before the pandemic — have surged amid the isolation, disruption and hardship of covid-19. [...]
The authors provide no evidence regarding the alleged surge of adolescent depression and anxiety, and I do not know of any compelling evidence so far that the prevalence of these did increase substantially within the U.S. during the pandemic.
Although there is no doubt that fears, stress and even trauma increased during the pandemic, it is mere speculation that this translated into a surge of outright illnesses like anxiety and depression -- let us keep in mind that experiencing severe grief due to the death of a grandparent does not mean a teen is suffering from a mental health disorder.
The authors do provide a link for their statement that Not long after the pandemic started, researchers began to document declines in child and adolescent mental health -- but this points to a 2022 study that found the frequency of pediatric emergency department visits related to mental health collapsed at the start of the pandemic and only slowly climbed back to pre-pandemic levels for girls and never did so for boys (not even in 2021):
Suicide
The authors assert the following about suicidal behavior:
Not long after the pandemic started, researchers began to document declines in child and adolescent mental health. The numbers are stark. Hospital emergency room visits spiked for suspected suicide attempts among girls ages 12 to 17, according to the Centers for Disease Control and Prevention. From February to March 2021, the number jumped by 51 percent compared with the same period during 2019.
The fact that From February to March 2021, the number of ED visits related to suspected suicide attempts among girls aged 12 to 17 jumped by 51 percent compared with the same period during 2019 is indeed startling, but the sudden spike may have been induced, paradoxically, by girls returning back to school and all the social challenges associated with such 'normal' environment.
Adolescent suicides have had a pattern of declining during summer vacations and surging during return to school -- so it would be no surprise if there was a temporary spike in suicidal behavior at the end of long irregular school closures during the winter.
Suicides for girls aged 12-17 actually declined slightly in 2020 (see Notes), so to blame the pandemic for a brief increase in suicidal attempts a full year after its start is tenuous at best.
Regarding completed suicides, the authors state:
Early research from MIT suggested the suicide rate for people aged 10 to 19 increased in 2020, compared with before the pandemic. More recently, CDC provisional data for 2021 showed an increase in the national rate from 2020 to 2021, especially for people ages 15 to 24.
This passage gives the impression that adolescent suicide rates have been increasing substantially two years in a row following the pandemic.
In reality there was no statistically significant difference between suicide rates in 2019 and 2020 for ages 10-19 per CDC data (see Notes), and the very slight increase in the raw number of suicides was mainly due to higher counts in the pre-pandemic months of January and February 2020. The MIT study itself found no statistically significant difference in suicide rates and, more importantly, was based on incomplete data (only 14 out of 50 states) and was quickly obsoleted by the release of full CDC data shortly after.
Since the Washington Post cites CDC provisional data for 2021, it is puzzling that it failed to check the easily accessible CDC regular data already available for 2020 and instead relied on speculation about the possible implications of the limited MIT study based on severely incomplete data.
As to 2021, the 3% increase in suicide counts for ages 10-19 is unlikely to equate statistically significant change in suicide rates (the latter depend on population estimates that CDC did not yet provide).
Even the troubling increase of 8% in 2021 versus 2020 counts for age group 15-24 (per provisional data) was smaller than the 9% increase in 2017.
In other words, it took two years during the pandemic for youth suicide to increase as much as it did in 2017 alone, and this was mainly due to increases among young adults.
Remarkably Unremarkable
Major indicators of adolescent mental health disorders, be it depression and anxiety or be it suicidal ideation and outright suicide, have shown no substantial increases during the pandemic so far, to the best of my knowledge.
There are important exceptions among less common disorders, such as eating disorders and the tic disorder -- but no national data is mentioned by The Washington Post regarding these.
Beyond this couple of less frequent disorders, there seems to be nothing about 2020 and 2021 that would indicate a massive surge of adolescent mental health disorders within the U.S.
Furthermore, the pandemic years of 2020 and 2021 seem especially unremarkable in the context of long-term trends in adolescent mental health -- after all teenage suicide rates have been rising steadily since 2007 (see Child Suicides Double in a Decade) and anxiety and depression have been on the rise since about 2012 -- see the ongoing documentation provided at Adolescent mood disorders since 2010: A collaborative review by Haidt & Twenge.
Consider the following graph of suicide rates for ages 12-17:
This hardly looks as if there was some extraordinary event in early 2020 that had an immediate unprecedented impact on adolescent suicide.
Incapacitating Sadness
Perhaps the most quoted text from the article, judging by Twitter comments, is the following: the CDC found nearly 45 percent of high school students were so persistently sad or hopeless in 2021 they were unable to engage in regular activities.
This assertion can be easily read to mean that on any given day in much of 2021 nearly half of the students were incapacitated by sadness; in reality, CDC asked if students felt incapacitated by sadness for 2 weeks at any time during the past 12 months. This is akin to the difference between 'on typical school day half the students were missing due to illness' and the far less alarming 'half the students missed school due to illness at least once last year'.
Note also that since the question was asked early in 2021, the past 12 months cover mainly 2020.
It is furthermore crucial to understand that being partly inactive for two weeks due to some trauma is far from being mentally ill: in fact such passivity may be a protective behavior for adolescents subject to severe stress. Again, experiencing great grief due to the death of a grandparent does not mean a teen is suffering from a mental health disorder.
Suicidal Ideation and Behavior
Frequently quoted in relation to the pandemic and school closings is also this excerpt from the article: "Almost 1 in 5 seriously considered suicide, and 9 percent of the teenagers surveyed by the CDC tried to take their lives during the previous 12 months."
What is missing here is the fact that this did not differ substantially from the 2019 CDC results (see Notes).
The 2021 data comes from the Adolescent Behaviors and Experiences Survey (ABES) that adapted the methodology and many of the questions from the biannual Youth Risk Behavior Survey (YRBS) of high school students. The questions about suicidal ideation and suicidal attempts were identical on both surveys, and the results from the 2021 ABES were nearly the same as those from the 2019 YRBS -- meaning the data provides no evidence that suicidal ideation and suicidal attempts increased substantially among teens after the pandemic.
School Closings
There is an underlying presumption within the article that school closures were a major cause of adolescent mental health disorders. This is especially evident in the following passage:
There are no directly comparable pre-pandemic studies, but Kathleen Ethier, the CDC’s director of the division of adolescent and school health, said student well-being is significantly better for teens who report feeling connected to their schools — a problem for a population that, nationwide, was kept out of them for so long. “There is 20 years of research showing that it not only has an impact on how young people do while they’re adolescents, but it has 20-year impacts on all kinds of measures of health,” including emotional well-being, suicidality and substance use, she said.
The stipulation of a problem for a population that, nationwide, was kept out of [schools] for so long implies that these students are doomed to suffer heightened rates of emotional ill-being, suicidality and substance use not only now but long into the future.
Note also that the word "impact" asserts that the correlation is caused by feeling connected to school, a proposition difficult to prove -- after all the correlation could arise simply due to already troubled kids having difficulties in school rather than due to connectedness itself affecting mental health. The Washington Post mentions no studies to substantiate causality and I found no studies that come anywhere close to doing so.
More importantly, even if school connectedness does impact mental health, all this may mean is that not feeling connected to school is harmful rather than that feeling connected is beneficial (it will then seem beneficial only because we are comparing it to the harm experienced by those not feeling connected). The overall impact of schools on mental health could still be negative (think academic overload or bullying and peer pressure issues and so on).
Therefore even if there is such a causation, it says nothing about not attending school being harmful to mental health, contrary to the assumption of the authors.
To better understand the flaw in the logic, imagine a country with compulsory military service for adult teens where studies show a correlation between feeling connected to your military unit and better mental health. Would you jump to the conclusion that canceling military service will harm teenage mental health? If not, then why make such a conclusion regarding school attendance based on mere connectedness correlations?
The closings of schools certainly have had a major effect on test scores and may prove disastrous for education, though this is a complex issue where much depends on how education is defined and evaluated.
The overall nature of its impact on mental health, however, is far from clear. In fact the closings of schools likely helped reduce the academic and social stress on adolescents in an otherwise extraordinarily stressful time. The effects on mental health need to be examined by carefully designed studies that take advantage of the 'natural experiment' created by differences in the timing and duration of school closings in various parts of the country. Until such studies are published we should be careful about presuming presuming we know much about the overall impact of school closings on mental health.
Why It Matters
The underlying narrative that the pandemic in general, and school closings in particular, have been proven the cause of a major surge in adolescent mental health disorders, not to mention suicides, is never substantiated within the article and is, as far as I know, contrary to currently available data.
Mistaken notions -- essentially myths -- about supposed massive mental health harms of the pandemic and school closings can mislead society in its effort to protect adolescents now and in the future.
Most of the comments and discussions about the article seem to concentrate on the implied or stated effects of the pandemic and school closings -- at least on Twitter the vast majority of postings do so, and there are thousands of comments on dozens of threads.
There is clearly a strong public craving for these myths to be seemingly confirmed by authoritative figures, be it journalists or scientists. That is all the more reason for such professionals to be careful about inadvertently misleading the public, even by mere ambiguity and omission.
Notes:
The ABES (YRBS) Sad or Hopeless Question:
During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?
The prevalence was 37% in 2019 (YRBS) and 44% (ABES).
For considering suicide, prevalence was 18.8% (2019 YRBS) and 19.9% (2020 ABES), for planning suicide 15.7% and 15.2%, for suicide attempt 8.9% and 9.0%. These are not directly comparable (ABES methodology was not an exact clone of YRBS) but it is clear there were no substantial increases regarding suicide -- unlike regarding trauma (the Sad or Hopeless question).
Suicide rates ages 10-19 per CDC WONDER tool (with confidence intervals):
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