Learning to cope: COVID-19 exacerbates growing youth mental health challenges

COVID-19 was a learning experience for Cecilia Ridgeway and her friends.

Its sudden onset and the changes it provoked in the La Follette High School junior and her friends’ lives brought “out things that we really didn’t know about ourselves, both good and bad.”

Among other feelings, the isolation brought a wave of stress and anxiety for the teenagers to face largely on their own.

“All of a sudden, everything started happening, me and my friends got health problems, our mental health just declined,” Ridgeway said.  “We just were upset and sad and we didn’t have our friends by us except on FaceTime and text.”

Ridgeway and her peers are far from alone. Recent surveys from the Centers for Disease Control and Prevention showed a sharp rise in the percentage of high school students around the country reporting “persistent feelings of sadness or hopelessness.”

In 2019, 36.7% of those surveyed reported that, a significant increase from the 26.1% from a decade earlier. By the January-July 2021 CDC survey, as the social isolation, distance from close friends and disrupted routines for young people had set in, the percentage grew to 44.1%.

Some of the restrictions put in place to protect peoples’ physical health — like social distancing, avoiding groups and moving from in-person to virtual school or work — hurt their mental health at the same time. Those changes took away some of the traditional coping skills professionals recommend — like seeing friends or getting yourself into a different physical setting.

“The pandemic kind of also preyed on those (who are) maybe more susceptible to things like depression, anxiety,” UnityPoint Meriter inpatient therapist Molly McDonough said. “So those who maybe in a perfect world would have been able to utilize some coping skills and maybe get by …were impacted harder by circumstances.”

It’s not getting easier, even as most kids have returned to school buildings. School and community resources for mental health are overwhelmed, with nowhere near enough of them to meet the growing demand.

Before the pandemic, UnityPoint Meriter child and adolescent psychiatry social worker Emily Cannon relied on those follow-up appointments with a mental health practitioner when discharging children she saw in crisis.

“Now it's like, okay, it's going to probably be about four weeks before you see a therapist, and let's see what we can do in that meantime,” Cannon said.

That can leave peers in positions to support each other, which was especially difficult with the social isolation brought by the pandemic and school closures. Even now, West High School sophomore Sandy Flores Ruiz said, it’s hard to figure out how to support others when you’re experiencing the crisis yourself.

“All of us are in a space where we don't know what to do with ourselves or how to support one another,” she said. “Every single person is living through different things right now. It's very hard to balance your own life plus trying to help other people with their own problems.”

Schools are trying to help, though students said they don’t always see the effects of those efforts. Madison Metropolitan School District mental health coordinator Kristen Guetschow pointed out in a February interview that the district has tried to meet the wide variety of needs its students and staff have had throughout the pandemic: “It's a shared experience, but lived very individually.”

“It's sometimes really helpful to remember that schools are just a microcosm of our community,” Guetschow said. “We're living through some of the similar stresses and trying to keep it very steady for our students in a place where we have staff shortages and people really working hard to keep structures safe around COVID.”

The variety of needs is striking, according to the data.

Of high school students identifying as LGBTQ+ in the CDC’s 2021 survey, for example, 75.7% said they had “persistent feelings of sadness or hopelessness,” nearly double the overall rate for the age group. Black students, meanwhile, had the lowest percentage of any racial demographic of those feelings of sadness or hopelessness, but were also the least likely to feel close to someone at school, with just 33.5% of responding teens saying they did.

While searching for answers in handling the immediate challenges facing kids and their mental health, a question with perhaps even larger policy implications looms: What happens in the long term if kids don’t get the help they need right now?

“That's a million dollar question,” UnityPoint Meriter clinical coordinator Elizabeth Sayles said.

'You're a different person'

When the pandemic arrived, Flores Ruiz was an eighth grader.

Now, she’s nearly halfway through high school, a period of her life that began with a mostly virtual freshman year.

“During that transition, I felt like I was still in eighth grade, it didn't feel real that I was in high school,” Flores Ruiz said. “It felt like our teachers were teaching us as if we were still in middle school.”

Outside of academics, those years came during a “critical period of development” for many kids, Sayles said.

“We're seeing 12- and 13-year-olds who really are needing the socialization of a 10- to 12-year-old,” she said.

Sayles explained that can look like a 12- or 13-year-old wanting to play pretend or with puppets and work through what would traditionally be considered an earlier developmental stage. Schools and other institutions need to be prepared to recognize and work with students as they catch up.

“It can be incongruent or hard for families and teachers and providers to see because we have an expectation of, if we had been hitting normal developmental milestones where we would expect 15-, 16-, 17-, 18-year-olds to be acting,” Sayles said. “But we have to work through these step stones before we’re going to get to some of these other expectations.”

La Follette junior Josepha Da Costa found it difficult to connect in-person with her peers and friends upon returning to school, considering how different it is to interact over social media versus face to face.

“You're a different person than you were,” Da Costa said. “It's kind of hard to grasp and think about.”

Back to school

Before the pandemic, Da Costa was “always a straight A student” without any significant mental health concerns.

At the beginning of the 2021-22 school year, however, she “struggled” as she turned in assignments late and received low grades. At the time, she didn’t understand that she was experiencing early signs of mental health issues, something she wishes the school had better prepared her for.

“The school should put an emphasis on catching the problem when it happens instead of letting it go on for a while and then the student has to play catch up, which is kind of what happened to me,” she said. “It took my own self-advocacy and my parents to get me back on track from the beginning of the year.”

Throughout the virtual learning phase of the pandemic, which lasted longer in Madison than any other Dane County school district, many people called for a “return to normal.” But that return, when it came, brought its own set of challenges that were heightened by the 12 months mired in the pandemic.

UnityPoint Meriter mental health specialist Rachel Roisum said for students who were strong in school before the pandemic but struggled upon the return to in-person learning, it added anxiety as they couldn’t meet their previous standards.

“Some (kids) that I've seen were really great students before, didn't have an issue with school, and now just with everything that's gone on, they really struggle,” Roisum said.

That perpetuation can then turn into “significant school avoidance,” UnityPoint Meriter’s McDonough said. That furthers the challenge of getting caught up, she said, adding more stress on the shoulders of kids already struggling.

“A lot of these issues where it's like, I have 15 missing assignments, so now I don't have the energy to work on the next five, which now becomes 20, and then this mountain becomes insurmountable,” McDonough said.

As the return to in-person instruction approached, MMSD’s Guetschow recalled, the district tried to prepare for all possibilities of what students would be ready for both academically and socially.

“We weren't 100% sure what we were going to see so we just had to lean in on those (support) systems that have always existed, and make sure they were strong and ready for whatever came,” Guetschow said.

All three of the students who spoke with the Cap Times for this story said the transition back to in-person learning, while welcomed for many reasons, was also exceptionally difficult. Ridgeway recalled moving to the hybrid model in spring 2021, with two days of school in-person each week for a little over a month, compared to moving back to five full days last fall.

“It almost felt like we were forgetting that we all had to go through that (change), and we just were shoved right in there,” she said. “I know for a lot of people, we got the hang of it because after the past three years we've learned to adapt like crazy, like no one should ever have to, but it was hard at the beginning.”

Coping alone

The limits on in-person interactions early in the pandemic put students dealing with a mental health crisis in a challenging position.

“My friends were worried yet they couldn't really do anything but text me and call me and sometimes that wasn't enough,” Ridgeway said. “We ended up having to learn (to) self-soothe, what we like, what makes us comfortable, what makes us happy and that was definitely a big challenge during pandemic learning.”

UnityPoint Meriter’s McDonough said it was something they heard widely from adolescents in their care over the past two years.

“When we talk about coping skill developments with kids to alleviate feelings of depression and isolation, it's like, ‘Hey, get out there, reach out to people, go do fun activities,’ right? Take your mind off of things,” McDonough said.

The pandemic “put up a barrier to being able to use typical coping skills,” she said.

Even upon returning to classrooms, school officials dealt with a difficult balancing act of physical safety versus emotional connections. Distancing in classrooms and changes to lunch and recess routines were among the changes to slow the spread of COVID that affected some of the interactions we think of as “normal” at school.

“There was a lot of planning that had to happen for physical safety that then had ripple effects for how our students were together… and how our staff were able to be present and do their work,” Guetschow said.

That sometimes left students feeling alone as they dealt with their mental health. Whether parents, who some students aren’t comfortable being completely open with, or even the friends they now see daily, Flores Ruiz said it’s hard to share when everyone is going through a challenging time.

“I feel like I'm disturbing another person when I talk about my problems because I know that they're going through something, so it's very hard to talk with my friends about things that I'm going through,” she said. “So that support system is kind of broken right now because everyone's living through their own things, everyone has their own problems, and it's just very hard to try to help one another right now.”

In looking at her friends and around her school, Flores Ruiz said she sees everyone “at different places right now.”

“Some are doing better, some are doing not that good,” she said. “But I feel I don't know how my friends do it. What I do when I'm not doing great, I just sit down and listen to music and not do anything. Or I let myself cry it out sometimes. Everyone handles it differently.”

The stress has affected their brains, according to a research paper published by Grace George, a University of Wisconsin-Madison doctoral candidate in neuroscience, last fall. George explained in an interview that stress over a long period of time creates a continuing push of adrenaline and cortisol in your body, which can eventually hinder emotional regulation, behavior control and memory.

Those changes mainly affect the hippocampus and the prefrontal cortex, she said, developing them more quickly.

“So they are functioning at a different kind of rate than the rest of the brain and that causes a lot of issues because they have not finished growing yet,” George said. “So you'll see a lot of kids who are traumatized, a lot of kids who have a lot of stress have older looking brains than their peers.”

Short-staffed

School staff are also adapting to the level of students’ needs.

But there’s not nearly enough of them to meet the demand.

The National Association of Social Workers recommends schools have one social worker for every 250 students. In MMSD, the ratio is 1 to 592.

While the district plans to add 9.4 full-time equivalent social work positions for the 2022-23 school year, reaching that recommendation will require years of significant investment: 11 more FTE social work positions each school year from 2023-28.

They’re being asked to do more than before as they navigate the fallout from the ongoing pandemic.

“We are looking to our social workers for (social and emotional learning) and mental health supports, we are looking to our social workers for support in increasing student engagement and attendance and we're looking to our social workers to plan and implement social and emotional learning interventions,” interim executive director of MMSD’s Office of Staff and Student Supports Leia Esser told the School Board in February.

Beyond social workers, the district is also short of the national recommendations for psychologists and counselors, though it’s closer than for social workers, Esser said.

Those staffers in schools are trying to implement programs and connect with students as best they can.

“We also know that in our community is where we find strength and in our relationships is where we find healing,” Guetschow said. “Our school district is a great place to build the conditions for those for the healing that can happen in individual relationships and community.”

Ridgeway said she felt the school staff “did their best” to support students during virtual learning, but student support staff were often “swamped.”

“Booking an appointment with your counselor was nearly impossible,” she said. “You would send an email and hope for a reply, but it might not get through for a while.”

That left many students uncomfortable asking for help. It didn’t get any easier upon the return to in-person instruction. Both Da Costa and Flores Ruiz said they wished their schools had more direct conversations about mental health.

“We definitely need more conversations because they just haven't been there about mental health and what exactly it is,” Da Costa said. “Telling people it's okay to feel like this, other people are feeling like this, too, it's not just one person and you feel alienated from everyone else.”

Guetschow said the district works to have conversations about coping mechanisms and social and emotional learning skills embedded within its normal curriculum. Among them is trying to recognize when more help is needed, how to ask for it and identifying the way we as a community get along with each other and manage conflict.

“The way out of this – I think has always been our philosophy, but it's especially more so now – is to really work on what are those skills and conditions that we all need to learn and grow in, build and strengthen our coping skills,” Guetschow said.

Long-term outlook

Within the brain, George said, the stresses of the past two years could lead to “a bunch of different consequences,” including those increases in anxiety and depression. She described the range of potential effects as “overall, worse later-life outcomes.”

“It's difficult to focus for a really long time, harder to make good relationships, a lot of people tend to revert back when they're older because their brain just didn't really develop correctly,” George said. “Not that there aren't ways to mitigate that and kind of help with that when you're older, but it takes a lot more work when you're not on a normal developmental path.”

There’s no clear answer as to how that plays out behaviorally, though UW-Madison assistant professor Alvin Thomas compared it to the aftermath of Hurricane Katrina in New Orleans, where there were increases in anxiety, post-traumatic stress disorder symptoms, substance abuse, risky behavior and self-harm. Given the scale, he expects “the pandemic has been significantly more impactful than Katrina.”

In the next few years, as the “immediate threat” of COVID hopefully subsides, people will begin to think a return to normal has arrived, Thomas said. That’s when the fallout risks arrive, as people begin to think they can move forward.

“Once the waters of Katrina had subsided, people thought, ‘Great, we're no longer in danger, we're fine,’” he said. “No, we're not fine.

“It's kind of like the tsunami, you see the big waves coming and everybody's concerned about the big waves. And the wave goes and it’s like, ‘Oh, great, this is done.’”

Without an investment now, Thomas said, he predicted more self-medication, suicides and violence.

“We're going to see an increase in all of those things over the next three to five years unless we do something at the very beginning, now, to pre-empt,” he said. “To identify the kids who might have risk for some of these issues and step in to prevent them from becoming full-blown mental health issues.”

Ridgeway suggested one way to stem the growing issues would be more access for youth to free therapy, something she acknowledged is “easier said than done.” Many of her friends, she said, feel “tired and exhausted” by this school year.

The group of UnityPoint Meriter child and adolescent psychiatry staffers had a variety of suggestions of what parents and the community can do to help. One of the most important may sound simple on the surface, but is something they hear from kids is not common in practice: asking your kids what they need.

McDonough compared communication to boxing or working out as “something that needs to be practiced,” and suggested parents find “an intentional way to check-in with your kids every day about their day.”

“If they're coming to you, say, ‘Do you want me to listen? Do you want advice or can we problem solve together?’” McDonough said. “Oftentimes, they just want someone to listen and parents’ innate gut is, ‘Let me try and fix it’ or give solutions.

“(That) often creates this dynamic then where kids don't want to come to them because they don't feel validated or heard and that they're hearing, ‘Oh, you can just fix it by doing this.’”

'Support to all kids'

Experts say the best strategy for schools is to focus on the “universal practices” that help all students, including those who need it most.

UW-Madison associate professor Katie Eklund, whose research focuses on school mental health, said kids are “most likely” to access mental health services within schools, “which I think is surprising to a lot of folks.”

“When I think about mental health services, I think about it much more broadly in terms of universally what can we do to offer support to all kids knowing this is a shared experience,” Eklund said.

She pointed to social and emotional learning in classrooms, developing coping and problem-solving skills and helping educators understand the signs of mental health crises as examples.

“Making sure that we have the approaches in schools that provide a warm, safe environment for kids and that they have an adult that they can go to, to develop that trusting relationship with,” Eklund said.

MMSD has focused on those practices in its return, Guetschow said, “creating safe school buildings, creating places of teaching around social (and) emotional learning.”

District student and staff support coordinator Sara Knueve said elementary teacher teams built lessons over the past two years focused on questions like “What is COVID?” and “How do I deal with big feelings?” In upper grades, she said, “it becomes much more nuanced,” with teachers having to weave in the social and emotional learning with standard classes.

“It's much more embedded in your content area, but we're always attending to both the academic instruction and how we're showing up for that academic instruction,” she said.

Schools are looking for funding to bolster these services and related staffing. The district is investing $2.93 million of its federal COVID-19 relief money toward mental health initiatives, including programming, adding staff members and $750,000 for an elementary school social and emotional learning curriculum.

Gov. Tony Evers also recently announced $15 million toward the “Get Kids Ahead Initiative,” which is focused on providing more school-based mental health support to students. MMSD will receive $361,660 of those funds, which can be used to provide direct mental health care, hire mental health staff, provide training or provide family assistance programs.

“We know that long before the pandemic hit, kids across our state were already facing immense challenges with their mental health, but as parents and educators are seeing firsthand, these challenges have only been made worse by the isolating and traumatic events of the past two years,” Evers said in his announcement of the awards.