How teenagers are coping in the COVID-19 pandemic

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For almost 12 months now, Canada’s teenagers have essentially been locked up with their parents. By the time the pandemic ends, two sets of graduations and proms will have been cancelled, along with a year and a half of sports tournaments, school plays, movies, dates and parties – basically, everything they’d been promised would make the final years of high school the best of their vanishing childhoods. And unlike the postponed vacations adults have been whinging about, there’s no rebooking. That time is gone for good.

They spent it in their bedrooms, saved only by the screens their parents once scorned. Some weeks, school was safe enough, as long as they wore masks and stayed away from each other. They were warned constantly: Hanging out, let alone hooking up, would mean more people would die. Not them, though – as an age group, they’re relatively safe from COVID-19. So when you think about it, in a year of uncertainty, threat and stress, teenagers have been asked (ordered, really) to perform the largest gesture of collective altruism in recent history – at great personal cost, with the least say in the matter, and at one of the most important stages of their social and mental development.

No wonder we’re worried about them.

COVID-19 has changed everything about the Canadian high-school experience

What happens to a generation that gets handed a global pandemic just as it’s preparing to launch into the world? The last time around – the Spanish flu of 1918 – teenagers, as a concept, didn’t even exist, and there wasn’t much research on the survivors anyway. That mistake won’t be repeated; mental health experts are already collecting reams of data on young people to analyze the long- and short-term effects of COVID-19. But their conclusions are pending; it will be years before the fallout of the pandemic is fully understood.

What we have now is a best guess, based on how things have gone so far, and at other times when humanity faced disaster and survived to answer research questions about it. Mental health data from the first seven months of lockdown suggests a mixed outcome – some kids, especially those with pre-existing mental health issues and risk factors, are having a very rough time; others are getting by, even benefiting from the slower pace of life.

The science of natural disasters and global events predicts much the same: Youth are often resilient as long as the stress doesn’t last too long or become too severe, and they get the support they need from adults. The theory of generations suggests that COVID-19 will have a long life in the collective memory of those coming of age in the middle of it – big events that happen in adolescence tend to be most formative for values and priorities. But underlying all that research is one important caution: Teenagers are not homogeneous, even though it’s convenient to think of them that way. When it comes to helping young people, the individual narrative trumps all.

“There is no one story,” says Joanna Henderson, a senior scientist at Toronto’s Centre for Addiction and Mental Health.

This diversity of experience is already evident in survey data and hospital statistics up to this past October. The pandemic doesn’t appear, so far, to have led to a rise in suicide rates, according to preliminary data from provincial coroners. In Ontario, hospitals saw an overall drop in pediatric emergency department visits, and admissions for suicidal ideation and self-harm. At the same time, calls to crisis lines have jumped exponentially, and the young people who are being admitted to hospital are in more serious condition. This includes patients with eating disorders, one diagnosis that has clearly spiked during the pandemic.

The why of all of this is still unclear. Hospital visits as a whole were down because people were avoiding the hospital, especially early on. But they may also have fallen off because, away from school, released from hectic schedules, and with their families around more, many kids felt okay. (Anecdotally, doctors are already reporting that their patients with social anxiety are in better shape.)

While some teens are developing pandemic-onset eating disorders in response to a loss of control and their usual coping strategies, it might also be that parents working from home are discovering a problem their children were hiding before the pandemic.

Hospital visits and admissions

for eating disorders

Ontario children and adolescents aged 3–17

(per 100,000 population)

Hospitalizations

Emergency department visits

3.0

2.5

2.0

1.5

1.0

0.5

0.0

2017

2018

2019

2020

Four-week average, Jan. 2017 to Sept. 2020

john sopinski/the globe and mail, source:

OHMHA Centre of Excellence analysis;

Data: ICES

Hospital visits and admissions for eating disorders

Ontario children and adolescents aged 3–17

(per 100,000 population)

Hospitalizations

Emergency department visits

3.0

2.5

2.0

1.5

1.0

0.5

0.0

2017

2018

2019

2020

Four-week average, Jan. 2017 to Sept. 2020

john sopinski/the globe and mail, source: OHMHA

Centre of Excellence analysis; Data: ICES

Hospital visits and admissions for eating disorders

Ontario children and adolescents aged 3–17 (per 100,000 population)

Hospitalizations

Emergency department visits

3.0

2.5

2.0

1.5

1.0

0.5

0.0

2017

2018

2019

2020

Four-week average, Jan. 2017 to Sept. 2020

john sopinski/the globe and mail, source: OHMHA Centre

of Excellence analysis; Data: ICES

The increase in calls to crisis lines is an indicator of widespread stress, but kids might also be calling more because they don’t have access to friendly teachers to ease their worries. And the fact that they’re reaching out at all is a positive trend.

Anxiety is a normal response to a dangerous virus; as one researcher put it, “If you don’t feel anxious, you aren’t paying attention.” Even so, young people merit particular concern. Doctors worry about the ones they aren’t seeing – especially since going into the pandemic, mental health presentations at emergency rooms, particularly for self-harm, had been steadily rising. (Over the past decade, they had roughly doubled, to about 80,000 visits a year.) Adolescence is the life stage when mental illness most often appears, suggesting a particular vulnerability to stress and trauma. Getting treatment early improves the chances of recovery; not getting it can forever alter an adult life.

“The most prominent thing I have seen is a sense of despondency and despair about the future,” says Javeed Sukhera, a pediatric psychiatrist at London’s Health Science Centre. “They just don’t have the experience to imagine an end, and for them, right now feels like forever.”

In Cochrane, Alta., high school teacher Scott Thompson sees the burden of the pandemic playing out in different ways. Many of his students feel dull from boredom and disappointment – as if they’re trudging through quicksand. For those teens actively involved in extracurriculars, he says, “we took away the things that brought them deep fulfillment.” For others, mental health problems were already simmering, and the pandemic has “turned the heat up on everything.” This stressful time may be further compounded by family dysfunction or anxiety about bringing the virus home to at-risk relatives.

Figuring out how to support all these kids, and help them grieve the loss of this broken year, would be daunting enough without masks and physical distancing and a teacher’s own stress.

“There’s not a single person alive who has gone through this,” Mr. Thompson says. “So we are all building the plane while we fly.”

A study at CAMH, led by Dr. Henderson, has been following 600 young people, between the ages of 14 and 28, at regular intervals over the course of the pandemic. Preliminary data shows that distress and worry were highest at the beginning of the lockdown, fell during the relative freedom of the summer, and began to rise again in the fall, with school resuming in fits and starts, and a second wave predicted. But at each sample stage, one-third or more of young people in the study were able to identify “positive changes in their lives” because of the pandemic. Some examples they gave: better mental health, greater self-care, reduced school stress and more time with their families.

“All this doom and gloom, that they are going to be damaged forever, is problematic,” says Dr. Sukhera, who has worked with child soldiers and young refugees who missed years of school. “We are wired to be very resilient.”

An encouraging Statistics Canada survey, released in February and conducted this past September, found that while 14 per cent of youth aged 12 to 17 said their mental health was worse than a year earlier, another 60 per cent described their mental health as roughly the same, and 26 per cent said it was actually better.

Still, survey data should be interpreted with caution. Surveys capture one moment in time, and they can skew positive because the kids faring most poorly are harder to reach. In a second October sample, the Statistics Canada numbers had worsened slightly, with 18 per cent saying their mental health was worse and 20 per cent saying it was better.

Most significantly, a lot has happened since October, and we are still in the middle of this crisis.

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In the meantime, the lessons of past disasters and global events offer a template for how today’s teenagers will fare long-term. Comparisons will be imperfect; these teens, and this event, are unique. A hurricane didn’t smash away their homes in an instant; no one is going to war. There is nothing to rebuild, and no tangible enemy to fight – two purposeful conditions that help people recover. COVID-19, by comparison, is a long, slow slog of trying to do as little as possible in a society that still enjoys uninterrupted Wi-Fi. But there are enough similarities – the unexpected disruption of regular life, the close proximity to death, the uncertainty swirling around the future – to take guidance from the findings.

Some of the most extensive North American research followed teenagers and children after 9/11 and Hurricane Katrina. What that research shows is that exposure to a disaster, and the severity of the consequences that follow, make a significant difference in how well they fare.

A study by researchers at Columbia University followed 844 children who were directly exposed to the terrorist attack – either as eyewitnesses or caught in the dust as the Twin Towers fell. As teenagers and young adults, those children had higher rates of psychiatric and physical disorders – as well as both together – compared to a control group of 491 kids in nearby Queens, who watched the collapse on television but weren’t close enough to see it.

One of the areas hit hardest by Hurricane Katrina was St. Bernard Parish, a county next to New Orleans that was devastated by flooding and the resulting oil spill. Even three years later, only about half of the residents were able to return home, and only half of the kids returned to their schools. Even so, a 2010 study of 387 St. Bernard Parish children between the ages of 9 and 18 found nearly three-quarters had recovered. In the study, 27 per cent had followed a normal response-and-recovery pattern – symptoms of trauma or depression that existed at the two-year mark had nearly disappeared by the third. Another 45 per cent were what researchers called “stress-resistant” – they functioned well during and after the disaster. Some 27 children were still reporting significant signs of post-traumatic stress and depression three years later.

That study and others found that youth who went into Hurricane Katrina with more risk factors and who experienced greater loss in the storm’s aftermath had poorer outcomes; those with protective factors, such as a stable home environment and higher family income, recovered faster. Research found that race and poverty were linked to more negative mental health, even years later – a trend that foreshadows Canada’s pandemic, where the virus has hit lower-income, racialized communities harder than wealthier white ones.

Personality and genes play a part, too – having self-control and being optimistic helps teenagers weather all kinds of storms better. In a New Zealand longitudinal study that closely followed 1,000 subjects for four decades, from birth to midlife, researchers found that just 17 per cent of participants had what they called “enduring mental health” – that is, no clinical diagnosis of either an acute or chronic mental illness. The finding was significant for normalizing mental illness, since the vast majority of people in the study had experienced an acute or chronic mental health problem by middle age. But it also found that the group with enduring mental health hadn’t been born into wealthier families, and they weren’t more intelligent. What appears to distinguish them is that they didn’t have a close family history of mental illness, and they possessed “agreeable personalities” – which, researchers theorized, meant they had more friends growing up and thus more social support. A Spanish study of adults during COVID-19 has also found that those with a positive outlook experienced better mental health in lockdown.

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The take-away from this research presents a challenge: The reason kids suffer most during disasters are out of their control and hard to remedy in the aftermath. But the work also helps identify those most at risk, so programs, health care systems and schools can target those teens with more intensive support. This includes teenagers with pre-existing mental illnesses, as well as those who’ve had a loved one die from COVID-19, or who are more precariously housed, more isolated or locked down in a dysfunctional household – especially with a parent who suffers from a mental illness or addiction.

That last point is important for all parents, because research consistently shows that how the adults in a teen’s life cope with stress and trauma during a disaster filters down to them – which is why Dr. Sukhera warns adults to be careful about projecting their own fears and anxiety upon their kids. “We look at the world through the lens of our own baggage,” he says. “Their experience will be completely their own.”

In fact, teenagers are in the unique position of being the ones most affected by the lockdown measures but with the least amount of control over the decisions being made. That’s a potential risk factor in itself: Studies from natural disasters suggest youth who felt less in control experienced increased negative mental health symptoms.

“It’s like the world is going in a certain way, and there is nothing I can do about it,” says Emma Harris, a Grade 12 student in Winnipeg, one of a dozen high school students who described their pandemic experience to The Globe in February. All the other problems of teen life, she could handle – fixing a fight with a friend, studying harder for a test – but not this one. In the beginning, “there wasn’t much else to do but stay home and feel sad about it.”

In previous research on disasters, and in more recent studies about the pandemic in general and the mental health toll of lockdown, one of the protective factors for youth was accurate information from credible sources. Having parents, for instance, who discussed the 9/11 attacks was found to make a difference in the post-traumatic distress of teenagers one year after the event. Open and supportive family chats – along with casual check-ins – can also reinforce coping skills. Joy Osofsky, a professor of pediatrics and psychiatry at Louisiana State University Health Sciences Center who has studied teenage outcomes from Hurricane Katrina, suggests parents adopt the simple practice during the pandemic of asking their kids to cite something positive that happened to them each day.

For teens, feeling as though they are contributing in some way – such as participating in disaster recovery, delivering groceries to isolated seniors or having a selfless reason to physically distance – has also been associated with increased self-efficacy, the belief that one’s action can improve their circumstances. This helps kids find meaning and purpose in times of uncertainty so they can make sense of what is happening, and also find an active, positive role to play.

Surviving a storm can foster resilience and even growth – when the emotional and material conditions are right.

In The Globe’s conversations with Canadian teenagers across the country, there were some common themes: the challenge of adjusting to disappointment, missing their friends, worrying about family members getting sick, feeling untethered and uncertain. They are by no means a scientific sample – many were high-achieving students and school leaders – but their answers, coming from different parts of the country, were remarkably consistent and aligned with the resilience research. Trapped at home, they sought purpose through new hobbies. They leaned heavily on social support from friends and family. They spoke about learning to make the best of a bad situation, over and over again, with each new twist in pandemic restrictions. They were also remarkably literate about mental health – the need to talk about their feelings, to take time for themselves, to even practise mindfulness.

“This was a test of our character,” said Tyshawn Grant, a Grade 11 student in Toronto. “In the beginning, I felt constricted. I can’t be how I want to be. I can’t grow.”

For most of them, the lowest point was the beginning of the pandemic. Gradually, they adjusted. Mr. Grant filled his time working as a virtual mentor to younger students, writing poetry, sketching and experimenting with fashion design. Ms. Harris said that though she’s still sad, she’s managing her negative emotions – partly by paying more attention to all the things she used to take for granted. “Now I get excited on the drive to school to see my friends,” she said.

History suggests that momentous cultural events seep into the air that a generation breathes, especially when it happens during adolescence. One theory of young people who grew up in the Great Depression, and lived through the World War that followed, was that they became more community-oriented and civic-minded as a result. At a key stage of their social development, they’d witnessed firsthand the importance of society pulling together against a common cause.

Could this also be the legacy of a pandemic that required universal sacrifice from young people, even though the danger was mainly to their elders? Too young to remember 9/11, they have now lived through a massive global event at the precise time research suggests it will make the largest impact on them. How will this group of teenagers – already more diverse and tolerant than any before them – respond to the social inequities highlighted so clearly by COVID-19 (and reinforced by the coinciding Black Lives Matter movement)? Will they become more invested in in-person relationships after losing them so abruptly? Will they see value in life at a simpler, slower pace? Will they be germaphobes? The truth is, we can’t know yet; the collective personality of a cohort coalesces over time.

They are unsure themselves, wondering how long the anxiety they now feel, say, watching an unmasked crowd in a Netflix movie, will last, or whether the joy of finally being free will erase any trepidation. They spoke, almost universally, of gratitude and self-reflection, and learning what’s really important – focusing on the people who matter to them, appreciating what they already have. Whether those feelings endure, when it is human nature to return to baseline, can be the subject of further study. For this group, however, their predictions are infused with optimism and transformation.

“We learned to deal with this whole situation that came out of nowhere,” says Ekram Maye, a Grade 12 student in Toronto. “When the world opens up again, I wouldn’t hold back, because you never know what can happen again. I have to live in the moment.”

Of course, it won’t be that simple – not for everyone. Each disaster, as the research shows, leaves a group of young people who struggle for years afterwards. Getting them good care will be the challenge of a mental health care system that was overwhelmed long before COVID-19. As the focus turns to vaccine delivery, getting through a possible third wave and eventually returning to regular life, CAMH’s Dr. Henderson offers this caution: “We need to ensure that the needs of young people are not overlooked.”

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