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Stuck at home and glued to screens, students face anxiety, depression and
even abuse, experts say
Students Deteriorating Mental Health
BY Deborah Sullivan Brennan
Feb 1, 2021.
San Diego Union-Tribune - Metro
Since the COVID-19 pandemic struck last March, psychiatric emergency visits at Rady Children’s
Hospital have crept up as youths and teens struggle with virtual learning, social isolation a nd
unstable home lives.
“March through May, we had a spike, about a 5 percent to 7 percent increase in the kids coming
to our emergency room,” said Sandy Mueller, senior director of behavioral health services for
Rady Children’s Hospital. “That dipped down in May to June, when school let out. And then we
saw a 7 percent increase to the present.”
In similar findings, a report released by the Centers for Disease Control in November showed that
mental health visits made up a greater percentage of pediatric em ergency room visits during the
pandemic in 2020, compared with the same months of the previous year. From mid-March 2020
through October, the report stated, “the proportion of mental health–related (emergency
department) visits increased sharply,” rising 2 4 percent among children ages 5 to 11, and 31
percent among adolescents ages 12 to 17, over the same period in 2019.
Moreover, many of the patients at Rady have more severe and complex problems than the
hospital typically sees, Mueller said.
“Those kids have higher acuity, higher levels of anxiety and depression,” she said, including
“social isolation, food insecurity, family stressors at home. There’s a stronger overlay of child
abuse issues. Those kids aren’t able to be in school, so they’re enduring more abuse at home.”
The problems facing families may have deeper, more enduring effects on children, who don’t
have the perspective to see the pandemic as a temporary circumstance.
“COVID, job loss, social isolation, that’s a global issue for adults and kids,” Mueller said. “But the
complexity of that for kids with underlying mental health issues is higher .... They don’t have free
meals. Their social network, after-school programs, those are severed.”
The increased mental health visits at Rady, however, aren’t consistent with the trend in San
Diego, where countywide mental health emergency room visits for youth have declined, said
Luke Bergmann, director of behavioral health services for San Diego County. Data from 12 local
hospitals show that psychiatric-related visits for youth declined 27 percent from February 2020
to January 2021, compared with the same period from 2019 to 2020.
That’s probably not a good sign, as the drop likely represents mental health problems that aren’t
getting treated.
“It’s not necessarily telling us that the need for crisis care is down, but it’s telling us that people
are accessing crisis care at much lower rates,” Bergmann said.
Parents may be taking children for emergency care at Rady because of its specialty in pediatrics,
he said, but could be reluctant to seek care at other hospitals during the pandemic, or unable to
navigate mental health systems.
Substance abuse treatment for all age groups, including young people, is also down, while
overdose deaths have risen, he said. The deferred treatment for mental health disorders will
likely have costs down the line, Bergmann cautioned. Mental wellness is a “lagging indicator,” in
which the effects of trauma today can show up months or years later, he said.
“We know that mental trauma experienced among young people has impacts on their lives that
can last many, many years,” he said. “We know this through ACEs data (adverse childhood
experiences) when young people experience trauma, we can see the impact in both their mental
health and their physical health even decades later.”
From frustration with virtual learning and anxiety about grades, to the loss of normal social life,
students now face a variety of stresses that can seem insurmountable, even for those without
underlying mental health problems, said Kristine Brady, a psychologist in private practice in
Encinitas.
“There’s just so much hopelessness, and teenagers have a hard time understanding just how
temporary this is,” she said. “They are 13 years old, so this feels like a lot o f their life. Kids are just
missing out on these milestones. There’s a lot of losses: no prom, no yearbook signing, no
graduation. Kids who used to complain about school are now saying, ‘I’m missing school.’ ”
Struggles with virtual education affect students across the academic spectrum. High-achieving
perfectionists fear not getting good grades or getting into the college of their choice, while those
with learning disabilities, attention deficit hyperactivity disorder and other challenges worry
they might not graduate at all.
“That high-functioning, high-academic kid is cutting, wanting to kill themselves, and has so much
anxiety because they feel they’re not going to succeed in life, and it’s very fatalistic. They feel it’s
ruined their life,” Mueller said. “Then you have kids who are academically struggling who are
failing even more, who feel like this is hopeless, and why bother, so they’re withdrawing.”
Virtual learning platforms themselves create stress, as students scramble to master content while
learning all the apps and systems used to deliver it, Brady said.
“They have a really hard time navigating the system,” she said. “The teacher may say turn on the
whiteboard, share your screen. They have to shift from three different apps on whiteboard,
which may be slow. If they’re called on to answer, and they’re locked, that brings on huge anxiety.
Especially if you have ADHD, those kids are really struggling and they already have trouble with
organization. To have to organize something on a screen you can’t even see is setting them up for
failure.”
Her own son Ryan Kies, 16, a student at San Dieguito Academy, said online learning can be
confusing and frustrating, even for students without academic obstacles.
“Not having classmates nearby is a big part,” he said. “Usually, if you have just a small question
you could ask the person sitting next to you, but now that’s not an option. If you miss just a small
bit of information that the teacher says, you have to stop the whole class.”
Students are self-conscious about participating on Zoom, and worried about being called to
answer questions online, Brady said. Without friends and classmates for support, they’re less
able to cope with those stresses.
“Teenagers need to be around other teens. Their job right now is to get out there and explore
with other kids, and that’s not possible right now for many,” she said.
Parents can help by expressing empathy, backing off from strict academic expectations, and
taking time for fun, safe family outings, or allowing students to take part in socially distanced
activities with friends, she said.
For students from troubled families, the setbacks of the pandemic are even greater, and
potentially life-threatening, Mueller said.
“We’ve had a lot more kids who have been significantly abused,” she said. “Parents are losing
jobs, stressed, and drinking more, and they’re all home. The environment is intensified, so we’re
seeing a lot more injuries to kids.”
For younger children, that often shows up as skull fractures, while adolescent s suffer bruising or
broken bones from physical abuse. Mental and physical health crises often overlap, she said.
“Older kids coming in saying they’re suicidal, but when we assess we find out they’re abused in
home and have acute injuries,” Mueller said.
Job loss and other financial pressures cause family conflict to escalate, and isolation obscures its
consequences. Child sexual abuse is both worsened and hidden under the cloud of the pandemic,
she said.
“Children being sexually abused in home had hours of reprieve (during the school day) and now
they’re with their perpetrator 24/7 and have no way to escape,” she said. “For our kids that have
child abuse issues, there’s a higher chance for their parents to reoffend or abuse, because those
kids can’t get a break from them.”
School closures also confound efforts to identify those threats. Teachers are mandated reporters,
who must notify public safety and health authorities of suspected child abuse. They are often the
first line of defense, and sometimes the only trusted adult whom abused children can turn to for
help. With schools out of session and students’ cameras often turned off during class Zoom
sessions, teachers might not see the danger signs, Mueller said.
“School is a safety net for kids, and we took that safety net away, and we don’t know what’s going
on in the homes and what their needs are,” she said.
deborah.brennan@
The Relation Between Adverse Childhood Experiences
and Adult Health: Turning Gold into Lead (The Permanente
JournalClinical Contributions)
By Vincent J Felitti, MD
Background
The Adverse Childhood Experiences (ACE) Study is a major research study that compares current
adult health status to childhood experiences decades earlier. With the cooperation of 17,421 adult
Health Plan members and with the ongoing collaboration of Dr Ro bert Anda at the Centers for
Disease Control and Prevention (CDC), the study is being carried out in the Department of
Preventive Medicine at Kaiser Permanente (KP) San Diego--where for many years we conducted
detailed biomedical, psychological, and social (biopsychosocial) evaluations of more than 50,000
adult Kaiser Foundation Health Plan members per year.
The findings are important medically, socially, and economically: They provide remarkable insight
into how we become what we are as individuals and as a nation. The ACE Study reveals a powerful
relation between our emotional experiences as children and our adult emotional health, physical
health, and major causes of mortality in the United States. Moreover, the time factors in the study
make it clear that time does not heal some of the adverse experiences we found so common in the
childhoods of a large population of middle-aged, middle-class Americans. One doesn't "just get over"
some things.
Study Design
The ACE Study was triggered by observations we made in the mid 1980s in an obesity program at
the KP San Diego Department of Preventive Medicine. This program then had a high dropout rate.
The first of many counterintuitive discoveries was that the great majority of the dropouts actually
were successfully losing weight. Detailed life interviews of almost 200 such individuals unexpectedly
revealed that childhood abuse was remarkably common and antedated the onset of their obesity.
Many patients spoke openly of an association between the two. The counteri ntuitive aspect was that,
for many people, obesity was not their problem; it was their protective solution to problems that
previously had never been discussed with anyone. An early insight was the memorable remark of a
woman who was raped at age twenty-three and gained 105 pounds in the subsequent year:
"Overweight is overlooked, and that's the way I need to be." The contrast was striking between this
statement and her desire to lose weight. Similarly, two men who were guards at the State
Penitentiary became anxious after losing more than 100 pounds each. They made it clear that they
felt much safer going to work looking "big as a refrigerator" instead of normal size. Overall, we
found the simultaneous presence of opposing forces to be common; many of our w eight program
patients were driving with one foot on the brakes and one on the gas, wanting to lose weight but
fearful of change.
In 1990 in Atlanta, I presented information about the frequent relation between obesity and abusive
childhood experiences to a largely skeptical audience at the North American Association for the
Study of Obesity. Unexpectedly, this presentation led to contacts with researchers at the CDC, who
recognized the importance of what had been reported. They proposed a large epidemiolog ic study to
provide definitive evidence of our clinical observations. This was the beginning of the ACE Study at
KP San Diego, where, each year, we could easily ask more than 26,000 consecutive adults seen in
the Department of Preventive Medicine if they would be interested in helping us understand how
childhood events might affect adult health status. Sixty-eight percent of this population agreed to
participate and understood that the information they provided about their childhood would never be
included in their medical records.
The ACE Study compared current adult health status of these participants with eight categories of
adverse childhood experience that we had frequently identified in the weight program. Three
categories pertained to personal abuse: recurrent physical abuse, recurrent emotional abuse, and
sexual abuse. Four categories pertained to growing up in a dysfunctional household--ie, with an
alcoholic person or a drug user; where someone was in prison; where someone was chronically
depressed, mentally ill, or suicidal; where the mother was treated violently; and where the parents
were separated, divorced, or in some way lost to the patient during childhood. In addition, we
decided to monitor this large cohort for at least five years to compare childhood experiences
prospectively against adult pharmacy costs, doctor office visits, emergency department use,
hospitalization, and death. An ACE score was constructed to analyze the huge mass of information
we gathered. A person exposed to none of the studied categories had an ACE Score of 0; an
individual exposed to any four had an ACE Score of 4, etc.
Because the average study participant was 57 years old, we actually were measuring the effect of
childhood experiences on adult health status a half-century later. Dr Anda, my coprincipal
investigator at CDC, designed the data management and retrospective and prospective components
of the Study with great skill. Here, I will only touch upon some highlights of our findings; details may
be sought in the anchor article of a series of publications deriving from the ACE Study. The initial
article was published in May 1998 in the American Journal of Preventive Medicine, v 14: 245-258;1
full text is at their Web site: www.meddevel.com/site.mash?left=/library.ex e&m1=4&m2=1&right=
/library.exe&action=search_form&search.mode= simple&site=AJPM&jcode=AMEPRE.
A list of published peer reviewed publications from the ACE Study is provided at the end of this
article.2-11
Findings
A striking finding was that adverse childhood experiences are vastly more common than recognized
or acknowledged. Of equal importance was our observation that they had a powerful correlation to
adult health a half-century later. It is this combination that makes them so important. Slightly more
than half of our middle-class population of Health Plan members experienced one or more of the
categories we studied. One in four was exposed to two categories of abusive experience, one in 16
to four categories. Given an exposure to one category, there i s 80% likelihood of exposure to
another. All this, of course, is well shielded by social taboos against obtaining this information.
Further, one may "miss the forest for the trees" if one studies these issues individually. They do not
occur in isolation; for instance, a child does not grow up with an alcoholic person or with domestic
violence in an otherwise well-functioning household. The question to ask is: How will these childhood
experiences play out decades later in a doctor's office? How does one perf orm reverse alchemy,
going from a normal newborn with almost unlimited potential to a diseased, depressed adult? How
does one turn gold into lead?
Smoking is a useful starting example to illustrate what we found; moreover, it allows us to start with
a minimally threatening topic. In California, there are now profound social pressures against
smoking; persistent smoking in the face of these is often attributed to "addiction." But did you know
that current smoking has a high degree of association with what h appened decades ago in
childhood? Figure 1 is a graphic illustration of how the ACE Score has a graded, dose-response effect
on the probability of current smoking. The higher the ACE Score, the greater the likelihood of current
smoking. This graded, dose-response effect is present for all the associations we found, although I
will only present three. All the relations have a p value of .001 or better. Further details of the ACE
Study findings are published in a series of articles exploring our findings from the retrospective and
prospective arms of the Study.
Figure1. Graph shows relation between Adverse Childhood Experiences (ACE) Score and
smoking status.
Lest one doubt the significance of smoking, we found that chronic obstructive pulmonary disease
(COPD) has a strong relationship to the ACE Score. A person with a midrange ACE score of 4 is
390% more likely to have COPD than is a person with an ACE Score of 0. What does this do to the
conventional concept of smoking that attributes addiction to characteristics that are intrinsic within
nicotine? We instead found "addiction" attributable to characteristics that are intrinsic in early life
experiences. If early emotional stress predicts COPD, is COPD properly understood as a
psychosomatic condition? Are certain common, chronic, adult diseases the result of attempts at self -
treatment of concealed problems that occurred in childhood?
When we looked at self-defined current depression, we found that a person with ACE score >4 was
460% more likely to be depressed than a person with ACE score of 0. Confirming the reliability of
this conclusion, we found a 1220% historical increase in attempted suicide between these two
groups. For groups with higher ACE scores, incidence of attempted suicide increases thirtyfol d to
fifty-one fold! Using the analytic technique of population attributable risk, we found that more than
two thirds of suicide attempts could be attributed to adverse childhood experiences.
Figure 2. Graph shows relation between longtime smoking, chr onic obstructive pulmonary disease
(COPD), and ACE Score.
Figure 3. Graph shows relation between ACE Score and illicit use of injected drugs.
Intravenous drug use is a major public health problem. In spite of massive efforts to curtail it, little
progress has been made. We found that IV drug use may properly be viewed as a personal solution
to problems that are well concealed by social niceties and convention. For example, a male child with
an ACE score of 6 has a 4600% increase in the likelihood of later using intravenous drugs. This
relation to adverse childhood experiences is powerful and is graded at every step; it provides a
perfect dose-response curve; and epidemiologically, these outcomes are nearly unique in magnitude.
Because no one shoots heroin to get endocarditis or AIDS, might heroin then be used for relief of
profound anguish dating back to childhood experiences? Might it be the best coping device a person
can find? If so, is this phenomenon a public health problem or a personal solution ? How often are
public health problems personal solutions? Is drug abuse self -destructive, or is it a desperate
attempt at self-healing, albeit at a significant future risk? This point is important because primary
prevention is far more difficult than anticipated--possibly because incomplete understanding of the
benefits of so-called health risk behaviors causes these behaviors to be viewed as irrational acts that
have only negative consequences. Does this incomplete view of drug abuse leave us mouthing
cautionary platitudes instead of understanding the cause of our intractable public health problems?
Beyond these few illustrations, we found many other measures of adult health to have a strong,
graded relation to what happened in childhood: hepatitis, heart disease, fractures, diabetes, obesity,
alcoholism, occupational health, and job performance. These findings are detailed in the original and
subsequent articles and will further be reported in publications of the yet -to-be-analyzed prospective
arm of the ACE Study.
Discussion
What do these findings mean for medical practice and for society? Clearly, we have shown that
adverse childhood experiences are both common and destructive. This combination makes them one
of the most important, if not the most impo rtant, determinants of the health and well-being of the
nation. Unfortunately, these problems are both painful to recognize and difficult to cope with. Most
physicians would far rather deal with traditional organic disease. Certainly, it is easier to do so, but
that approach also leads to troubling treatment failure and to the frustration of expensive diagnostic
quandaries where everything is ruled out but nothing is ruled in.
Our usual approach to many common adult chronic diseases reminds one of the rela tion between
smoke and fire. A person unfamiliar with fires would initially be tempted to treat the smoke--ie, the
most visible aspect of the problem. What we have learned in the ACE Study represents the
underlying fire. Fortunately, fire departments learned to distinguish cause from effect long ago; if
they had not, they would use fans instead of water hoses.
If the treatment implications of what we found in the ACE Study are far-reaching, the prevention
aspects are positively daunting. The very nature of the material is such as to make one
uncomfortable. Why would one want to leave the relative comfort of traditional organic disease and
enter this area of threatening uncertainty that none of us has been trained to deal with? And yet, as
I write these words, I am interrupted to consult on a 70-year-old woman who is diabetic and
hypertensive. The initial description given to me omitted the fact that she is morbidly obese (one
doesn't go out of one's way to identify what one can't handle). Review of her chart shows her to be
chronically depressed, never married, and, because we ask the question of 57,000 adults a year, to
have been raped by her elder brother six decades ago when she was ten. The same brother also
molested her sister, who also is said to be leading a troubled life.
We found that 22% of our Health Plan members were sexually abused as children. How does that
affect a person later in life? What does it mean that early sexual abuse is never spoken of? We find it
useful routinely to ask all patients acknowledging this experience, "How did that affect you later in
life?"
What, then, is this woman's diagnosis? Is she just another hypertensive, diabetic old woman, or is
there more to the practice of medicine? Here is the way we conceptualized her probl ems:
Childhood sexual abuse
Chronic depression
Morbid obesity
Diabetes mellitus
Hypertension
Hyperlipidemia
Coronary artery disease
Macular degeneration
Psoriasis
This is not a comfortable diagnostic formulation; it points out that our attention is comfortably
focused on tertiary consequences far downstream. The diagnosis shows that the primary issues are
well protected by social convention and taboo and points out that we have limited ourselves to the
smallest part of the problem: the part where we are comfortable as mere prescribers of medication.
Which diagnostic choice shall we make? Who shall make it? And if not now, when?
This article, with minor change, was originally published in The Family Violence Prevention Fund's
"Health Alert," Volume 8, No. 1. Adapted and reproduced with permission of the publisher, Peter
Sawires.
Acknowledgments
The original study was funded by the US Department of Health & Human Services; the CDC Foundation; and the Kaiser Permanente
Garfield Memorial Fund.
Selected ACE Study Publications
1. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading
causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998 May;14(4):245-58.
2. Foege WH. Adverse childhood experiences: A public health perspective. Am J Prev Med 1998 May;14(4):354-5.
3. Weiss MJ, Wagner SH. What explains the negative consequences of adverse childhood experiences on adult health? Insights
from cognitive and neuroscience research. Am J Prev Med 1998 May;14(4):356-60.
4. Anda RF, Croft JB, Felitti VJ, et al. Adverse childhood experiences and smoking during adolescence and adulthood. JAMA
1999 Nov 3;282(17):1652-8.
5. Dietz PM, Spitz AM, Anda RF, et al. Unintended pregnancy among adult women exposed to abuse or household dysfunction
during their childhood. JAMA 1999 Oct 13;282(14):1359-64. Hillis SD, Anda RF, Felitti VJ, et al. Adverse childhood
experiences and sexually transmitted diseases in men and women: a retrospective study. Pediatrics 2000 Jul;106(1):E11.
6. Edwards VJ, Anda RF, Nordenberg DF, et al. Bias assessment for child abuse survey: factors affecting probability of response
to a survey about childhood abuse. Child Abuse Negl 2001 Feb;25(2):307-12.
7. Edwards VJ, Fivush R, Anda RF, et al. Autobiographical memory disturbances in childhood abuse survivors. In: Freyd JJ,
DePrince AP, editors. Trauma and cognitive science: a meeting of minds, science, and human experience. Binghamton (NY):
Haworth Press; 2001. Published simultaneously as a single-topic issue of J Aggression Maltreatment Trauma Vol 4(2), No. 8.
8. Anda RF, Felitti VJ, Chapman DP, et al. Abused boys, battered mothers, and male involvement in teen pregnancy. Pediatrics
2001 Feb;107(2):E19.
9. Dube SR, Anda RF, Felitti VJ, et al. Adverse childhood experiences and personal alcohol abuse as an adult. Addict Behav. In
press 2002.
10. Dube SR, Anda RF, Felitti VJ, et al. Exposure to abuse, neglect and household dysfunction among adults who witnessed
intimate partner violence as children: implications for integrated health and social services. Violence Vict. In press 2002.
11. Dube SR, Anda RF, Felitti VJ, et al. Childhood Abuse, Household dysfunction, and the risk of attempted suicide throughout
the life span. Findings from the Adverse Childhood Experiences Study. JAMA 2001;286:3089-3096.