COVID-19 and the lockdown measures to control it have unquestionably affected all our mental health and wellbeing. But children and young people may have been hit the hardest, according to a number of surveys and reports. Last month, the Royal College of Psychiatrists issued a warning of ‘terrifying’ levels of mental health problems in under-18s, based on its analysis of NHS and Office for National Statistics data.1 Young people are ‘bearing the brunt of the mental health crisis caused by the pandemic and are at risk of lifelong mental illness’, said Bernadka Dubicka, Chair of its Child and Adolescent Faculty, due to ‘the devastating effect’ of school closures, disrupted friendships and the uncertainty caused by the pandemic.

One organisation, the Health Foundation, is even talking about ‘Generation COVID-19’. In its report into the impact of the pandemic,2 it points to emerging evidence that young people aged 12 to 24 are one of the most negatively affected groups, particularly in terms of employment and mental health. ‘As the Government looks to “build back better”, creating a national cross-government strategy on health inequalities becomes more important than ever and it is vital that young people are placed at the heart of this plan,’ the Foundation says.

In June 2020, their fears about the repercussions for children and young people’s mental health prompted more than 100 psychologists to write an open letter to Education Secretary Gavin Williamson urging him to reopen schools and colleges.3 The risk of catching COVID-19 was far less than the risk to our children’s long-term futures, they said: ‘Allow them to play together and continue their education… When many of this cohort enter adulthood, we will be deep in recession, so they will need mental resilience and educational preparedness. Instead, we are damaging both, with lifelong consequences for them and society.’

Early signs of the impact were revealed in an NHS Digital follow-up survey of children and young people in England published in October 2020.4 This found a rise in the overall rate of mental disorder from one in nine (10.8%) of children aged five to 16 in 2017, when they were first interviewed, to one in six (16%) in July 2020, when they were followed up online. Writing in The Lancet,5 the study’s authors reported on the particular impacts of the pandemic: more than a quarter of children and young people reported disrupted sleep and one in 10 (5.4% of children and 13.8% of young people) said they often or always felt lonely.

In both cases, this most affected those with ‘probable’ mental health problems, who were unable to access their usual sources of support. These children and young people were more likely to say that lockdown had made their life worse (54.1% of 11- to 16-year-olds, and 59% of 17- to 22-year-olds); 44.6% of the 17- to 22-year-olds reported not seeking help because of the pandemic, and 21.6% of children and 29% of young people with mental healthcare needs reported having no adult at school or work to whom they could turn for support during lockdown. The impact, the researchers warned, could be ‘widening health and education inequalities’.5

These findings are echoed by Young Minds, who in January 2021 polled more than 2,000 children and young people aged under 25 with a history of mental health problems. Some 24% said they were not able to access their usual sources of support, 67% believed the pandemic would have long-term negative impacts, and 49% said their school or college was not focusing on mental health and wellbeing following the pandemic.6

The Mental Health Foundation and Swansea University jointly launched an ongoing survey of teenagers aged 13 to 19 in England, Wales and Scotland, which has so far produced three quarterly reports. In its January 2021 report,7 of the 2,395 young people surveyed, 27% reported feeling ‘nervous, anxious or on edge’; 27% said they felt ‘easily annoyed or irritable’; 26% had had trouble concentrating on things like schoolwork, reading and watching TV, and 32% said they had trouble sleeping. They said these were affecting them most or nearly every day. Teenagers whose parents were unemployed and those in the social grades C2DE were much more likely to report these experiences, which, the report points out, are all common symptoms of anxiety and depression.6

A survey of nearly 20,000 children and young people aged three to 18 published by the Children’s Commissioner for Wales, also in January,8 found that disabled children and young people were more likely to be worried about the coronavirus, more likely to feel sad and more likely to feel unsafe. Those of black, Asian and other ethnic minority ethnicities were also more likely to feel lonely and less likely to say they felt safe.

‘Lifelong consequences’

In January this year, the NSPCC put out an appeal for more volunteers. Its Childline telephone support service reports that it has delivered more than 61,000 counselling sessions since the March 2020 lockdown. This includes a 15% increase in the number of counselling sessions about mental health with children aged 11 and under and an increase of 16% in sessions about loneliness across all age groups. Neil, a volunteer with 12 years’ experience on the phones, said: ‘A lot of callers have taken their pre-pandemic anxieties into the past 12 months, which has exacerbated the situation for them. The only positive is that, with the schools closing, bullying has almost disappeared. I’ve not had a single bullying call in the past 12 months. But once we go back to normality, these things will start appearing again.’

Kooth, one of the UK’s biggest online and digital mental health support provider charities for children and young people, logged what it calls ‘alarming’ increases in contacts related to self-harm (up 24%); suicidal thoughts (up 35%); sleep difficulties (up 77%) and school/college worries (up 100%) in the period March to November 2020, compared with 2019. Says Dan Mills-Da’Bell, Head of Safeguarding: ‘The impact has been staggering. The main presenting issues before were anxiety and relationships, and they remained but increased hugely, but we’ve seen 67% more self-harm and many more presenting with trauma than in 2019. There’s been a 40% increase on 2019 in terms of young people accessing the service. That’s not surprising, given we are at their fingertips, literally – they don’t need referral or even to leave the house.’

Youth services have historically taken a big hit from the Government’s austerity policies of the past decade. Recent research from UK Youth, a leading charity for the sector, found that 66% of the 1,759 youth services surveyed had seen an increase in demand due to the impacts of COVID-19.9 Yet 83% reported that their level of funding had decreased and 64% said they were at risk of closure in the next 12 months. Young people are ‘falling through the net’ while crucial services are being allowed to disappear at a time when the personal wellbeing and mental health of many are being negatively affected by the pandemic, said Chief Executive Ndidi Okezie.

Ann John is a professor in public health and psychiatry at Swansea University and worked with the Mental Health Foundation on its teenage study. She says: ‘For young people with pre-existing mental health problems and other key factors such as living in poverty, domestic violence or sexual abuse and coming from a minority ethnic background, there is going to be a much slower recovery, and we will need to be very proactive and very transparent about the opportunities that are available to them. Often young people are working in the industries that are hardest hit, so we need real incentives for business to employ and train them. The Government needs to deliver targeted support to those most at risk of developing a mental health problem in the context of their economic circumstances. This is vital for them now – and to our recovery as a nation going forward.

‘More than this, the Government must address the factors that can contribute towards young people having problems with their mental health in the first place. Ultimately, the task is to lift young people out of the impoverished conditions that underlie so much distress.’

Looking for positives

Amid this torrent of data, it is hard to hold onto the reverse positives: that, while some children are negatively affected, the larger number are not, or less severely so, and that, as is always the case, those who are already vulnerable are the ones who are primarily suffering the most. This is not to deny the impact, but most children are more resilient than the headlines would have us believe. We can be hopeful that the majority of children and young people will regain their footing and confidence once the factors driving some of their reactive feelings of distress are removed.

A BBC Newsround survey,10 released in late March this year, of 2,013 six- to 16-year-olds from across the UK, found that, for half, time spent during lockdown had been a better experience or hadn’t really changed things: 24% said they felt better and 25% felt the same as usual, while 49% said they felt worse. Similarly, 23% were happy about not going into school and 30% ‘didn’t mind either way’, although 45% said they were unhappy about it. Moreover, 51% felt they were where they should be in their schoolwork and 12% felt they were actually ahead of where they should be, although 28% said they felt they were behind.

Essentially the overall message might be read as, ‘Things have been tough for children and young people, but by and large, half have been relatively unaffected, a quarter have struggled a bit and a quarter have faced serious challenges to their wellbeing and are likely to need extra help.’

Calls to action

So, what should the Government, the NHS, local authorities and third sector provider services do to respond to these needs and ‘build better’ for the future?

BACP says that emergency funding measures are needed in the first instance. In March this year, as schools reopened and the pressure began to ratchet up to get children back on their academic tracks, it launched a national campaign calling on the Government to provide an emergency resilience fund so head teachers and college principals can pay for counselling to be available in every school and college.11 Going forward, it argues that embedded school counsellors in every school are essential – especially in England, where there is currently no statutory provision.

The NSPCC also wants the Government in the short term to set in place systems and train teachers to recognise and respond to children who have had traumatic experiences in lockdown, and to ensure ‘catch-up’ activities include checking in on children’s wellbeing, alongside wider measures to ramp up mental health resources for children and young people more generally. Childline volunteer Neil says a much stronger mental health presence in schools would help stem the flood of young people needing to call Childline and referrals to CAMHS: ‘A lot of schools do have their own counselling services, but I think a lot could do more to deal with mental health issues and that would certainly help Childline to cope better because it would enable young people to think about their own situation a bit more and for schools to help them build that resilience. The kids we were talking to pre-pandemic haven’t gone away – those issues will come back, and they will need support for them. When we talk to the kids about what would help their situation, a lot say more support in school.’

In the longer term, there is general agreement that CAMHS is being expected to cope with the consequences of the failure to provide sufficient support to children and young people earlier on in their trajectory – along with a strategy and funding to tackle childhood poverty and the ills that cause it, such as unemployment, low pay, poor housing and discrimination. What CAMHS is seeing is the consequence of the lack of a comprehensive approach including education and employment opportunities for young people, more youth services, access to embedded counselling in schools, more mental health psychoeducation in schools, and ‘layers’ of intervention and different kinds of mental health workers for school-age pupils and for students in further education colleges.

Just listen

For Niki Gibbs, a school-based counsellor in Bristol working with children aged 11 to 18, what’s needed is more support provision in the ‘missing middle’ before the young person hits crisis point and breakdown: ‘I am absolutely convinced we should have one or two counsellors based in every school. One of the reasons why what I do here works is because I am in the school. I am plugged into a multiagency, multidisciplinary network all in one building. We are all trained to different levels – mental health first aid, some pastoral staff have counselling skills – and we can tap into these levels from within the school’s own resources.

‘I get calls from teaching staff wanting to talk things through about a pupil. I can advise them about support and referrals but often I can reassure them that they are doing a good job; that there’s no need to pass it up to an expert so it becomes something that is more serious. There’s a whole-school culture that says it’s OK to have feelings, which we are modelling by demonstrating that you can be unhappy in school, you don’t have to take your unhappiness somewhere else, and it’s much better to talk about your concerns than to express them in ways that are damaging to yourself or to others.’

The importance of being totally honest with young people and not rushing to find solutions is also stressed by Dan Mills-Da’Bell at Kooth. ‘So many young people, especially teenagers, are coming in with fears and worries about the future and going to uni and getting jobs. You have to be able to stay alongside them with that. Our instinct to cheer them up is huge and their vulnerabilities trigger ours. But trying to give them a solution just invalidates their experience.’ The rush to ‘get back to normal’ doesn’t acknowledge the losses that all children and young people are having to deal with, he says: ‘People talk about “going back to normality”. But the world has changed. Hopefully we have learned a lot and we are moving into a different world. I would encourage people not to aim backwards. Listen to young people, respond to them, don’t rush things. A method I love using is PACE – playfulness, acceptance, curiosity and empathy. It’s a beautiful model from dialectic behavioural therapy. Let’s talk to them about what they need and want and not just return to old models that might not have worked before.’

Kate Rufus has been leading a project to deliver training to schools on self-harm – one of the issues that emerged strongly during the pandemic. The Self-Injury Pathway Project was funded by NHS commissioners in Somerset for a year (it ended in March this year) to work with schools, create a training programme for teachers and produce a guide. She believes the way to tackle self-injury is to give teachers the confidence to hold pupils’ distress: ‘There’s a real anxiety among teachers around how to support these kids. If a young person is self-injuring, the best thing teachers can do is give them time and space and active listening. Don’t immediately refer them on; just listen. It’s that simple. You can’t fix what is wrong in their life, but you can give a child a safe space to be heard, and that is what the vast majority need.’

Says Juliet LeCointe, a counsellor working for the voluntary sector Croydon Drop-In and with the local Parent-Infant Partnership scheme: ‘There is a lot more resilience in children and young people than perhaps we think. It’ll depend on a lot of things like their age and things that kept them buoyant through lockdown. The older ones have exam stress, the emphasis on catching up, but the younger ones have a natural spontaneity. We don’t credit kids with their sense of adventure. Children embrace change quicker than we do; they aren’t going to be clouded by adverse thinking and fears about what might happen. They just grab their bags and bounce out. I think we have to trust that they have the capacity to deal with the ordinary sadnesses that are part of life. As long as we are authentic, open and transparent about what’s been going on, most will come out of it with a solid foundation. We need to give them that level of normalcy – that it’s OK to be sad.’

Ben Nuss, a school counsellor working in north-east Wales, likens the impact of the pandemic and lockdown to bereavement. He says adults working with children and young people need to be sensitive to that deep sense of loss: ‘I see it with my own kids. I think there’s a huge amount of loss, bereavement if you like, of experiences, and I think we do a disservice to young people if we don’t acknowledge that experience. They have been deprived and it is a duty on us to acknowledge that.’

There’s general agreement that there is an overwhelming need to do things differently – not to go back to the long waiting lists and reliance on an overworked, under-resourced CAMHS. There needs to be many more preventive and protective ‘layers’ of service provision for ‘Generation COVID’ out in the community, and a better understanding of children’s behaviour so there isn’t always a rush to refer them on to the specialist mental health services. Says Dan Mills-Da’Bell: ‘We need to educate, support and train all adults working with young people, not just professionals, so they are able to look beyond the behaviour and see the young person.’

Childline is looking for more evening and weekend volunteers. Go to www.nspcc.org.uk

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References

1. Royal College of Psychiatrists. Country in the grip of a mental health crisis with children worst affected, new analysis finds. RCPsych, 2021, 9 April. https://bit.ly/3s4EV8w
2. Leavey C et al. Generation COVID-19. Building the case to protect young people’s future health. London: The Health Foundation; 2020. https://bit.ly/2PiRvUs
3. School shut-out is crushing children. The Times 2020; 14 June. https://bit.ly/3cyvcmo
4. Thandi S. Mental Health of Children and Young People in England, 2020: Wave 1 follow up to the 2017 survey. NHS digital; 2020. https://bit.ly/3cCLzi6
5. Newlove-Delgado T et al. Child mental health in England before and during the COVID-19 lockdown. The Lancet; 2021 (pub online 11 January). DOI: https://doi.org/10.1016/S2215-0366(20)30570-8
6. Thomas E. Coronavirus: Impact on Young People with Mental Health Needs. London: Young Minds; 2021. https://bit.ly/39vbjuy
7. Teenagers’ mental health under severe pressure as pandemic continues – new research. London: Mental Health Foundation; 2021. https://bit.ly/3u6W4A6
8. Coronavirus and Me – Nation-wide survey for children and young people in Wales. Swansea: Children’s Commissioner for Wales; 2021. www.childcomwales.org.uk/coronavirusandme
9. The impact of Covid-19 on England’s youth organisations. London: UK Youth; 2021. https://bit.ly/31utX1v
10. Atherton R. Coronavirus and UK Kids: a Newsround survey. London: BBC; 2021. www.bbc.co.uk/news/extra/nfpahaz8or/newsround-survey
11. Petition for a School Counselling Resilience Fund. Lutterworth: BACP; 2021. https://bit.ly/2PI3cnk
12. Cooper M, Stafford MR, Saxon D et al. Humanistic counselling plus pastoral care as usual versus pastoral care as usual for the treatment of psychological distress in adolescents in UK state schools (ETHOS): a randomised controlled trial. The Lancet Child & Adolescent Health 2021; 5(3): 178-189.