They’re missing their friends. Watching family members head out to risky frontline jobs. Struggling to learn in a digital environment.

Across the nation, Covid-19 is taking a mental health toll on kids and teenagers, at precisely the moment when some of the structures designed to identify those who need help are, as one California school-based social worker put it, “absolutely…breaking down.”

“Every young person I’ve been talking to has brought up themes of loss,” said Linda Dick-Olson, the director of behavioral and mental health at Minnesota Community Care in St. Paul.

“They were sad about not being able to go on field trips at the end of the year. They weren’t in the play they were going to be in…Graduation was going to look very different. They really were grieving all of those things that they lost.”

An uncertain moment

At first, said Kimberly Renk, a professor of clinical psychology at the University of Central Florida who specializes in pediatric mental health, many people assumed that the pandemic would be a temporary inconvenience.

But “as we’ve had more and more time being at home, I think kids realized that things were going to be different,” she said. “Kids were starting to experience some isolation, depression, anxiety, some acting-out behaviors, some family stress.”

With the new school year looming, Renk said, she’s seeing an increase in anxiety that’s in part due to the fact that school itself is such an uncertainty, with many school districts still deciding among in-person instruction, virtual classes, or some combination thereof. “Parents are looking uncertain and that’s creating anxiety for kids.”

Not everyone is seeing precisely the same results. One California school-based social worker, who asked to remain anonymous because they did not have permission to speak on behalf of their school district, said they’d actually seen improvements in some students.

“Kids who are struggling with anxiety, especially related to school, are doing better, getting to be home with their parents,” they said. “Kids who were struggling with depression are probably not doing as well. And kids who were having problems at home, that’s the group I’m most worried about.”

Mindi Tambellini, a mental health counselor at International Community Health Services in Seattle, works with a population of primarily immigrant and refugee students at Seattle World School. She said, unsurprisingly, that she’s seen mental health issues grow worse in students whose situations are more precarious.

“I think that kids who things have really fallen apart for, because of health reasons or financial reasons, there’s been that combination of a lot more anxiety or depression and loss of a place where they can connect” – in other words, school, she said.

Tambellini explained that, for many of her patients, school is a source of community and comfort, a place where their friends are and where teachers and staff members look out for them.

Contact, lost and gained

School is more than just a place of community for some students. It’s the place where they’re likely to be identified as needing mental health care.

And just at a moment when need is increasing, teachers, school counselors, administrators, and mental health workers have less engagement with students. Some students have disappeared from virtual classes altogether, and aren’t responding to phone calls, several mental health providers said.

“What I think is the hardest thing is that we don’t have as much of a sense of what’s going on for kids because of Covid,” the social worker said. “We actually saw a decline in referrals because of Covid…which is really worrisome.”

Both Dick-Olson and Tambellini work at school-based health centers – essentially, locations adjacent to a school where students can receive anything from primary care to mental health interventions.

For Dick-Olson, stationed at Creative Arts Secondary School in St. Paul, students “would identify teachers and school staff members as supporters, and the reason they would get up in the morning and come to school,” she said. “That was the person who had gotten them down the hall to meet with me.”

Even before Covid-19, a number of Dick-Olson’s patients have parents who only begrudgingly allowed them to see a therapist, she said. Some didn’t see the purpose of therapy. Others objected for cultural reasons. Still others, Dick-Olson said, were concerned about having a family secret, like alcoholism, come out.

And it’s those students who are most likely to miss out on the virtual therapy services that Minnesota Community Care is offering, Dick Olson said: “There was an extra consent form that needed to be signed, that could be signed online, but [parents] didn’t take the steps to ensure that that happened.”

“The biggest thing that I have found is that there are all kinds of reasons a kid is going to show up to your office at school,” Tambellini said. “All of that goes away when there’s not that safe place in school.”

Kira Armajani, a program manager of pediatric behavioral health at the Dimock Center in Boston, said she’s seen something quite different at her health center: an increase in mental health referrals, and reduced barriers to mental health care.

“Normally, in the summertime, we tend to have a decrease in volume at the clinic,” she said. But now, “the referrals are just coming in nonstop.”

For parents trying to balance child care and transportation issues, telehealth visits have made it easier for them to get their children for therapy.

And for virtually-inclined teenagers, “there’s something about removing themselves physically that makes them feel less vulnerable,” Armajani said. One long-term patient came out to her therapist during a virtual visit.

Creative solutions

Teachers, school counselors, and mental health providers have all reached out to students, attempting to reestablish connections, the California social worker said. Their district also compiled a list of community resources – including mental health resources – for students and their parents.

Tambellini described carefully navigating phone calls to students’ households, trying to carefully reach out to patients without violating confidentiality.

For many of her patients, sessions have become “more like emotional check-ins” to see how the student is doing – and whether food or other resources are needed.

Tambellini and a colleague, Ana Short, have also accompanied health workers as they administered vaccine doses to students in the community – which both of them said was a valuable way to connect both with students and with their parents.

And Tambellini described a new idea: Resource Wednesdays, a day when students can go to the doctor, get help with their homework – or receive therapy or contraception confidentially if need be.

Short described distributing food and other resources to students and their families, as well as helping families find resources to help them meet expenses like rent.

“Sometimes you have to address the food, shelter, those kinds of basic needs” before addressing mental health concerns, she said.

It’s important to remember that everyone is affected, the social worker explained: “I think that Covid is a collective trauma, so we’re all going through this together. The students, the parents, the teachers, the mental health providers.”

For kids in particular, Renk explained, the new school year may come with increased mental health needs.

“Everyone should be looking at the adjustment of our kids as we figure out what’s happening with this upcoming school year. Things are going to be different…and kids are going to have reactions to that,” she said. “There are going to be impacts from this pandemic that we may not see right away.”