Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students - Adolescent Behaviors and Experiences Survey, United States, January-June 2021

Federal, State, and Local Mental Health Policy Interventions in Response to the Pediatric Mental Health Crisis following the COVID-19 Pandemic

The state of pediatric mental health in the United States has been declining prior to the coronavirus disease 2019 pandemic and was also acutely exacerbated by it as well. Federal, state, and local governments have increasingly prioritized pediatric mental health by investing critical resources through the implementation of policies at all levels of government to reverse this disturbing trend. Despite these investments, there remains a need to improve access to critical pediatric mental health prevention and interventions. When all stakeholders are actively and authentically engaged in the creation and implementation of policy, there is the greatest potential for widespread impact.

Adolescents' Adverse Childhood Experiences, Poor Mental Health, and Substance Use During the COVID-19 Pandemic

PURPOSE

Adverse childhood experiences (ACEs) increase the risk for poor mental health (MH) and substance use. We describe relationships between adolescents' ACEs, substance use, and poor MH occurring during the COVID-19 pandemic.

METHODS

We conducted a secondary analysis of data among U.S. high school students aged <18 years, who participated in the nationally representative Adolescent Behaviors and Experiences Survey. Data were collected from January to June 2021. Bivariate and multivariable analyses assessed associations between individual ACEs (physical, emotional abuse by parent or caregiver, parent or caregiver job loss, food insecurity, sexual violence, physical dating violence, or cyber bullying) and cumulative ACEs (0, 1-2, 3, 4+) experienced during the pandemic and substance use; stratified analyses assessed effects of poor MH on associations between ACEs and substance use.

RESULTS

Use of all substances was higher among adolescents with ACEs, particularly those who experienced both ACEs and poor MH during the COVID-19 pandemic. Prevalence of substance use was especially high among adolescents exposed to any sexual violence or physical dating violence. Compared to adolescents without ACEs, a higher percentage of adolescents with 4+ ACEs reported current use of alcohol (adjusted prevalence ratio [aPR], 5.32) or marijuana (aPR, 5.86), misuse of prescription pain medications (aPR, 8.82), binge drinking (aPR, 7.70), and increased alcohol (aPR, 6.54) or drug (aPR, 7.09) use during the pandemic.

DISCUSSION

The individual and combined impact of ACEs and MH on adolescent substance use reinforce the need for trauma-informed care and primary prevention of ACEs to prevent and mitigate poor MH and substance use among adolescents.

Project SUCCESS: Youth Substance use and Mental Health

This study aims to assess whether students at schools implementing Project SUCCESS (PS) have different substance use and mental health outcomes than those at schools not implementing PS. Surveys were administered to 18,151 middle and high school students from 29 school districts and 50 schools. Multivariable logistic and linear regressions controlling for individual- and school-level characteristics were used. Students at schools with PS had lower odds of past month cigarette use, vaping, alcohol use, marijuana use, past year suicide ideation, and had fewer depressive symptoms relative to students at schools without PS. Findings suggest students at schools with PS may be less likely to engage in substance use and less likely to experience mental health challenges than students at schools without PS.

Adverse Childhood Experiences: Health Care Utilization And Expenditures In Adulthood

Adverse childhood experiences (ACEs) have been shown to be strong predictors of socioeconomic status, risky health behaviors, chronic health conditions, and adverse outcomes. However, less is known about their association with adult health care utilization and expenditures. We used new data from the 2021 Medical Expenditure Panel Survey-Household Component (MEPS-HC) to provide the first nationally representative estimates of ACEs-related health care utilization and expenditure differences based on direct observation, rather than model-based extrapolation. Compared to demographically similar adults without ACEs, those with ACEs had substantially higher utilization and 26.3 percent higher expenditures. The aggregate spending difference across the 157.6 million US adults with ACEs was $292 billion in 2021. Moreover, we observed large, graded relationships between ACEs and health status, health behaviors, and some dimensions of socioeconomic status. We also found associations between ACEs and a range of adverse adult circumstances, also newly measured in the 2021 MEPS, including financial and housing problems, social network problems, little or no life satisfaction, stress, food insecurity, verbal abuse, physical harm, and discrimination.

The long shadow of accumulating adverse childhood experiences on mental health in the United Arab Emirates: implications for policy and practice

Introduction

This study investigates the cumulative effects of adverse childhood experiences (ACEs) on adult depression, anxiety, and stress in Abu Dhabi, controlling for demographic factors, lifestyle, and known health and mental health diagnoses.

Methods

Utilizing a cross-sectional design and self-report measures, the research aims to fill a critical gap in understanding the specific impacts of ACEs in the UAE. Based on a multi-site, cross-sectional community sample of 697 residents of Abu Dhabi.

Results

The findings reveal significant variances in current screening values for depression, anxiety, and stress attributable to ACEs after controlling for demographic factors, lifestyle risk factors, and adult diagnoses of health and mental health conditions.

Discussion

The results underline the lifelong impact of ACEs and reinforce the importance of early identification and intervention. In particular, the implications for policy and practice in understanding and mitigating ACEs long-term effects on mental health are considered.

Adverse childhood experiences, gender, and suicidality among Florida high school students: Examining intervening mechanisms

BACKGROUND

Adverse childhood experiences (ACEs) represent a key risk factor for suicidal thoughts and behaviors among adolescents. However, the intervening mechanisms linking ACEs and suicidality, and whether such processes vary by gender, remain underexplored.

OBJECTIVE

The present study examines whether the relationships between ACEs and the likelihood of experiencing suicidal thoughts and attempting suicide are indirect through depressive symptoms and low self-control. This study also investigates whether these direct and indirect paths might be moderated by gender.

PARTICIPANTS AND SETTING

The analyses make use of data on a statewide representative sample of students enrolled in public high schools in Florida (N = 23,078) from the 2022 Florida Youth Substance Abuse Survey (FYSAS).

METHODS

Generalized structural equation modeling (GSEM) was used to estimate the direct and indirect effects of ACEs on the likelihood of suicidal thoughts and attempting suicide. The indirect effects were assessed using bootstrapping, and between-gender differences in the coefficients were tested.

RESULTS

ACEs has direct associations with depressive symptoms, low self-control, and both suicidality outcomes. The effects of ACEs on suicidal thoughts are indirect through both depressive symptoms and low self-control, and the effects of ACEs on suicide attempts are indirect through depressive symptoms. Limited gender differences in these pathways emerge.

CONCLUSIONS

For male and female youth, ACEs are associated with heightened depression symptoms and reduced self-control, and both of these factors partially explain the previously established relationship between ACEs and suicidality.

The mental and behavioral health crisis in youth: Strategic solutions post COVID-19 pandemic: An American Academy of Nuring consensus paper

The COVID-19 pandemic wrought significant negative impacts on youth well-being, particularly among Black, Hispanic, American Indian, Alaska Native, and LGBTQ+ (Lesbian, gay, bisexual, transgender, queer or questioning) youth. The pandemic disrupted connections to family, school, and community, which are essential supports for youth mental health. Lessons learned from the pandemic suggest the role of stress and windows of opportunity to build resiliency. Drawing from a policy dialog on the youth mental health crisis conducted by 4 American Academy of Nursing Expert Panels, we present approaches to the current increase in youth mental health problems. Included is emerging literature on building youth resilience, particularly via re-establishing school and community connections. The role of families, schools, and community support is emphasized, particularly by creating a healing school environment and the pivotal role of school nurses. Recommendations include increased support for families, engaging the school nurse role, and developing school-based innovative programs to build connections and youth wellness.

Successes and Lessons Learned in Responding to the Needs of Pediatricians, Children, and Families During the COVID-19 Pandemic

The coronavirus disease 2019 pandemic has presented tremendous challenges to the United States health care system, as well as to individual physicians, communities, and families. Throughout the pandemic, the American Academy of Pediatrics (AAP) has striven to elevate the needs of infants, children, and adolescents, as well as the pediatricians who care for this population. Historically, these communities have often been overlooked and deprioritized in health care systems, and these deficits persisted into the pandemic. To fill this gap, the AAP took on an essential role in leading the national response for pediatrics. This article details the AAP pandemic response and includes the perspectives of multiple AAP leaders involved in the response and details on Academy advocacy with high-level staff and officials at federal agencies and the executive branch. The AAP provided initial guidance to pediatricians that predated the World Health Organization's declaration of a public health emergency. The Academy then developed entirely new approaches to meet the unprecedented needs of its practicing members and families by providing timely, rigorous information endorsed by pediatric experts. When coronavirus disease 2019 vaccines were developed, the AAP strongly advised the inclusion of those younger than 18 years in vaccine trials and advocated for equitable distribution plans. The AAP provided its members with strategies for combating misinformation. The Academy was at the forefront of advocating for the safe return to in-person schooling, recognizing that social isolation was contributing to the growing mental health crisis among youth. In 2021, the AAP, the American Academy of Child and Adolescent Psychiatry, and the Children's Hospital Association declared a national emergency in child and adolescent mental health. In addition, the AAP implemented educational and training opportunities for clinicians and developed resources for youth and their families. After the end of the public health emergency, AAP members continue to use innovations and efficiencies developed as part of their pandemic response. The successes of the AAP pandemic response, alongside lessons learned, help define an important model for responding to future pandemics and public health emergencies in ways that support children, families, and the pediatric workforce.

Structural adverse childhood experiences associated with suicidal ideation, suicide attempts, and repetitive nonsuicidal self-injury among racially and ethnically minoritized youth

INTRODUCTION

High rates of suicidal ideation (SI), suicide attempts (SA), and repetitive nonsuicidal self-injury (NSSI) among some ethnoracially minoritized United States youth populations may be related to adverse childhood experiences (ACEs) with structural roots.

METHODS

Using the 2013-2019 Minnesota Student Surveys, we assessed associations of student-reported structural ACEs (parental incarceration, housing instability, food insecurity, and foster care involvement) with SI, SA, and repetitive NSSI within the past 12 months using multilevel logistic regression stratified by ethnoracial group (American Indian/Alaskan Native [AIAN], Hmong, other Asian, Black Latino, other Latino, Somali, other Black/African American [AA], Native Hawaiian/Pacific Islander [NHPI], and multiracial), and adjusted for sex, grade, ACEs experienced within one's household, mental health treatment, and perceived safety.

RESULTS

Structural ACEs were strongly associated with increasing SI, SA, and NSSI. At ≥2 structural ACEs, repetitive NSSI rates ranged from 7% to 29% (female), 8% to 20% (male); SA rates ranged from 13% to 35% (female), 10% to 22% (male); and SI rates ranged from 31% to 50% (female), 20% to 32% (male). Black Latino, NHPI, AIAN, and Black/AA students most often reported structural ACE exposures.

CONCLUSION

Reducing structural ACEs may reduce SI, SA, and repetitive NSSI among ethnoracially minoritized youth populations. Disaggregating diverse youth groups revealed variations in these outcomes that remain hidden when subpopulations are aggregated.

Reducing Pediatric Mental Health Boarding and Increasing Acute Care Access

BACKGROUND

There have been notable increases in pediatric mental health boarding in the United States in recent years, with youth remaining in emergency departments or admitted to inpatient medical/surgical units, awaiting placement in psychiatric treatment programs.

OBJECTIVES

We aimed to evaluate the outcomes of interventions to reduce boarding and improve access to acute psychiatric services at a large tertiary pediatric hospital during a national pediatric mental health crisis.

METHODS

Boarding interventions included expanding inpatient psychiatric beds and hiring additional staff for enhanced crisis stabilization services and treatment initiation in the emergency department and on inpatient medical/surgical units for boarding patients awaiting placement. Post-hoc assessment was conducted via retrospective review of patients presenting with mental health emergencies during the beginning of intervention implementation in October-December 2021 and one year later (October-December 2022). Inclusion criteria were patients ≤17 years who presented with mental health-related emergencies during the study period. Exclusion criteria were patients ≥18 years and/or patients with >100 days of admission awaiting long-term placement. Primary outcome was mean length of boarding (LOB). Secondary outcome was mean length of stay (LOS) at the hospital's acute psychiatry units.

RESULTS

One year after full intervention implementation (October-December 2022), mean LOB decreased by 53% (4.3 vs 9.1 days, P < 0.0001) for boarding patients discharged to high (e.g., inpatient, acute residential) and intermediate (e.g., partial hospital, in-home crisis stabilization programs) levels of care, compared to October-December 2021. Additionally, mean LOS at all the 24-hour acute psychiatry treatment programs was reduced by 27% (20.0 vs 14.6 days, P = 0.0002), and more patients were able to access such programs (265/54.2% vs 221/41.9%, P < 0.0001). Across both years, youth with aggressive behaviors had 193% longer LOB (2.93 ± 1.15, 95% CI [2.23, 3.87]) than those without aggression, and youth with previous psychiatric admissions had 88% longer LOB than those without (1.88 ± 1.11, 95% CI [1.54, 2.30]).

CONCLUSIONS

The current study shows decreased LOB and improved access for youth requiring acute psychiatric treatment after comprehensive interventions and highlights challenges with placement for youth with aggressive behaviors. We recommend a call-to-action for pediatric hospitals to commit sufficient investment in acute psychiatric resources to address pediatric mental health boarding.

Emotion regulation as a mediator in the relationship between childhood maltreatment and symptoms of social anxiety among college students

OBJECTIVE

The current study explored emotion regulation strategies (ie, suppression, cognitive reappraisal, experiential avoidance) as mediators in the relationship between childhood maltreatment and social anxiety.

PARTICIPANTS

One hundred and ninety-three undergraduate students (Mage = 19.5 years; 83.9% female) were recruited from a public university in the northeastern United States.

METHODS

Participants completed measures assessing childhood maltreatment, emotion regulation strategies, and social anxiety.

RESULTS

Structural equation modeling was used to examine the mediation paths. Childhood maltreatment was negatively associated with cognitive reappraisal and experiential avoidance, and positively associated with suppression. Higher suppression was associated with higher social anxiety, and higher experiential avoidance was associated with lower social anxiety. The association between childhood maltreatment and symptoms of social anxiety was mediated by suppression and experiential avoidance, but not cognitive reappraisal. All other paths were nonsignificant.

CONCLUSIONS

Findings suggest that treatments for childhood maltreatment should aim to bolster experiential avoidance and minimize suppression to address social anxiety symptoms.

Long-term impact of the Fostering Healthy Futures for Preteens program on suicide-related thoughts and behaviors for youth in out-of-home care: A randomized controlled trial

Youth in out-of-home care are at high risk for suicide-related thoughts and behaviors (STB), yet there are no known efficacious interventions that reduce STB for this population. Fostering Healthy Futures for Preteens (FHF-P) is a 9-month community-based mentoring and skills training preventive intervention for children in out-of-home care. A randomized controlled trial enrolled 156 participants aged 9-11 years who were placed in out-of-home care over the prior year. Participants were 48.9% female, 54.1% Hispanic, 30.1% Black, and 27.1% American Indian. Follow-up interviews, conducted 7-12 years postintervention (85.2% retention rate), asked young adult participants, aged 18-22, to self-report lifetime STB as indexed by non-suicidal self-injury, suicidal thoughts, plans, and/or attempts. There was a nonsignificant reduction in the odds of STB for the intervention group at follow-up (OR = 0.74; CI, 0.32, 1.69). However, FHF-P significantly moderated the effect of baseline STB; control youth who reported baseline STB had 10 times the odds of young adult STB (OR = 10.44, CI, 2.28, 47.78), but there was no increase in the odds of adult-reported STB for intervention youth. Findings suggest that FHF-P buffers the impact of pre-existing STB on young adult STB for care-experienced youth. Further research is needed to identify mechanisms that may reduce STB in this population.

Mental Well-Being Among Adversity-Exposed Adolescents During the COVID-19 Pandemic

Importance

Further research is needed to understand factors associated with well-being during the COVID-19 pandemic among adolescents who have experienced adverse childhood experiences (ACEs).

Objective

To explore factors associated with improved mental health during the COVID-19 pandemic among adolescents who have experienced ACEs.

Design, Setting, and Participants

This cross-sectional study used data from the baseline (2016-2018) and sixth (March 2021) COVID Rapid Response Research (RRR) surveys of the Adolescent Brain Cognitive Development study, which includes 21 sites across the US. Adolescents aged 11 to 15 years who completed the COVID RRR mental health measures were included. Data analyses were conducted from June to August 2023.

Exposures

School-based factors (eg, in-person school) and 8 coping behaviors (eg, exercise).

Main Outcomes and Measures

The primary outcomes were adolescent-reported positive affect (PA) and perceived stress (PS). Adolescents were stratified by no ACEs, low-to-intermediate ACEs (1-3), and high ACEs (≥4). Linear regressions estimated associations between factors and mental health, adjusting for potential confounders. Unstandardized beta coefficients (B) were compared with equality of coefficients tests.

Results

The 4515 adolescents in this study (mean [SD] age, 13.3 [0.88] years; 51% [95% CI, 50% to 53%] female) were racially and ethnically diverse (American Indian/Alaska Native, 2% [95% CI, 2% to 3%]; Asian, 8% [95% CI, 7% to 9%]; Black, 11% [95% CI, 10% to 12%]; Latino or Hispanic, 17% [95% CI, 15% to 18%]; White, 61% [95% CI, 60% to 63%]; other, 1% [95% CI, 0% to 2%]). For youths with high ACEs, caring for one's body (PA B = 4.02 [95% CI, 1.39 to 6.66]; PS B = -0.92 [95% CI, -1.84 to 0.00]), exercising (PA B = 3.19 [95% CI, 0.46 to 5.92]; PS B = -1.41 [95% CI, -2.40 to -0.43]), and engaging in healthy behaviors (PA B = 4.07 [95% CI, 1.28 to 6.84]; PS B = -1.01 [95% CI, -1.98 to -0.05]) were associated with higher PA and lower PS scores. In-person schooling had a greater impact on PA scores for youths with high ACEs (B = 5.55 [95% CI, 2.08 to 9.01]) than youths with low-to-intermediate ACEs (B = 1.27 [95% CI, 0.27 to 2.27]).

Conclusions and Relevance

These findings suggest that in-person schooling and several coping behaviors (caring for one's body, exercising, and engaging in healthy behaviors) were associated with significantly higher PA and lower PS during the COVID-19 pandemic among adolescents with high ACEs. Adolescents with high ACEs demonstrated especially greater mental health scores when they reported in-person schooling. Future studies should build on these findings to identify clinical and school-based mental health protective factors for adolescents with high ACE risk.

Adverse childhood experiences are associated with perceived cognitive difficulties among high school students in the United States

Objective

Adverse childhood experiences (ACEs) are associated with mental health and cognitive problems, and mental health problems are associated with perceived cognitive difficulties among adolescents. The unique contribution of ACEs to cognitive difficulties after adjusting for poor mental health is not well understood and represents the purpose of this study.

Methods

The Adolescent Behaviors and Experiences Survey was conducted in 2021 with high school students in the United States. Cognitive difficulty was assessed with: 'Because of a physical, mental, or emotional problem, do you have serious difficulty concentrating, remembering, or making decisions?' Four ACEs were examined: sexual violence (lifetime and past 12 months), parental emotional abuse, and parental physical abuse. Students were asked about feeling sad or hopeless (past year), considering suicide (past year), and having poor mental health (past month). Binary logistic regressions examined the association between ACEs and cognitive problems, adjusting for mental health.

Results

Participants were 6,945 students. Students reporting poor mental health were very likely to endorse difficulty concentrating, remembering, or making decisions (girls = 81% and boys = 67%). Cognitive difficulty was uncommon among students who denied poor mental health (girls = 17% and boys = 12%). For boys [p < 0.001; R2 = 0.22] and girls [p < 0.001; R2 = 0.31], after adjusting for mental health problems, independent predictors of cognitive difficulties included parental verbal abuse and physical abuse. For girls, lifetime forced sexual intercourse and sexual violence during the past year were also independently associated.

Conclusion

ACEs are associated with perceived cognitive difficulty in both adolescent girls and boys, even after adjusting for poor mental health.

Research, practice, and data informed investigations of child and youth suicide: A science to service and service to science approach

BACKGROUND

Suicide rates for children and adolescents have been increasing over the past 2 decades. In April 2023, the National Institute of Mental Health (NIMH) convened a two-day workshop to address child and youth suicide.

PURPOSE

The workshop focus was to discuss the state of the science and stimulate a collaborative response between researchers, death investigators, and data collection teams to build a science to service and service to science approach toward understanding - and ultimately preventing - this growing problem of child and youth suicide.

HIGHLIGHTS

Topics that meeting participants highlighted as worthy of further consideration for research and practice were: increasing awareness among death investigators, medical examiners, and coroners that child suicide deaths under age 10 years do occur and should be investigated and documented accordingly; emphasizing the value of science based protocols for child and youth death investigations to enhance consistency of approaches; and articulating needs for postvention services to suicide loss survivors.

OUTCOMES

The importance of collecting an accurate and complete cause and manner of death (i.e., unintentional, suicide, homicide, undetermined) among all child decedents, and demographic information such as race, ethnicity, and sexual/gender minority status was underscored as critical for enhanced surveillance. For prevention efforts, approaches to assessing and understanding suicidal thoughts and behaviors among diverse groups of children, and the variability in proximal and distal risk factors are needed to inform opportunities for preventive interventions for diverse communities. The need for consistent measures and processes to improve death investigations, fatality review committees, and coordination between data collection systems and agencies was also raised.

PRACTICAL APPLICATIONS

Collaborations among researchers, death investigators, and data collection teams can help to fully describe the child and youth suicide crisis and provide actionable information for new research, and prevention and response efforts.

Supportive Relationships Mitigate the Effect of Cumulative Exposure to Adverse Childhood Experiences on Depression, Anxiety, Stress, and Suicide Considerations-The Arizona Youth Risk Behavior Survey

Declining adolescent mental health is a significant public health concern during the COVID-19 pandemic. Social distancing and stay-at-home orders have led to missed social connections with peers and adults outside households, and this has increased the risk of mental health problems in children and adolescents, particularly those with adverse childhood experiences (ACEs). Studies have shown that strong interpersonal support improves adolescent mental health. We examined the association between ACEs and poor mental health (including stress, anxiety, and depression) and how the presence of interpersonal support from caring adults and friends and school connectedness can mitigate this relationship among adolescents in Arizona. This study analyzed data from the 2021 Arizona Youth Risk Behavior Survey (YRBS; n = 1181), a population-based survey conducted biennially across the United States. The Arizona sample included high school students in grades 9-12 who were enrolled in public and charter schools. This study revealed that nearly three of four adolescents experienced an ACE, and one of five experienced ≥4 ACEs. Compared with adolescents who experienced zero ACEs, those with ≥4 ACEs experienced less interpersonal support from caring adults, friends, and school and more frequently reported poor mental health and suicidal thoughts. However, adolescents with interpersonal support consistently reported lower rates of mental health issues, even with exposure to multiple ACEs. Post-pandemic programs to improve social relationships with adults, peers, and schools are critical, especially for adolescents with multiple adversities.

Risk Factors and Trends in Adolescent's Suicide Attempt Rates Before and After the Coronavirus Disease 2019 Pandemic

BACKGROUND

Understanding adolescents' mental health during the coronavirus disease 2019 (COVID-19) pandemic and identifying those most at risk is an urgent public health challenge. This study explored the trend of suicide attempts and the association between loneliness, family financial stress, and suicide attempts during the COVID-19 pandemic among adolescents.

METHODS

Data of the 2020 to 2022 Korea Youth Risk Behavior Surveys for adolescents aged 13-18 years were used. Multivariate logistic regression analyses were performed to examine the association between suicide attempts, family financial stress, and loneliness during the COVID-19 pandemic.

RESULTS

The trend of suicide attempt rates was lowest in 2020 (1.9%, 1,034 out of 53,534) and it showed an increasing trend with rates of 2.2% (1,159 out of 53,445) in 2021 and 2.5% (1,271 out of 50,455) in 2022. The risk of suicide attempt was higher among adolescents who experienced financial stress (in 2020: adjusted odds ratio [AOR], 1.53, 95% confidence interval [CI], 1.26-1.88; in 2021: AOR, 1.63, 95% CI, 1.03-1.54) and felt lonely (in 2020: AOR, 2.19, 95% CI, 1.78-2.70; in 2021: AOR, 2.65, 95% CI, 2.16-3.26; in 2022: AOR, 1.3, 95% CI, 1.04-1.55) than those who did not.

CONCLUSION

The COVID-19 pandemic affected the suicide attempts of adolescents, with financial stress and feelings of loneliness closely linked to this impact. Although the pandemic nears its end, the persistent risk of suicide attempts among adolescents remains a concern. Therefore, it is imperative to implement targeted screening and interventions to address adolescent suicide risk.

An examination of the effects of family, school, and community resilience on high school students' resilience in China

Introduction

Resilience plays a pivotal role in shaping the academic accomplishments, psychological well-being, and future prospects of high school students. Despite its significance, there is a notable dearth of studies examining the current state and determinants of resilience among high school students in China.

Methods

This research addresses this gap by assessing and exploring levels of resilience and their interconnections across four key domains-individual, family, school, and community-among Chinese high school students. The study also investigates variations in resilience based on factors such as gender, geographical location, and grade levels. A total of 667 high school students participated in the study, responding to four resilience scales.

Results

Chinese high school students exhibited generally low levels of resilience, with family resilience ranking the highest and community resilience the lowest. The study revealed that resilience is positively influenced by resilience levels in school, family, and community settings. Consequently, strategies aimed at fortifying resilience should prioritize interventions in familial, educational, and communal environments.

Discussion

Moreover, the research findings indicate noteworthy disparities in resilience among high school students based on gender, urban-rural divide, and grade levels. Female, urban, and lower-grade students displayed higher resilience compared to their male, rural, and higher-grade counterparts. This highlights the importance of focusing on resilience-building measures tailored to male, rural, and higher-grade high school students, given their increased likelihood of facing significant challenges and stressors in both academic and personal spheres.

Conclusion

This study contributes to the broader understanding of resilience by investigating the correlations between individual, family, school, and community resilience among Chinese high school students. The findings underscore the need for targeted interventions to enhance resilience, particularly in specific demographic groups, thereby advancing the efficacy of resilience-building techniques in high school settings.

Parenting During the COVID-19 Pandemic

Parenting during the COVID-19 pandemic was an unprecedented experience for many families around the world. With the sudden closure of schools and child care centers and the implementation of stay-at-home orders, parents were required to adjust to a new normal, one that required them to take on numerous responsibilities, all with diminished levels of social support. These changes resulted in a wide range of experiences, from feelings of overwhelm and stress to gratitude for time that was often not a reality in the hustle-bustle of everyday life in pre-pandemic times. This chapter discusses parenting during the COVID-19 pandemic, reviewing the impact on parental mental health, the impact on the parent-child relationship, and the implications for families and societal support.

COVID-19-related stress exacerbates the effect of child maltreatment on negative affect via increased identity confusion during adolescence

INTRODUCTION

Exposure to childhood maltreatment may undermine the crucial developmental task of identity formation in adolescence, placing them at risk for developing negative affect. The current study investigated whether COVID-19-related stress intensified the indirect link between child maltreatment and adolescents' negative affect through identity confusion.

METHOD

Using multidimensional assessments of child maltreatment (threat vs. deprivation), the study included a sample of 124 adolescents (Mage  = 12.89, SD = 0.79; 52% female) assessed before (January 2018 to March 2020) and during the pandemic (May to October 2020) in Georgia, United States. The majority of the participants were European American (78.8%), followed by African American (11.5%), Hispanic (3.8%), Asian/Pacific Islander (1.0%), and other (4.8%). We used structural equation modeling to test (a) the mediating role of identity confusion in the link between childhood maltreatment and negative affect and (b) whether COVID-19-related stress moderated these indirect effects. Simple slopes and Johnson-Neyman plots were generated to probe regions of significant interaction effects.

RESULTS

Threat and deprivation predicted an increase in adolescent identity confusion. Additionally, childhood threat and deprivation were indirectly linked to adolescents' negative affect through increased levels of identity confusion. COVID-19-related stress significantly exacerbated the link between identity confusion and negative affect.

CONCLUSION

Identity confusion is a mechanism underlying the link between child maltreatment and the development of negative affect in adolescence. Our results inform prevention and intervention programs that aim to reduce negative affect among adolescents who experience threatening and depriving rearing environments.

Independent and joint associations of aerobic and muscle-strengthening exercise with mental health in adolescents: A cross-sectional analysis before and during COVID-19 using the 2015-2021 National Youth Risk Behavior Survey

PURPOSE

COVID-19 led to social isolation that may have compromised adolescent mental health. This study examined the independent and joint associations of aerobic physical activity (PA) and muscle-strengthening exercise (MSE) with mental health problems in adolescents.

METHODS

Participants were US adolescents who completed the 2015-2021 National Youth Risk Behavior Survey (N = 61,298; 45.7% female). Data were collected between 2015 and 2021 and analyzed in 2023. Outcomes were binary response items asking about feeling sad/hopeless, having difficulty concentrating, remembering, or making decisions, and having a suicidal ideation. Preventive exposure variables were items asking about frequencies of aerobic PA and MSE with responses dichotomized to align with recommendations. Independent and joint associations were examined using robust Poisson regression with covariates selected using double selection lasso. Structural equation models examined the associations treating PA and MSE as continuous predictors and poor mental health as a latent dependent variable.

RESULTS

Meeting either recommendation alone associated with a 4-10% lower prevalence of mental health problems (APR = 0.90-0.96, p < 0.05), and meeting both recommendations associated with a 15%-20% lower prevalence of mental health problems (APR = 0.80-0.85, p < 0.001). Although categorical joint associations were stronger in males (p < 0.05), multiplicative interactions were observed in females using continuous variables for PA and MSE (β = -0.09, p < 0.001).

CONCLUSION

Meeting aerobic PA and MSE recommendations associated with lower prevalence of mental health problems. Participation in MSE below recommended levels may be beneficial for females when combined with aerobic PA. Future research should examine these associations by acquiring contextual information and device-based assessments.

Identifying disparities in suicidal thoughts and behaviors among US adolescents during the COVID-19 pandemic

BACKGROUND

Suicidal thoughts and behaviors (STBs) became more common among racial and ethnic minorities and sexual and gender minorities (SGM) during the COVID-19 pandemic relative to White and non-SGM adolescents. This study examines associations between pandemic-related stressors and STBs among a nationally representative sample of adolescents to identify vulnerable subpopulations.

METHODS

We analyzed data from 6769 high school students using the 2021 Adolescent Behaviors and Experiences Survey. Pandemic-related stressors were assessed via seven items related to negative experiences (e.g., parent job loss; food insecurity) during the COVID-19 pandemic. Logistic regression analyses estimated the association between pandemic-related stressors and four outcomes: (1) sadness/hopelessness; (2) suicidal ideation; (3) suicide planning; and (4) recent suicide attempt (i.e., past 12 months). Interactions were modeled by sex, race/ethnicity, and sexual identity.

RESULTS

A greater number of pandemic-related stressors was associated with higher odds for sadness and hopelessness (aOR: 1.55; 95% CI:1.44-1.67), suicidal ideation (aOR: 1.48; 95% CI:1.39-1.57), suicide planning (aOR:1.47; 95% CI: 1.36-1.59), and recent suicide attempt (aOR: 1.64; 95% CI:1.42-1.88). Pandemic-related stressors were also more strongly associated with some types of STBs in males (relative to females) and SGM females (relative to heterosexual females).

CONCLUSION

Study findings indicate that pandemic-related stressors are associated with STBs within the US adolescent population, particularly among male and SGM female adolescents. Researchers are encouraged to use this knowledge to ensure nationwide suicide prevention efforts adequately address inequities in suicide risk.

Feasibility of recruiting adolescents into a prospective cohort study of the effects of social isolation during COVID-19

BACKGROUND

Social connection and loneliness in adolescence are increasingly understood as critical influences on adult mental and physical health. The unique impact of the social isolation imposed by the COVID-19 lockdown on emerging adults is therefore expected to be especially profound. We sought to investigate the feasibility of using ecological momentary assessment (EMA) and wearable accelerometers to characterize the effects of social isolation and/or loneliness experienced by adolescents during the COVID-19 pandemic.

METHODS

We recruited 19 participants aged 13-18 from an Adolescent Medicine practice in Atlanta, GA. Participants completed surveys at baseline and throughout a 2-week study period using EMA regarding their degree of social isolation, loneliness, family functioning, school climate, social media use, and COVID-19 experiences surrounding their physical, mental, and social domains. Six participants agreed to wear an activity tracker and heart rate measurement device for 14 days to monitor their emotional state and physical health. Participant feedback was collected via open-ended exit interviews. Feasibility of recruitment/retention, adherence, and outcome measures were investigated. Implementation was also assessed by evaluating the barriers and facilitators to study delivery. Associations between the social isolation and loneliness variables and all other variables were performed with univariate linear regression analysis with significance set at p < 0.05. The progression criteria were a recruitment rate of > 30% and a retention rate of > 80%.

RESULTS

Progression criteria were met for recruitment (76%) of participants, but not retention (38%). Adherence to EMA survey completion was highly variable with only 54% completing ≥ 1 survey a day, and accelerometry use was not feasible. Social isolation was significantly correlated with lower school climate, higher COVID-19 experiences, higher depression scores, and lower sleep quality. Loneliness also showed a significant correlation with all these factors except COVID-19 experiences.

CONCLUSIONS

EMA and wearable accelerometer use was not feasible in this longitudinal study of adolescents during the COVID-19 pandemic. Future research should further investigate barriers to conducting long-term research with adolescents and the potential effects of the pandemic on subject recruitment and retention.

Emergency department visits and boarding for pediatric patients with suicidality before and during the COVID-19 pandemic

OBJECTIVE

To quantify the increase in pediatric patients presenting to the emergency department with suicidality before and during the COVID-19 pandemic, and the subsequent impact on emergency department length of stay and boarding.

METHODS

This retrospective cohort study from June 1, 2016, to October 31, 2022, identified patients ages 6 to 21 presenting to the emergency department at a pediatric academic medical center with suicidality using ICD-10 codes. Number of emergency department encounters for suicidality, demographic characteristics of patients with suicidality, and emergency department length of stay were compared before and during the COVID-19 pandemic. Unobserved components models were used to describe monthly counts of emergency department encounters for suicidality.

RESULTS

There were 179,736 patient encounters to the emergency department during the study period, 6,215 (3.5%) for suicidality. There were, on average, more encounters for suicidality each month during the COVID-19 pandemic than before the COVID-19 pandemic. A time series unobserved components model demonstrated a temporary drop of 32.7 encounters for suicidality in April and May of 2020 (p<0.001), followed by a sustained increase of 31.2 encounters starting in July 2020 (p = 0.003). The average length of stay for patients that boarded in the emergency department with a diagnosis of suicidality was 37.4 hours longer during the COVID-19 pandemic compared to before the COVID-19 pandemic (p<0.001).

CONCLUSIONS

The number of encounters for suicidality among pediatric patients and the emergency department length of stay for psychiatry boarders has increased during the COVID-19 pandemic. There is a need for acute care mental health services and solutions to emergency department capacity issues.

Exploring the national prevalence of mental health risk, multimorbidity and the associations thereof: a repeated cross-sectional panel study

Objective and methods

South Africans were affected by the COVID-19 pandemic and resultant economic hardships. As a result, mental health within this region may have worsened. Therefore, using large scale nationally representative data, we repeated the cross-sectional panel study to investigate mental health risk post COVID-19 to explore mental health and multimorbidity and to examine the relationship between adverse childhood experiences (ACEs) and comorbid health conditions in South African adults (aged 18 years and older).

Results

Post-pandemic, 26.2, 17.0, and 14.8% of the South African respondents reported being probably depressed, anxious and had suffered high exposure to early life adversity, respectively. Nationally, the prevalence of mental health across the country remained alarmingly high when compared to Panel 1. The prevalence of multimorbidity (2 or more chronic morbidities) among the South African population was reported at 13.9%, and those with 2 or more morbidities were found to have increased odds of early adversity, irrespective of differing socio-demographics. Furthermore, early adversity was also associated with multimorbidity partly via mental health.

Conclusion

This repeated cross-sectional national study reiterated that the prevalence of mental health across South African adults aged 18 years and older is widespread. Mental health remains worryingly high post-pandemic where more than a quarter of respondents are probably depressed, nearly one in every five respondents are anxious, and 14.8% reported high exposure ACEs. Public health interventions need to be upscaled with efforts to reduce the incidence of early adversity that may have the ability to lower adverse health outcomes and mental ill-health in adulthood.

The impact of the Community Resiliency Model (CRM) on the mental well-being of youth at risk for violence: A study protocol

PURPOSE

Assess the effect of a brief, somatic awareness resiliency training, the Community Resiliency Model (CRM)®, on the mental well-being of incarcerated youth. SPECIFIC AIM 1: Explore the relationship between youth demographics and justice history to baseline well-being scores and response to treatment. Q1: How do personal variables, including length of time in juvenile justice, relate to baseline mental health scores and response to the wellness skills intervention? SPECIFIC AIM 2: Examine the mental health scores over time to determine effectiveness of participating in CRM training while incarcerated. Hypothesis 1: Well-being scores will increase after CRM training. Hypothesis 2: Emotional distress will decrease after participating in a CRM training. Hypothesis 3: Pro-social feelings and behaviors will increase after participating in a CRM training.

Life satisfaction in the context of the COVID-19 pandemic among middle school adolescents in France: findings from a repeated cross-sectional survey (EnCLASS, 2012-2021)

Background and aims

Since the COVID-19 pandemic, several studies have reported a decrease in adolescents' well-being. We aim to describe life satisfaction over the last decade and examine the factors associated with its variations between 2020 and 2021 among French students in their last year of middle school (around 14-15 years old).

Methods

Data were drawn from a repeated biennial cross-sectional national survey conducted in French schools over the last decade (EnCLASS study), using a self-administered questionnaire. After describing life satisfaction trends between 2012 and 2021 using the Cantril ladder, we examined individual changes in life satisfaction between 2020 and 2021 and their associations with housing and studying conditions during the COVID-19 lockdown, using multinomial logistic regression analysis (decrease, increase, no change as reference).

Results

Among the 17,686 survey respondents, an overall slight decrease in the prevalence of adolescents reporting high life satisfaction (i.e., Cantril score ≥6) was observed since 2012 with the lowest proportion reported in 2021 (77.4%). Between 2020 and 2021, 16.3% of French adolescents experienced an improvement in life satisfaction, while 17.7% experienced the opposite. Decrease in life satisfaction between 2020 and 2021 was more likely experienced by adolescents living in reconstructed families [aOR 2.09 (95%CI, 1.58-2.77)], those who did not have their own room [aOR 1.58 (1.16-2.15)], nor access to the Internet to interact with their friends during the lockdown [aOR 1.47 (1.09-1.98)]. Interestingly, more girls than boys were represented in both those reporting increase and decrease in life satisfaction [aOR 1.82 (1.40-2.37) and 1.43 (1.14-1.79), respectively].

Conclusions

This study shows that the way adolescents experienced the first 2020 lockdown in France was not uniform, and that one must consider sex as well as housing and studying conditions when interpreting adolescents' life satisfaction decrease during the COVID-19 pandemic.

Substance Use Disorders and Medication-Assisted Therapies: Current Practices and Implications for Nursing

In the United States, the opioid epidemic and COVID-19-related substance use have exacerbated the overall incidence of substance use disorders (SUDs). Medication-assisted therapy (MAT), or cognitive and behavioral therapy that combines medications that reduce substance use or acute withdrawal symptoms, has dramatically improved outcomes for SUD patients, including preventing mortality. With recent US Congressional funding for MAT, patients presenting for acute care on MAT-related medications will continue to increase. Nurses should be aware of these medications' mechanism of action, typical side effects, and implications on treating acute pain to optimize their care.

Emergency Department Visits Involving Mental Health Conditions, Suicide-Related Behaviors, and Drug Overdoses Among Adolescents - United States, January 2019-February 2023

The U.S. adolescent mental and behavioral health crisis is ongoing,* with high pre-COVID-19 pandemic baseline rates^† (1) and further increases in poor mental health (2), suicide-related behaviors (3), and drug overdose deaths (4) reported during 2020-2021. CDC examined changes in U.S. emergency department (ED) visits for mental health conditions (MHCs) overall and for nine specific MHCs,^§ suicide-related behaviors (including suspected suicide attempts), and drug-involved overdoses (including opioids) among children and adolescents aged 12-17 years (adolescents) during January 2019-February 2023, overall and by sex. Compared with fall 2021, by fall 2022, decreases in weekly ED visits were reported among all adolescents, and females specifically, for MHCs overall, suicide-related behaviors, and drug overdoses; weekly ED visits among males were stable. During this same period, increases in weekly ED visits for opioid-involved overdoses were detected. Mean weekly ED visits in fall 2022 for suicide-related behaviors and MHCs overall were at or lower than the 2019 prepandemic baseline, respectively, and drug overdose visits were higher. Differences by sex were observed; levels among females were at or higher than prepandemic baselines for these conditions. These findings suggest some improvements as of fall 2022 in the trajectory of adolescent mental and behavioral health, as measured by ED visits; however, poor mental and behavioral health remains a substantial public health problem, particularly among adolescent females. Early identification and trauma-informed interventions, coupled with expanded evidence-based, comprehensive prevention efforts, are needed to support adolescents' mental and behavioral health.

Sleep Duration, Mental Health, and Increased Difficulty Doing Schoolwork Among High School Students During the COVID-19 Pandemic

We estimated the prevalence of short sleep duration (<8 h/average school night) among high school students (grades 9-12) during the COVID-19 pandemic by using data from the Adolescent Behaviors and Experiences Survey (January-June 2021; N = 7,705). An adjusted logistic regression model predicted prevalence ratios for more difficulty doing schoolwork during the pandemic compared with before the pandemic. Most (76.5%) students experienced short sleep duration, and two-thirds perceived more difficulty doing schoolwork. Students who slept less than 7 hours per school night or experienced poor mental health were more likely to report increased difficulty doing schoolwork. Addressing students' sleep duration could complement efforts to bolster their mental health and learning.