Teenagers, Covid & mental health: the parallel pandemic

"During the pandemic I had nothing else to do all day: there was my illness and me and nothing else. There wasn't even me anymore. I had completely lost my identity, I had just become an anorexic person.”

This was the comment of one teenage girl who was among a handful of teenagers that joined a group of child and adolescent health professionals in late November to discuss the impacts of the Covid-19 pandemic on teenagers’ mental health.

The conclusion of the two-day workshop was unanimous: the psycho-social burden linked to Covid-19 has created a “parallel pandemic” whose collateral effects may extend well beyond the pandemic itself.

The workshop, sponsored by the Brocher Foundation, featured presentations by the young members of the Youth & Health Committee set by the Division of Adolescent Health (DISA) of the Centre Hospitalier Universitaire Vaudois (CHUV). They were based on interviews conducted over the past few months with peers aged 11-25, living in the Canton of Vaud. Their vivid testimonies describe the ways in which the lives of young people have been disrupted by the pandemic across areas ranging from communication to health care, school, and the loss of other benchmarks of daily life.

The intimate stories and observations shared at the workshop have been echoed by much broader studies conducted by the Organization for Economic Co-Operation and Development (OECD), the World Health Organization (WHO) and UNICEF among others. UNICEF, which surveyed some 15,000 young people across Europe and Central Asia, found that 56.4 per cent of respondents said that Covid has affected their learning. With pandemic-related school closures, malnutrition has increased along with social disparities. Educational gaps have been exacerbated by disparities in access to technology among the one-half of the world's population lacking Internet access, WHO notes.

Why is the pandemic particularly difficult for young people? The paradox for teenagers is that they need a great deal of autonomy to develop - to feel free and take risks. But they also need the protective base of a clear educational framework. The closure of schools - 1.5 billion children out of school at the peak of the pandemic - and lockdowns have produced exactly the opposite - depriving them of both freedom and secure reference points. Instead they became locked up in their parents' homes, barred from engaging in many types of routine, outside activities.

While they don't have a role in the policy decisions that changed their lives, they were subjected to the guilt-ridden pressures of becoming potential vectors of disease or rule-breakers, if they did take risks to gather and socialise in otherwise normal ways . Anne-Emmanuelle Ambresin, head of the Interdisciplinary Division of Adolescent Health (DISA) of the CHUV - Center Hospitalier Universitaire Vaudois, and co-organiser of the conference:

"Many teenagers are questioning the meaning of their lives, whether they are worth anything on the market. They feel sacrificed on the altar of Covid. Young people carry our future and they know it. They reap all our uncertainty, our inconsistencies, our anxiety without being allowed to act, to contribute to tomorrow's world or being questioned regarding their needs. ”

While teenagers develop in singular ways, adolescents, teens and young adults across the 11-25 year range are particularly vulnerable as a group. Research on the brain over the last 20 years shows that the ability to reason, anticipate and control emotions is only acquired very gradually up to the age of 20-22. "Brain plasticity also implies increased vulnerability," according to Professor Pierre-André Michaud, former head of adolescent medicine at the CHUV and co-organiser of the conference.

What do young people say? At the workshop, the teenage members of DISA's Youth & Health Committee described the ways in which young people were impacted, in areas ranging from the disruption of communication channels to health care, learning and the loss of other routine benchmarks of daily life.

Fragmented communication: the announcement of the lockdown was experienced as an abrupt and even brutal event, with the media contributing to the drama. A 16 year old teenager hospitalised several months following the lockdown for anorexia testified that she felt "abandoned".

"Our teacher gave us a leaflet to warn us that we would be in lockdown until the end of April. He left us in front of a film and left without a word,” she said. “In the corridors, it was like in a jungle. The little ones were shouting with joy, some were crying because they didn't understand what was happening, others were having panic attacks. All I could think about was my exams. We were all in shock.”

Healthcare disruptions: the abrupt cessation of non-urgent health care completely destabilised R, 24 years old, who suffers from a rare genetic disease. Her non-urgent treatments were all cancelled: "a virus shows up and everything stops".  Isolated to protect her from infection, she saw her physical and psychological  health gradually  decline, including sharp bouts with pain:

"It was destabilising to see changes appear without having any control over them. I felt like every time I went out of my room I was going to discover something new. They went so far as to cancel all visits, all outings, all group activities. Meals alone in your room, being isolated when you're already depressed doesn't help.”

In fact, experts say that the  10 to 15 percent of adolescents in Switzerland with chronic illnesses or physical disabilities have paid some of the highest costs during the pandemic. Only 22 percent of adolescents with a disability were able to continue their medical care. As one doctor at the workshop explained:

"During the first wave, we were instructed to cancel everything that was 'non-urgent'. But what defines urgent and non-urgent? Cancelling annual checks has had catastrophic consequences. The teenager is in peak growth, nine months later everything changes. What was not urgent has become super urgent. A British study reports missed diagnoses: cases of diabetes, infections, tumours and even deaths attributed to delay because of the fear of Covid-19.”

Distance learning: The Youth & Health Committee report bears witness to the  stress experienced by students due to  the lack of supplies, the absence of a framework, homework routines, out-of-reach teachers, and isolation.

Adds Valentina Baltag, a WHO expert present at the meeting:

“According to UNESCO,  at least 24 million learners are projected to drop out of school due to COVID-19. Even before COVID-19 access to education was inequitable, and the pandemic has increased the equity gap even more. Without remedial actions, repercussions will be dramatic.”

Loss of benchmarks: According to Nina Ferencic,  senior adviser on adolescent programming  at UNICEF, all over the world young people have been impacted by brutal changes in every benchmark of normal life. The testimonies of the Youth & Health Committee described in personal terms how rhythms had been broken - including rhythms of day and night; school and sport/leisure activities; and even meal times. One 19 year-old adolescent, for instance, described how the lockdown increased her sports addiction:

"At the basis of all lives, there is a framework that gives you a rhythm.  Covid has taken up all the space. Without classes, my life has only revolved around sport. training up to 11 hours a day. This addiction led to multiple fractures due to the repetition of movements and stress on my lower limbs.”

According to Philippe Stephan, child psychiatrist at the CHUV, 58 per cent of the adolescents did not know who to turn to in case of difficulty, when schools were closed and in the absence of direct interlocutors. Another adolescent said:

"My family situation was awful, I was in bad shape and I couldn't get help. The only psychiatrist we found was not specialised,” said one teenager at the meeting. “When we finally managed to get an appointment on her landline, I was afraid to be heard. I wasn't well, I was locked up alone between four walls, I was crying alone on my bed and she was miles away and she didn't understand anything. I told my parents I wanted to stop. There was no way out, we were lost."

Other alarming trends. Other issues reported upon at the workshop, included weight loss; domestic violence, physical inactivity and an upswing in psychiatric referrals.

Weight loss and gain: 50 per cent of adolescents who suffered from eating disorders have reactivated their symptoms during lockdown. Among others, continuous snacking has increased. According to a study by the Children's Hospital in Lausanne (HEL), 30 per cent of parents feel that their children have gained weight and 40 per cent of teenagers say they have snacked more. DISA reports weight gains ranging from two to 15 kilos during lockdown.

Domestic violence: the world average is around 20 per cent of the upsurge observed in hotlines in particular and rises to 40-50 per cent in Brazil.

Physical inactivity: the majority of teenagers have become totally sedentary and 100 per cent have increased their screen consumption.

Psychiatric referrals: Lausanne’s CHUV observed a 60 per cent increase in psychiatric hospitalisation requests between June and September compared with the same period in 2019. Child psychiatrists are overwhelmed by requests. There was also an upsurge in suicide attempts during the lockdown, followed by another surge in October.

Solutions - invite young peoples’ participation. The greatest mistake, the experts and the adolescents agreed, was not to have asked young people for their opinion about decisions made without their involvement. Young people paid the price for incoherent policies set out by adults. For instance, studies show that life in the classroom is not a particular risk, the virus spreads very little there.

"We live in a rather paternalistic society. During the crisis, speeches were generally adult-centred and children (0-18) were listened to even less than usual,” stated Philip Jaffé, a member of the UN Committee on the Rights of the Child. “The pretexts are straightforward: the economy and health come first. When young people were visible, it was to be stigmatised as virus spreaders or rule transgressors.”

In the context of post-pandemic reconstruction, health, legal and education professionals working with young people need to call upon political and health authorities to provide children and adolescents with opportunities to participate and be heard, in the context of the UN Convention on the Rights of the Child.

"Children should be partners at all levels in the management of this crisis, in the way needs are assessed, in the way resources are mobilised, in strategic planning, as co-researchers from an academic point of view. Children are unique vehicles for communication, said Jaffé. “They should be actors.”