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The pandemic is not the only reason.
Last June, researchers from Texas Children’s Hospital and Baylor College of Medicine documented six unusual cases in the journal Movement Disorders. The subjects were teenage girls between 13 and 16 who had started having “abrupt-onset tic-like movements.” The tics were puzzling because Tourette’s syndrome and other tic disorders — characterized by involuntary and repeated movements or sounds — are far more common among boys and tend to first appear in early childhood with small movements; the girls’ movements, though, were large, accompanied by vocalizations and had other unique traits. Among them: The girls all described having watched TikTok videos of tics before their symptoms began, suggesting the potential spread of a social contagion.
Indeed, the C.D.C. last month reported a pronounced increase in similar tics based on evidence from a source never before used to assess specific mental-health conditions among the nation’s children: emergency-room data. For girls ages 12 to 17, the proportion of visits to the E.R. for tics nearly tripled during the pandemic as of January 2022. Visits also doubled for eating disorders, and there were increases related to anxiety, trauma and stress and obsessive-compulsive disorders.
These findings, particularly the rise in what have been called TikTok tics, have received considerable media coverage. But “equally striking,” says the lead author, Lakshmi Radhakrishnan, a health scientist at the C.D.C., is the marked but less widely discussed decrease in mental-health visits by adolescent boys.
Why do girls appear to be struggling? Are boys faring better? Or are their problems more likely to be overlooked? The numbers can’t answer questions like these. “No single, comprehensive surveillance system for children’s mental health in the United States exists,” the C.D.C. noted in a supplementary report. The current surveys that keep tabs on various aspects of mental health in children are too slow to capture swift changes amid a national crisis. And though rapid surveys have evaluated the pandemic’s impact on the mental health of adults, fewer have considered how children are doing. “A lot of times kids aren’t the first in line,” says Daniel Dickstein, the associate chief and director of research at McLean Hospital’s child and adolescent psychiatry division. And, he points out, if more children were getting adequate mental-health care earlier, fewer would end up in the E.R., a venue that is not set up for ongoing treatment of psychiatric conditions.
Emergency-room data has been monitored for almost two decades by the C.D.C. as part of a response to 9/11 and a congressional mandate to track health measures in the event of disease outbreaks or other public-health emergencies. Though mental-health data from the E.R. has not been a specific focus for the C.D.C. over the years, it has now enabled the agency to produce a report that is meant, Radhakrishnan says, to raise awareness among parents, physicians and mental-health organizations.
This is especially important for emerging conditions in order to reduce misdiagnoses. For the tics many adolescent girls are having, for example, “we would want to treat looking at anxiety and depression,” says John Piacentini, an expert in tic disorders and director of the Child Anxiety Resilience Education Support Center at the University of California, Los Angeles. Those conditions can increase the vulnerability of children to developing tics and eating disorders. Hence doctors should use great care in prescribing medications for tics because Tourette’s syndrome and other movement disorders — and kids can have more than one — often involve different neurological pathways.
“With the social isolation and lack of social connection, I think that hit girls harder than boys,” Piacentini says. “Girls tend to socialize in different ways.” If, as experts believe, the tics that many of them have experienced during the pandemic mirror behavior they saw online, it may be an unintentional way of trying to make connections during what for many has been a period of loneliness. “I think it’s a little beyond their control,” he says of the tics. “I don’t think most kids are doing this for attention.”
It would be easy to blame the pandemic for changes in mental health that have been observed since March 2020. But in December, when the surgeon general noted a “mental-health crisis” among young people, he made clear that rising numbers of children and young adults were struggling with anxiety and depression before Covid-19. Between 2013 and 2019, A.D.H.D. and anxiety were the most common mental disorders among those 3 to 17 years old, with each condition affecting roughly one in 11 children, according to the C.D.C. More than one in five 12- to 17-year-olds experienced a major depressive episode. Yet in 2019, fewer than 15 percent of children between the ages of 5 and 17 received some kind of mental-health treatment. “Pre-Covid we had a mental-health crisis,” says John T. Walkup, chairman of the psychiatry and behavioral-health department at Lurie Children’s Hospital of Chicago. “The biggest misconception is that Covid makes people mentally ill. From my point of view, Covid unmasked people who have underlying vulnerabilities.”
Unfortunately, that means letting go of the popular notion that a return to “normal” for children — in-person schooling, no more masks — will reverse those trends. In fact, such measures may compound the stress many students already feel, says Lisa Fortuna, the U.C.S.F. chief of psychiatry at Zuckerberg San Francisco General Hospital. And an estimated 200,000 children in the U.S. who lost a parent or guardian to Covid-19 may need additional support. Screening for depression and anxiety at schools and pediatricians’ offices will be crucial, because the symptoms associated with those conditions are easier to manage and do less damage when addressed early. For adolescents, substance abuse, eating disorders and thoughts of suicide can be complications of both anxiety and depression.
In preadolescent children, Fortuna says, depression may reveal itself as touchiness and irritability rather than sadness. For all ages, a withdrawal from routine activities is a warning sign, as is excessive worry. Symptoms vary greatly, but in general, depressed girls may become withdrawn, whereas boys may fight or act out, incurring the label of behavior problem rather than, say, mood disorder. “Clinically, I’m seeing a lot of young men presenting with depressive symptoms,” Fortuna says. That’s despite the decrease in male visits to the E.R. that the C.D.C. found. “They are still there,” she says. “They might not be as loudly presenting.”
Opening a dialogue with children about how they are feeling and listening without judgment are critical. “I would encourage parents to talk to kids and ask them, ‘Are you feeling sad?’” says Anita Everett, director of the Center for Mental Health Services at the Substance Abuse and Mental Health Services Administration. “We encourage people to also ask about suicide,” she adds. Doing so won’t plant the idea. If there’s a problem, don’t ignore it and hope it will go away. “Some sort of path forward is important,” Everett says.
That path may well be arduous. A recent survey in Annals of Family Medicine found that 85 percent of primary-care practices are having difficulty accessing evidence-based mental-health care for children. Nationally, Fortuna says, some children are waiting six months to a year for help. She suggests first seeking advice from a primary-care doctor or school counselor. The SAMHSA website includes a treatment locator, and churches and other community groups can be valuable resources. Everett urges caregivers to ensure that weapons, especially guns, and medications and other dangerous substances are well secured in any home where a child will be. And, she says, parents should look for support for themselves. Perhaps it’s helpful — as well as tragic — to know that finding others whose children are struggling, and who are struggling themselves, won’t be difficult.
If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can find a list of additional resources at SpeakingOfSuicide.com/resources.
Kim Tingley is a contributing writer for the magazine.