The COVID-19 pandemic has revealed the interdependence of children's schooling and their mental health, with each child being unique in response to pandemic-related disruptions. There is a will and a financial path forward to work across sectors to promote a mental healthcare model that champions the unique challenges facing each child. This model requires individualized care plans and proactive outreach to children who are reluctant to disclose their suffering.

Changing Assumptions about Childhood Mental Health

An influential report entitled COVID-19: Recommendations for School Reopening was published by The Hospital for Sick Children (SickKids) in Toronto five months after Canada's first reported case of COVID-19 (Science and Bitnun 2020). The report put the spotlight on childhood mental health in a way that eclipsed the media attention paid to later scientific papers on the same topic. Due to the lockdown and associated school closures, the SickKids' report speculated that, because schools were closed, “increased rates of depression, trauma, drug abuse and addiction and even suicide can be anticipated” (Science and Bitnun 2020: 3).

The June 2020 report was cited by many observers across North America to argue that all children need in-person schooling and that school closures carry severe mental health consequences for all children. Absent from most media commentary on this report was a reference to its conclusion:

…these recommendations reflect the evidence available at the present time and may evolve as new evidence emerges and as information is gathered from other jurisdictions that have opened schools already. (Science and Bitnun 2020: 10)

A later report, published by SickKids on January 21, 2021, called for a balanced approach as community transmission of SARS-CoV-2 continued its spread among children. The report noted:

…it is important to balance the health risks of SARS-CoV-2 infection in children and their role as potential transmitters of SARS-CoV-2 with the significant harms of school closure on children's physical health, developmental health, mental health and learning (Science and Bitnun 2021: 2).

Contrary to certain fears expressed in these attention-getting reports – on which many school reopening decisions relied – Canada's official suicide statistics show that deaths by suicide dropped by 15% in 2020 (Duong 2022). Calls to suicide hotlines had increased, yet suicides declined. British Columbia, Alberta, Saskatchewan and Nova Scotia saw decreases in suicide rates in 2020. Mental health service utilization decreased in Ontario (Duong 2022).

A study published in the JAMA Network Open reviewed emergency department (ED) data for Ontarians between 14 and 24 years old. It reported a decrease in ED visits for both self-harm and accidental overdose in the first 15 months of the pandemic as compared with data from 2018 and 2019 (Ray et al. 2022).

A decrease in ED visits for mental health acuity for adolescents does not necessarily mean a lower prevalence of pandemic-induced mental illness. The opposite may be true since during the early period of the pandemic patients purposefully avoided crowded emergency rooms.

Even if suicides had decreased, holistic mental health could have worsened. There are alarming reports of heightened demand for child therapy and counselling services, with waitlists doubling in some regions of Canada. Many studies have noted increased self-reports of depression and anxiety since the onset of the pandemic. There have been reports of rising rates of eating disorders in teenage girls (Duong 2022). Other pandemic-era data from Statistics Canada suggest that the majority of Canadian adolescents reported no change, or even improvement, in mental health (Duong 2022).

Looking at the studies reported thus far, what we have learned is not that the pandemic has harmed all children's mental health equally but rather that the schooling environment can present diverse mental health risks to different children. We need to learn more about why. For example, one child's mental health – especially when the child lives in a multi-generational home – may be negatively affected by the deleterious consequences of SARS-CoV-2 infection in a vulnerable relative. For children in families facing financial hardship, the prolonged ill health of a working parent may spell food and housing insecurity for the family. If these children see themselves as transmitters of a dangerous virus on account of attending in-person schools, their mental health may suffer from school reopenings. For many other children, returning to in-person schooling can be empowering and a positive experience for themselves and their families.

The Particularity of Childhood Mental Health

If childhood mental health were “one-size fits all” – if we could predict what all children need in a new era of infectious disease where troubles come not in what the character Claudius in Shakespeare's Hamlet called “single spies” (Shakespeare 1974) but in unforeseen “battalions” – mental health practitioners would not need to offer individual therapy. Different clinicians, as the pandemic has taught us, hold divergent opinions about what is best for the child population. These opinions are based on the healthcare provider's training and experience, the makeup of their practice, the journal articles they read and many other variables, including a bias called “consensus bias” – causing people to “see their own behavioral choices and judgments as relatively common and appropriate to existing circumstances” (Ross et al. 1977: 280).

None of this is meant to minimize the serious hurt that many children and parents have endured during the pandemic. Rather, it is to celebrate how all children are unique – unique in response to various adversities, specifically – in ways that author and polymath Nassim Nicholas Taleb calls “antifragility” – a property by which systems and people can bolster their capacity to thrive in reaction to stressors, shocks and attacks (Taleb 2012).

Observations of Childhood Adversity and Resilience

In his masterpiece, Man's Search for Meaning, Viktor Frankl – the psychiatrist and Holocaust concentration camp survivor – describes how frail humans can behave unexpectedly under new conditions to which they had never been exposed; they respond variously, often unpredictably (Frankl 1946). In concentration camps, prisoners survived, Frankl notes, on scarce rations of bread and broth; many showed selflessness and kindness to strangers, including to their captors even when prisoners knew with certainty that they were putting themselves at risk of a swift death. Some acted otherwise. People differ. The pandemic represents an unprecedented and stochastic event in human history; so, too, is the mental health reaction of all individuals, including all children, to this phenomenon.

Now is the opportunity to implement policy and administer mental health services in ways that align with the unique challenges and contexts facing each child. Consider, again, the data showing that some children fared better away from school. These may be children who have certain advantages – access to good remote learning facilities, parents who could work from home, socializing possibilities with siblings in person or via online networks and the good fortune of COVID-19 not infiltrating their homes (especially early in the pandemic and before the arrival of vaccines). There are, as well, children with auditory sensitivities and social anxiety, children who learn better on their own, away from the noise and clutter of the classroom. There may be children for whom the lockdown was an oasis in the dangerous desert of schoolyard teasing, taunting and bullying.

Observational studies that explain why certain children's mental health is antifragile and improves in situations of societal distress can offer insights into interconnected parts of our child health and the educational system that have, until now, been overlooked. For example, do we have an accurate pulse on the intensity of school pressure exerted against those who appear different from the “norm?” Are children who insist on wearing masks in school being teased and taunted now that masks have mostly been abandoned? Are schools inadvertently promoting a norm of child behaviour that hurts vulnerable children to the point of fearing school? Has school phobia increased since the pandemic; if so, why?

Childhood (and adult) mental health is inherently specific to the person. That is why we talk of “precision medicine,” because each person requires somewhat different healing environments. Much more important than diagnostic categories is the personality of the patient. As William Osler wrote, “[i]t is much important to know what sort of a patient has a disease than what sort of a disease a patient has” (Bean 1961).

Children are products of their genetic and cultural heritage, their experiences and their exposures or, in modern scientific language, their exposome. A recent paper in Biological Psychiatry – a journal that usually addresses topics about the genome – dealt, instead, with the exposome – consisting of, for example, pregnancy and birth complications, family values, neighbourhood characteristics, major and minor life events and minority status – to show how these can contribute to individual personality and psychopathology (Pries et al. 2022).

If we treat children as if they belonged to one conglomerate, we do none of the individual children in that conglomerate a service. Especially harmed are the quiet voices who go unnoticed, their unique needs unheard. We need – through new and heavily promoted clinical and public health protocols – to hear from the quieter children. Through these protocols, we can better understand their needs by proactively reaching out to them – the school-phobic children who find it hard to leave the safety of their homes, the introverts who enjoy life best when secluded from others, the children who may find it hard to be overly scheduled, the children with attention deficit hyperactivity disorder for whom sitting all day in school is a challenge or those children who always learn best in groups of one.

For the next pandemic – and for the as-yet unknown challenges that may arise from the current pandemic to our already distressed health system – health policy can learn from the particularity of mental health that we witnessed in 2021 and 2022. When children have physical pain, we ask them where the pain is, what it feels like, how severe it is and how it came to be. However, when children have emotional pain, we tend not to ask and they, in turn, tend not to speak. We need to listen attentively to unspoken pain because it shows itself differently in different children. We need to be alert to silent suffering. Careful observation may yield new insights into how the classroom and school culture can adapt to meet the needs of all children, each one unique.

Promising Future Directions

Big data – large datasets embedded in digitized records, organizations and on the web, where patients are able to describe their particular needs – can lead to a form of precision medicine based not on the genome but on the exposome. We can further individualize care plans according to a child's needs as expressed by the child – and the child's parents and teachers. Such an approach presupposes healthcare access and adequate resources throughout the country, which is an ideal to be strived for but probably not easily reachable within the immediate future. One potential low-cost, high-return initiative is to ensure that families are made aware of the options, tools and resources offered. Various organizations – notably, Healthy Minds Cooperative (https://www.healthyminds.ca/) and the Canadian Mental Health Association (https://cmha.ca/) – are exemplary in this manner of communications.

Furthermore, we have encouraging evidence that the finance sector, over the course of the past decade – as exemplified by the leadership of organizations such as Capitalize for Kids (www.capitalizeforkids.org) – has been eager to contribute financially to build capacity, to reduce wait times and to identify and share emerging best practices across the nation that improve access to childhood mental health services. Impact-driven youth-focused charities (such as Jack.org) are working in concert with the private and public sectors by building high-school student chapters across Canada to help reduce the stigma associated with seeking care.

There is a will and a financial path forward to work across sectors to deliver on the promise of individualized childhood mental health that recognizes the interdependence of schooling and mental health. The pandemic has helped reveal that interdependence. Our childhood mental healthcare system has been stressed but it is antifragile, too. It can grow stronger – for the health of every child.

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