Leveraging Longitudinal Pre-pandemic Data to Understand Mental Health Vulnerability and Resilience Among Young People During the Early Pandemic.

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It is, by now, cliché to say that the COVID-19 pandemic has been an unprecedented experience. Age and social inequality have proved to be two of the most significant determinants of that experience, with older adults and those with social and economic vulnerabilities experiencing the greatest burden of illness and mortality. While children and young people have thankfully been largely spared the worst of the immediate health impacts of COVID-19, they have unquestionably experienced a different set of impacts—those associated with how the pandemic, and the restrictions on normal life it has entailed, have disrupted their worlds, particularly their typical family, educational, recreational, social, and emotional interactions. For example, some of the most severe indirect effects of the pandemic experienced by children and young people have been the extended periods of school closure and the knock-on effects of these in terms of disruptions to learning and school-based supports, to sports and other extracurricular activities, and to family life and peer interactions.

Childhood and adolescence are critical periods for brain development, during which the brain is incredibly plastic but also sensitive to adverse experiences. Prolonged periods of stress and disruption to age-typical learning and socioemotional experiences may have long-term effects on cognitive, social, and emotional development. It will take years before we fully understand the true impact of the pandemic on the well-being of children and young people. Thankfully, the process of examining that impact is already under way. Developmental psychologists all over the world immediately understood the potential for significant mental health and well-being impacts of the pandemic and began to ascertain them.

Early in the pandemic, studies asking parents to report on the perceived effects of the pandemic revealed worsening mental health and well-being among parents and among children and young people during the pandemic relative to before (1, 2, 3). Some of these changes were associated with specific stressors, such as school closures, loss of childcare, and interacting socioeconomic impacts such as worsening food security (2,4,5). One important observation arising from these studies is that there has been considerable variability in responses to the pandemic across youths. As with exposure to other stressful experiences, some individuals have been vulnerable to negative outcomes, while others have remained resilient. Identifying the factors that predispose individuals toward vulnerability is a centrally important task, since it enables us to best direct resources and supports to those who need it most.

This is where longitudinal studies are proving particularly valuable, such as the study by Porter et al. (6) in the current issue of Biological Psychiatry: Global Open Science. By leveraging valuable longitudinal data collected at multiple pre-pandemic time points, Porter et al. (6) identified pre-existing factors that predisposed young people to better or worse responses to the pandemic. While other studies have focused largely on mood-related symptoms as markers of vulnerability [e.g., Barendse et al. (1)], Porter et al. (6) examined the impact of pre-existing attention-deficit/hyperactivity disorder (ADHD) symptoms, and uniquely, of pre-existing symptom trajectories (e.g., worsening, stable, or improving) on mental health and well-being during the early part of the COVID-19 pandemic. As a common childhood condition [approximately 8.4% of 2- to 17-year-olds in the United States are estimated to have a current diagnosis (7)], it is important to understand whether ADHD symptomatology represents a specific vulnerability factor that determined youth responses to the pandemic.

Focusing on outcome measures indexing the impact of COVID-19 on parent and youth mental health and well-being during the early part of the pandemic (May–July 2020), Porter et al. (6) leveraged 2 approaches to examine links between pre-pandemic mental health burden and pandemic responses. The first was to generate percent of maximum scaling scores, a common metric used in longitudinal studies, to examine associations for reported pre-pandemic mental health symptom burden (derived from the Child Behavior Checklist or Adult Self-Report for participants >18 years of age) and ADHD symptom burden (derived from the Conners-3 Self-Report or Conners’ Adult ADHD Rating Scale for participants >18 years of age). The second was to measure associations between pandemic response and pre-pandemic mental health trajectories by computing a slope (i.e., rate and valence of change) of self-reported ADHD symptom burden across pre-pandemic time points for each participant. The authors also investigated whether participant age and parental education (as a proxy for socioeconomic status) predicted pandemic responses.

Porter et al. (6) found that pre-pandemic ADHD symptom burden was associated with poorer self-reported cognitive and emotional well-being among young people during the early pandemic. Within their cohort, this link was specific to ADHD symptom burden; associations for general mental health burdens were weaker. In addition, a pre-pandemic trajectory of worsening self-reported ADHD symptoms was associated with poorer cognitive well-being during the early pandemic, even after controlling for baseline levels of ADHD symptom burden. These findings suggest that ADHD symptoms constitute a risk factor for poorer outcomes during the pandemic and that particular attention should be paid to supporting young people who are experiencing a worsening of their ADHD symptoms over time. Other research has shown that use of positive coping strategies buffered adolescents with ADHD against increased mental health difficulties during the pandemic (8), which highlights specific avenues for intervention and promotion of healthy adjustment.

Porter et al. (6) also found that older youths showed greater mental health difficulties during the pandemic, relative to younger children, a finding that has been echoed in some, though not all, international samples (5,9). This may reflect a greater awareness of the pandemic and its risks and costs among older youths, as well as more severe direct impacts, in terms of restrictions on their activities and opportunities for social interactions, and suggests that attention should be paid to the specific needs of different age groups.

Families showed synchrony in their well-being responses to the pandemic; parents reporting poorer physical and emotional well-being had children and young people who also reported poorer emotional and cognitive well-being. This is in line with the widespread finding that parental responses to stressful life events significantly impact their children’s well-being (10) and highlights the importance of attention to and interventions that target socioeconomic factors that constitute specific vulnerabilities for families. In Porter et al.’s (6) study, higher socioeconomic status (proxied by parental education) was, somewhat predictably, associated with higher economic well-being during the pandemic. In contrast to several other studies (4,5), however, this measure did not show associations with other parent or child mental health outcomes, possibly due to the socioeconomically homogeneous sample. Nearly 18 months after the declaration of the pandemic by the World Health Organization, it is now clear that socioeconomic disadvantage is a primary risk factor for a host of direct and indirect impacts of COVID-19, and that there is an urgent need for governments worldwide to address the root causes of social inequality and to invest in the social and economic supports, including mental health services, that can help individuals and families to recover from the stresses of the pandemic and build resilience for the future.

The true impact of this pandemic will not be felt for some years yet—longitudinal studies such as that by Porter et al. (6) will be invaluable to our estimation of these long-term effects and to the identification of those most vulnerable so that interventions to mitigate those impacts can be directed at those who need them now. As the world begins to move on from the COVID-19 pandemic, there is a moral obligation to take the lessons we have learned and use these to inform policy change and resource allocation now so that those who are most vulnerable may be better protected in future emergencies.