The Growing Mental Health Needs Of School-Aged Children

Editor's note: This text-based course is a transcript of the webinar, The Growing Mental Health Needs Of School-Aged Children, presented by Moni Keen, OTD, OTR/L.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

• After this course, participants will be able to list three mental illness diagnoses of school-aged children.
• After this course, participants will be able to identify reasons/events for childhood mental illness and how it impacts occupational engagement.
• After this course, participants will be able to recognize the role of OT in addressing these mental health issues in the school setting.

Introduction/COVID-19 & Its Lasting Impact

I am so glad to be here to talk about the growing mental health needs of school-aged children.

As I approached retirement age, I noticed a concerning shift—an increase in behavioral challenges among children in the school setting. At first, these behaviors seemed more prominent among students in special education than in regular education. Then COVID came along. When schools finally reopened in 2022—my last year in the profession—I was hopeful. I expected things to feel like they used to. In reality, it was the most challenging year of my career. The difficulty wasn’t in working with the children themselves, but in the sheer scope of behavior modification required across the board, especially among students in regular education.

I hope you can develop a deep appreciation for why we are seeing what we’re seeing in our children today. I am especially interested in hearing from school practitioners about what it’s like in schools now.

In my research, I have taken a top-down approach. I looked at the effects of COVID and resulting behaviors through three perspectives: teachers at the top, parents in the middle, and children at the base. Negative experiences tend to roll downhill. Whatever stress teachers felt trickled down to parents, and whatever parents felt, combined with what teachers were experiencing, ultimately landed at our children's feet. Developmentally—physically, mentally, cognitively, and emotionally—these kids were not, and still are not, equipped to handle the events they experienced during that time. We continue to see the fallout today.

One positive outcome of COVID was that it brought mental health needs to the forefront. Unfortunately, funding for interventions is now decreasing, even though mental health challenges remain significant for teachers, parents, and students. We are still grappling with the lingering effects of the pandemic, alongside new challenges that have emerged. This requires new considerations for how we address behavior moving forward.

We have already touched on some of this background, but I want to give it greater meaning as we continue.

What Changed in March 2020?

What has changed since March 2020? I don't know about you guys, but life as we knew it has not ever come back to be the same.

It literally stopped in its tracks. Public education as we knew it utterly changed, and it has not gotten its grip back. And then mental health as we knew it was exposed. So, again, that was one of the blessings. But we are still experiencing a lot of the fallout from what we experienced, what we went through in Covid.

The World Stopped

As occupational therapy practitioners (OTPs), we often discuss occupation and why it is so important. However, there is a difference between having an occupation and engaging in it. Occupation includes the things you love to do, the activities that give your day structure and routine. Engagement, however, is the active participation in those activities, and it is through engagement that we find purpose and meaning.

When COVID arrived, the world stopped almost instantly. For me, it was a Friday at work, and by Monday, we could no longer go in. Everything was shut down, and we were teaching virtually from home. That shift brought significant challenges, which I’ll discuss later.

It’s important to remember that, as a global population, we had no say in what was happening. We had no control. We lost many aspects of our lives during that time, but one of the most profound losses was the ability to adapt in ways that could protect our mental health. Times were deeply uncertain, and uncertainty often leads to stress. Stress, in turn, can manifest as anxiety, depression, suicidal ideation, and, in some cases, the loss of life.

Parents who were the primary breadwinners often found themselves doubling as teachers. Suddenly, they were not only trying to earn a living and keep food on the table, but also ensuring that their children were seated in front of a computer, learning—and more importantly—comprehending material in a way they were not naturally equipped to process in a hybrid or virtual format.

For children, school is their primary occupation. From early childhood through high school, it is where they spend most of their time and where they develop academic skills, social connections, and life routines. When that occupation was taken away, the loss was not only academic—it was cognitive, social, and developmental. The impact was all-encompassing.

We had to establish new norms and routines in an instant. This wasn’t limited to one community or one group of people; it affected everyone. And change, as we know, is not always comfortable.

Let’s break this down further into the experiences of teachers, parents, and children.

Effects on the Teachers

Teachers were forced to transition to virtual instruction almost overnight. In my district, we did the best we could. Every child was provided with a piece of technology—whether a tablet, Chromebook, or iPad—and if they didn’t have internet access, we worked to provide hotspots. That said, countless stories from those early days would surprise you.

The directive to teachers was straightforward but daunting: you still have to meet all academic standards, you still have to teach all required subjects, and you must now do it virtually—and master the process as quickly as possible. Research shows that even when all resources are available, transitioning from in-person to fully virtual teaching typically takes about a year and a half. Our teachers were given a weekend. Unsurprisingly, many felt frustrated and stressed, knowing they were still accountable to county and federal standards while navigating an entirely new format.

A 2024 RAND study highlighted the impact. Female teachers reported higher stress levels than male teachers. Teachers of color were less likely to report difficulty with stress and coping, not because they didn’t experience it, but because they were less likely to report it. Twenty-two percent were likely to leave their jobs at the end of the school year, and 17% planned to leave education altogether for a new career. RAND described the overall sentiment as a “deep undercurrent of discontent.” Teachers were retiring and resigning at higher rates than before COVID. Out of 1,500 participants, a quarter experienced stress daily, and 60% reported feeling burned out.

The structure of the school year is also a factor. Some schools have shifted to year-round schedules, while others still maintain long summer breaks. Without adequate downtime, teachers and students lose opportunities to rest, regroup, and return ready to succeed. Many teachers feel the stress and disappointments of modern teaching aren’t worth the toll on their mental health.

In 2024, 59% of teachers reported being stressed, compared to 78% in 2021. While that shows some improvement, the levels remain significant. A 2021 study by Silva and colleagues—conducted during the height of COVID—found alarming increases: anxiety rates among teachers rose from 10% to nearly 50%, depression increased from almost 16% to close to 30%, and stress more than doubled from 12.7% to nearly 51%.

When we are anxious, depressed, and under constant stress, it impacts not just our emotional state but also our behavior, decision-making, and ability to regulate emotions. That burden weighed heavily on teachers, and the effects inevitably extended to families.

Effects on the Families

Let’s take a step back and think about life during COVID, when you were with your family 24/7. If you had school-aged children at home, you likely remember the challenge of supporting their learning while trying to keep up with your work remotely.

As a parent myself, my daughters were already out of school and college at the time, but I tried to put myself in the shoes of the parents whose children I was working with. Questions they faced daily included: Do I still have a job? How will I work from home? How will I pay my bills? How can I effectively do my job while being my child’s teacher?

One memory that stands out involves a student I worked with in special education. He was seven years old, had ADHD, and was being raised by his grandmother. His younger brother was five and in kindergarten. The grandmother left the five-year-old responsible for making sure his older brother sat down, stayed engaged, and learned his lessons for the day. When we checked in, we would find the five-year-old running around the house with his iPad camera on, snapping pictures. He still had his kindergarten lessons to complete, but the situation was chaotic and unmanageable.

Parents also asked themselves: How do I maintain structure and routine in the home when the previous structure is gone? How do I care for a sick family member when hospital visits aren’t allowed? For those with loved ones in the hospital, not being able to be with them was deeply painful. Some parents were hospitalized themselves, cut off from contact with their children. And when children were struggling emotionally, parents were left wondering: How can I, in my stress and anxiety, help my child?

Statistics from this period highlight the strain. Negative interactions between parents and children increased. Rates of yelling and shouting within families rose to nearly 32%. Disciplining—often for issues that might not have warranted it—rose to almost 24%. The use of harsh words also escalated, and this is particularly concerning. Words hold tremendous power, both positive and negative. When a child hears something repeatedly, especially in a harsh or critical tone, it can shape their reality.

There was also increased concern about domestic violence, heightened anxiety and depression, and 8.3% of parents reported having suicidal thoughts or feelings during this time.

Effects on the Children

Let’s start with the youngest children—those seven years old and younger. Many became more clingy, with an increased fear of the unknown. They often didn’t understand what was happening, sometimes leading to uncooperative behavior or misbehavior. Boredom was present every day—young children could only engage in a single activity for so long. Many sought more attention, and as therapists, we know that negative attention can be just as reinforcing as positive attention. Anxiety levels in this age group also increased significantly.

Moving into the 7–13 age range—children approaching puberty and already experiencing physical and emotional changes—the impact was even greater. Anxiety rates spiked dramatically, surpassing the increase in depression, which also rose. PTSD became a consideration as well, as COVID contained elements that could be traumatic for children. This group frequently displayed problematic behaviors and a strong need for reassurance, which was understandable given the uncertainty in every aspect of life at the time.

Academic challenges were also common. Not all children are suited to learning through a computer. I can relate personally, as I am a very kinesthetic learner. I must interact with materials—seeing, hearing, touching, and writing—to fully process information. Many children learn similarly, and the virtual format removed those opportunities. This often resulted in frustration, difficulty grasping concepts, and a higher likelihood of misbehavior, anxiety, social isolation, and depression.

For some children, especially those with ADHD, academic struggles triggered one of two responses: they either shut down and withdrew, or they acted out to avoid the task. This was particularly noticeable in classrooms during the post-COVID era.

Then we move into adolescence, an already emotionally complex and vulnerable developmental stage. Puberty brings significant physical, emotional, and social changes even under normal circumstances. Studies during the COVID period showed that adolescents experienced increased rates of depression, anxiety, PTSD, misbehavior, poor attention, and impulsivity. The pandemic’s disruptions amplified these challenges, creating an even more difficult environment for teens.

What is Research Revealing Now?

Research is shifting toward understanding the ongoing impact of COVID and the stressors that have emerged since the height of the pandemic. Teachers, who spent years navigating the challenges of pandemic-era education, are now facing new stressors. The federal pandemic relief funds have ended. In my district, those funds were used to implement meaningful programs in physical fitness, emotional wellness, and other support for children. With those programs now gone, teachers—both in regular and special education—are left with fewer resources to meet classroom needs. Political agendas targeting public education have resulted in further budget cuts, deepening inequities in access and support. This strikes at the core of our work as occupational therapy practitioners (OTPs), as we advocate for diversity, inclusion, occupational justice, and equality—principles now under pressure. The teaching profession is changing, with many people who once dreamed of becoming teachers now reconsidering due to the lack of support.

Parents, too, continue to feel the effects. Research is showing that those with a history of adverse childhood experiences (ACEs) coped more poorly during COVID’s unpredictable and stressful environment. Prior maltreatment in childhood was linked to an increased likelihood of repeating similar behaviors toward their children during the pandemic, perpetuating retraumatization. These parents were also more likely to withdraw into isolation during lockdowns. Mothers with ACE histories, in particular, demonstrated reduced resilience during this period.

The impact on children varies by age. While the probability that a child would develop a new mental health disorder post-COVID might seem small (0.026%), the fact that the risk now exists is notable. When these new diagnoses occurred within two years, they were most often developmental disorders, anxiety disorders, ADHD, or conduct disorders. Among adolescents, females were more likely to receive a new diagnosis. The overall probability for adolescents was slightly higher at 0.05%, with common post-COVID diagnoses including anxiety disorders, mood disorders, substance use disorders, ADHD, and, most concerning, increased suicide attempts. A Japanese study conducted during two COVID waves found a 49% increase in suicidal ideation and self-harm behaviors, underscoring the seriousness of this issue.

Looking at children, adolescents, and teens as a whole, depression and anxiety remain the most common mental health outcomes, both during and after the pandemic. PTSD is also present, as well as loneliness. Loneliness makes sense when we consider that children were isolated from peers for extended periods; returning to school meant re-learning how to socialize after a year or more of primarily interacting with family members. Psychological distress has also been linked to separation anxiety, especially in children who lost a parent or other close family member to COVID. Other reported issues include anger, irritability, boredom, fear, and stress. Eating disorders, while not necessarily initiated during the pandemic, were often reactivated due to the heightened stress and anxiety.

One particularly insightful global meta-analysis examined anxiety and depression rates in youth ages 8 to 18 across the USA, Greece, Norway, Australia, and Canada. Conducted in 2022, it included both cross-sectional and longitudinal data. For anxiety, the USA, Canada, and Greece were studied:

• USA: 4.67% pre-COVID to 5.37% post-COVID

• Canada: 6.06% to 6.23%

• Greece: 7.93% to nearly 11%

For depression, the USA, Norway, Greece, and Australia were studied:

• USA and Norway: 3.44% to 4.37%

• Greece and Australia: 10.82% to nearly 14%

These numbers show clear increases in mental health concerns among children and adolescents in the post-COVID world, reinforcing that the effects of the pandemic are far from over.

ACEs, Trauma, and Resulting Behaviors

Adverse childhood experiences (ACEs) are potentially traumatic events that occur during childhood, and they are preventable. That fact is important to remember because it means children who experience ACEs have no control over them. These events can include sexual abuse, verbal or emotional abuse, physical abuse, neglect, and domestic violence. Research in the post-COVID period has revealed that the pandemic itself can be considered a traumatic experience and that it has amplified depression, anxiety, and PTSD in many children.

During COVID, children exposed to emotional abuse, sexual violence between parents, or physical dating violence had a 0.32% increased likelihood of engaging in substance abuse. Those with one or two ACEs during the pandemic doubled or tripled their chances of using substances. For those with four or more ACEs, the risk was even higher—5.32 times more likely to drink alcohol, almost eight times more likely to binge drink, and nearly seven times more likely to increase alcohol consumption. Marijuana use prevalence also increased to almost 6%. These patterns show how ACEs, especially when introduced or compounded during the pandemic, can have long-term negative impacts on mental health and behavior.

The original 10 ACEs include physical and emotional abuse, physical and emotional neglect, parental separation (distinct from divorce), domestic violence against the mother, substance abuse by a household member, mental illness in a household member, and incarceration of a household member. In my work at Presbyterian College, I’ve had the opportunity to visit a maximum-security prison in Pelzer, South Carolina, to work with inmates on mental health. One inmate shared that both of his parents were incarcerated when he was a child. For him, incarceration was normalized, and his own began at age 13 or 14. His early environment likely exposed him to multiple ACEs—physical abuse, emotional abuse, and domestic violence—which contributed to his life trajectory.

Proposed additions to the ACE framework include peer victimization, household gambling problems, discrimination, foster care placement (or even just contact with child protective services), poverty, and neighborhood violence. These, too, can have a profound effect on children’s well-being.

The prevalence is sobering. Almost 63% of high school students have experienced at least one ACE from the original framework. In one U.S. longitudinal study, 70% of children had experienced three or more ACEs by age six. In Dutch studies, 45% of 9–13-year-old regular education students had at least one ACE, and 11% had three or more. Adolescents with ACE histories are more likely to struggle with depression, anxiety, drug abuse, antisocial behavior, suicidality, and cognitive difficulties.

Trauma, like ACEs, fundamentally changes how the brain processes information. As described in The Body Keeps the Score, trauma reorganizes how the mind and brain manage perception. Recalling an emotional event can trigger visceral feelings as if the event were happening again. Even when we try to suppress these emotions, the body continues to release harmful stress hormones, which can lead to chronic illness, organ failure, or death. Trauma imprints vivid, long-lasting memories of terrifying events, and finding words to describe these experiences can be transformative, though it doesn’t always stop flashbacks or improve concentration. For children without the verbal ability to articulate their trauma—such as those on the autism spectrum—behavior becomes their primary form of communication. This makes it critical for us as OTPs to be attuned to non-verbal expressions of distress and to help verbal children build the skills to articulate their experiences.

COVID-19 is now recognized as a traumatic event for some children, making trauma-informed care an important framework for our practice. Trauma-informed care shifts the focus from “What’s wrong with you?” to “What happened to you?” This approach fosters active listening, promotes resilience, respects the client’s lived experience, builds trust through collaboration, and focuses on strengths as a source of hope.

The CARES model is one way to structure trauma-informed care:

• Context: Understand the circumstances in which the trauma occurred.

• Ask: Use open-ended questions to encourage clients—children, adolescents, or teens—to share their experiences.

• Resiliency and Resources: Identify strengths and provide resources that children can access anytime to help manage stress and anxiety.

• Educate: Teach clients and caregivers about the relationship between trauma and its physical and mental effects, and provide strategies for emotional and sensory regulation.

• Self-care: Help clients develop meaningful leisure and self-care routines that prepare them to face current and future challenges.

By applying trauma-informed principles, we can help children process their experiences, regulate their emotions, and rebuild resilience—key steps in addressing the lasting impact of both ACEs and the COVID-19 pandemic.

Internal Vs. External Behavior

Trauma and ACEs can significantly influence both internalizing and externalizing behaviors.

Internalizing behaviors are those we keep inside, often hidden from others. These can manifest as fear, persistent worrying, or somatic complaints such as headaches, stomachaches, or muscle pain. Children may experience anxiety, withdraw from others, or isolate themselves entirely. In many cases, the fear and anxiety feel so overwhelming that engaging with others seems impossible, and solitude feels safer.

Externalizing behaviors, on the other hand, are more visible. These may include disruptive outbursts, aggressive actions, or impulsive choices. They can present as bullying, lower academic performance, or poor relationship skills. Often, these external behaviors stem from an inability to verbalize or articulate feelings. When emotions can’t be expressed through words, they frequently emerge through actions—sometimes as behavior disruptions, aggression, or impulsivity.

Both internalizing and externalizing behaviors can interfere with a child’s ability to fully engage in their occupations—whether that’s school, play, social interaction, or self-care—underscoring the importance of identifying and addressing the underlying trauma.

Role of OT

So, what is our role in all of this? I feel very strongly about this because I believe we, as occupational therapy practitioners, have lost sight of our foundation in mental health. That’s where our profession began. Over time, as we shifted toward the medical model, we were taught that everything had to be backed by standardized testing. Somewhere along the way, it created the misconception that we aren't addressing it if we aren’t using a formal tool to assess mental health. Nothing could be farther from the truth.

Every interaction is an intervention. Every time we connect with a client, we have an opportunity to address areas where they may be feeling anxious, insecure, or depressed—and to celebrate when they’re feeling confident and successful. We can intentionally influence a client's mental well-being through the intentional relationship model and the therapeutic use of self.

We also embed mental health work into the activities we choose. When we set clients up for success, praise them, or help them problem-solve through challenging tasks, we reinforce self-efficacy and emotional resilience. Understanding the difference between occupation and engagement is key here. Occupation refers to the things a person values and does regularly; engagement is the active participation in those things. Without engagement, the benefit is lost. This is why we must continually learn what occupations matter to our clients—through occupational profiles—and recognize that these can change from week to week.

In school settings, for example, a child you see this week may be a very different version of the child you saw last week, depending on their day or what they’ve experienced recently. We always assess cognitive status, mood, and decision-making, whether consciously or not.

If you have the opportunity to become certified in trauma-informed care, it can deepen your practice. Even without formal certification, you can implement its principles—many of which you may already use. Learning about trauma-informed care helped me see where I was already applying these approaches and where I could strengthen them.

Continuously updating the occupational profile is essential. Equally important is appreciating the totality of a client’s situation. Context matters—understanding not only the trauma itself but the circumstances in which it occurred allows us to interpret better how it impacts behavior. For some clients, the root issue may be the accumulation of multiple smaller events; for others, it might be one profound, life-altering trauma.

Adversity is not experienced the same way by everyone. As Martini and Backman remind us, “Adversity is not experienced the same by all.” Each individual’s wiring, experiences, and coping mechanisms shape their response. One size never fits all. Our role is to adapt occupations so clients can engage meaningfully, knowing that loss of engagement will impact psychosocial well-being. Our responsibility is to keep occupation and engagement at the center of our work to support functional and mental health.

Questions and Answers

My 12-year-old has shown most of these characteristics this past year. What can I do?

I validated this experience, noting that children across developmental stages were showing increased anxiety, depression, and emotional dysregulation. I encouraged parents to reestablish routines, prioritize sleep hygiene, and support emotional expression through creative and structured activities.

Do you have ideas for activities for 4–7-year-olds to promote social interaction?

I suggested using sibling interactions, FaceTime calls with friends and family, letter writing, and even virtual playdates on platforms like Zoom to maintain social engagement. Participants also shared additional ideas, such as parent-supervised creative projects and structured game times.

Did social media use affect suicidal ideation among adolescents?

I explained that social media often exacerbated feelings of inadequacy and isolation, particularly for adolescents comparing their lives to curated online personas. This increased social media use, combined with isolation, likely contributed to heightened rates of suicidal ideation.

Have you noticed increased aggression in neurodiverse classrooms?

I shared that many educators and caregivers reported heightened aggression and challenging behaviors in children on the autism spectrum, largely due to disrupted routines, loss of services, and heightened family stress.

What was in the take-home OT kits you mentioned?

The kits included pipe cleaners, beads, scissors, markers, chalkboards for wet-dry-try writing, and stress balls. These provided sensory input and supported fine motor development while learning at home.

References

See additional handout.