Adolescence is a time of growth and discovery, but also of disappointments and uncertainty. Teenagers in today’s complex world face many more challenges than were common for American youth a generation or more ago. According to the February 2023 report from the Centers for Disease Control and Prevention (CDC), based on its biennial Youth and Behavior Risk Survey System (YBRSS), many important measures of teenagers’ mental health have declined significantly in recent years, especially among females and LGBQ+ persons. (LGBQ+ is the term used in the report in presenting survey data. Gender identity—the “T” for “trans”—was not a survey question, although the full acronym LGBTQ+ is used to highlight actions for the whole group.)
Why is this decline in mental health happening? And what can be done to help these suffering students? This commentary highlights key findings, discusses the proposed causes, and provides some suggestions for responding to this crisis. The first step, however, is recognizing that it is indeed a crisis.
Data from the CDC Report
The 89-page report is based on data collected by the CDC’s Division of Adolescent and School Health from a nationally representative group of high school students in fall 2021, with comparisons to the 2011 survey. In 2021 the national YRBSS included three new measures: school connectedness, parental monitoring, and unstable housing.
The good news: responses to some questions in the survey improved, including declines in reported risky sexual behavior (defined in part as having four or more lifetime sexual partners), drug use (defined in part as ever misusing prescription drugs), and being bullied at school. And 61 percent of high school students felt close to people at school, and 86 percent said that their parents or other adults in their family knew most of the time or always who they were with and where they were going. The CDC concluded, however: “Unfortunately, almost all other indicators of health and well-being—including protective sexual behavior (i.e., condom use, STD, and HIV testing), experiences of violence, mental health (feeling sad and hopeless), and suicidal thoughts and behaviors worsened significantly.”
Some key data points from the report:
Reasons for the Decline in Mental Health
There is no single overriding cause for the stark declines in mental health reported by students in 2021, the first YBRSS survey conducted after the COVID-19 pandemic began. COVID has clearly been a contributing factor, as school closings or lockdowns isolated teenagers from their usual routines, friends, teachers, and other sources of support. Other studies have also found a decrease in educational achievement during this time.
But COVID was not the only factor. The opioid epidemic, especially the shift from prescription drugs to street drugs, often mixed with fentanyl, has been a major source of trauma for many teens, who have seen a family member deteriorate and possibly overdose and die from opioid use. Some unknown number of teens, particularly females, have been recruited as caregivers in these epidemics, filling in for ill or employed parents who had been taking care of chronically ill grandparents or younger children in the family.
Technology is frequently cited as a major cause of teenage angst, particularly by people who blame parents, the information environment (social media or cell phones) in general, or as tools of their political opponents. In a New York Times Opinion essay, Michelle Goldberg warns against political interpretations that blame either Trumpism or “woke” protests. She found that the point at which sadness began to increase rapidly was not 2016 when Trump was elected or 2020 when COVID spread rapidly, but 2012. That was the year the Sandy Hook school shooting took place, when Facebook began to include Instagram posts, and the word “selfie” was coined. Goldberg says, “Social media didn’t just cut into offline socializing. It precipitated a revolution in consciousness, in which people are constantly packaging themselves for public consumption and seeing their popularity and the popularity of others quantified.”
Fear of violence in person or online, or random violence in the school or community, has only increased since Sandy Hook. Not that long ago providing a “safe space” meant encouraging open communication of opinions and questions. Now a “safe space” is sometimes literally where a child or teenager can hide from intruders wielding guns or knives.
Other key questions have, to my knowledge, not been raised. With so much sexual violence reported in the survey, what happens when a rape results in a pregnancy? The availability of safe abortions is no longer standard health care (although it remains so for now in states like New York). How many of the suicide attempts or hopeless thoughts were related to rape or its aftermath? What is the impact on mental health of teens with gender identity questions of legislation to prevent medical treatment?
Stigma surrounding mental health, drug use, and other risky behaviors is still strong, perhaps even stronger because of the tendency to blame the victim for behavior contributing to the drug use or assault. Why is so much attention given to changing female behavior to reduce sexual violence instead of focusing on the male perpetrators who see power to control females as acceptable masculine behavior?
Proposed Solutions
The problem has deep roots and touches some of the most sensitive areas that arise in adolescence. There is no single solution. The CDC report is a good place to start, to stimulate discussion, innovation, and further research. Another study, published in April 2023 in the Milbank Quarterly, noted a divergence between positive social indicators for adolescent health—such as high school graduation and food insecurity—and worsening subjective indicators of mental health, and called for “significant investments in population-level data systems to support a more holistic, child-centric, and up-to-date understanding of young people's lives.”
The CDC report stressed that school programs are essential in supporting students. Schools are teenagers’ usual environment; they have (or should have) trusted contacts among teachers and counsellors; and their friends are exposed to the same experiences. The CDC supports school programs and has resources such as “What Works in Schools” to help leaders develop programs. The programs aim to provide quality health education, links to needed services in the community, and improving connectedness in schools.
While this approach has clear merit, it cannot do the whole job. Teachers, to take one example, are also in a period of transition from various types of COVID protection to more open settings. They must readjust to help students make up for the educational ground lost in the past few years. School administrators, personnel, and boards—not to mention parents—want this to happen successfully so that youngsters overcome their lagging test scores.
Underlying stigma is a complicating factor in any educational effort to combat mental health problems related to sex, drugs, or violence. Many teachers need training and guidance to be the supporting adults the CDC report envisions. This is especially significant in the interactions with LGBTQ+ students and their families, who may be at different stages of understanding and acceptance of their child’s identity.
Cooperation with community agencies that deal with students in any of these situations can become a source of support for everyone. Many agency staff have the lived experience of dealing with mental health and behavioral issues as well as the passion to make the world a better place for their younger counterparts.
Parents and other family members must be part of the solution. They can be partners in learning about mental health as well as contributing to a safe environment. And we can’t forget to include teenagers themselves in the solutions. Christina Diep, 18, profiled in an NBC News report, joined a chapter of the National Alliance on Mental Illness at her high school in Villa Park, California, during her sophomore year and continued to attend meetings virtually during the pandemic. Diep, who recently graduated, said she’s proud of the club she helped foster, which gives students a space to talk about their emotions, educate one another, and spread awareness about broader mental health issues. “People are more open to sharing their stories” in such groups, Diep said, “and they know out there, someone is struggling — or was struggling — just like you.”
The teen mental health crisis in the U.S. is daunting and pervasive, cutting across many issue areas and demographic groups. The CDC report and the data it represents are an important milestone and an invaluable opportunity to chart a compassionate and life-saving path forward.
Carol Levine is a senior fellow at United Hospital Fund and former director of UHF’s Families and Health Care Project.