The anxiety, isolation, and uncertainty brought on by the COVID-19 pandemic has been an unprecedented emotional challenge. Adolescence is a period of drastic emotional, social, and cognitive development, making this age group particularly vulnerable to the short- and long-term impact of the pandemic on mental health. Teen anxiety prevalence has steadily increased over the past several decades. Nearly 1 in 3 teens meet criteria for an anxiety disorder by age 18, and 70% of teens describe anxiety as a major problem for people their age. The growing pervasiveness of teen anxiety is further exacerbated by the pandemic. A recent study showed that many teens are experiencing unusually elevated anxiety symptoms, with average ratings reaching levels seen in anxiety disorders. Ratings were particularly high for panic symptoms, such as difficulty breathing, and negative feelings about the future. Preliminary data from our own Penn State teen anxiety study reinforces this striking pattern of growing anxiety. Compared to pre-COVID-19, anxiety severity among our respondents has increased 29%, largely driven by significantly heightened generalized anxiety (up 45%) and school anxiety (up 143%).
How can we lessen the potentially drastic effects of the pandemic on mental health?
Decades of research suggests that a linchpin between stress, risk, and well-being is emotion regulation (ER), through which we control our emotions, both intentionally and automatically. In times of intense or chronic stress, ER is simultaneously more difficult for anxious teens, and more critical since poor ER contributes to anxiety disorders in development.
What is adaptive emotion regulation?
Certain ER strategies have been more adaptive than others. For instance, reappraisal, which involves thinking about something threatening or unpleasant in a more positive light, buffers against the negative effects of stressors, while relatively maladaptive ER strategies, such as suppression. are associated with mental health difficulties. A recent study showed that greater use of reappraisal to cope with the stress of COVID-19 was linked with greater well-being.
Another aspect of healthy ER is the ability to flexibly shift attention, strategies, and expression of emotion to fit the situation. For example, dysregulated fear in childhood, a mismatched pattern of high fear in low threat contexts, predicts greater social anxiety in adolescence. In adults, following the 9/11 terrorist attacks, a wide-scale event inducing levels of stress and uncertainty comparable to the pandemic, individuals with greater range of emotional expression flexibility showed lower degrees of long-term negative consequences of the event years later. These findings and others suggest that our ability to engage situation-specific, dynamic emotion management has lasting effects on mental health and well-being.
While we often think about our management of emotions as effortful and conscious, we also do so on an automatic, unconscious level. Those habits learned throughout the lifespan, from explicit guidance from parents and everyday emotional experiences, become internalized. For example, the anxiety-related attention bias, or AB, is an automatic attention filter that has been linked with anxiety and represents how, for some people with anxiety, attention is rapidly captured by and sustained to threats in our environment. This attention filter becomes ‘tuned and re-tuned’ based on emotional experiences throughout development, and the COVID-19 pandemic is certainly an emotionally evocative event that could systematically shape biased attention toward threat.
Promoting adaptive ER, and managing the detrimental effects of poor ER, is particularly critical during childhood and adolescence, because the biological foundations of ER abilities are forged in development. ER often requires a great deal of cognitive effort, including abstract thinking, impulse control, and attention shifting, abilities which are limited in adolescence due to neural and physiological maturation. ER developmental changes are driven by neural connections between regions supporting emotion control (e.g. prefrontal cortex) and reactivity (e.g. amygdala). These emotion control regions are the last to mature, with development spanning through adolescence into early adulthood. These neural pathways are ‘plastic’ during this period, with emotional events and ER habits molding and refining the brain, resulting in a heightened vulnerability to the disruptive force of stress. Long-term effects on the pandemic on mental health will be investigated over the coming months and years, but prior research has shown that exposure to chronic stressors during foundational brain development has long-lasting consequences.
COVID-19 pandemic exacerbates ER challenges
Unplug, meditate, exercise, sleep well. As with many recommendations, following these prescriptions is often easier said than done. The same can be said for ER, even under typical circumstances. Despite research showing that strategies like reappraisal are adaptive, real-world observations reveal we may not use them frequently in daily life. When we are faced with an intense or uncontrollable emotional event, we may be less likely to use adaptive, cognitive strategies. Further, when we spend effort and energy on managing emotions, other mental abilities suffer, making impulse control and decision making more difficult.
The widespread anxiety brought on by the pandemic is a double-edged sword. This emotional response realistically reflects the massive threat to global health and increases compliance with safety recommendations. Knowing that others are similarly anxious makes us feel that we are in this together. However, the knowledge that your anxiety is rational, warranted, and necessary, may make ER more difficult than usual. A particular challenge in the transitional period of adolescence is that the future seems confusing, nebulous, and distressing. Intolerance of uncertainty, or difficulty with coping with the impending unknown, is linked with anxiety. In our preliminary findings, 65% of teens reported that they find the pandemic-induced uncertainty about the future to be moderately to extremely stressful.
The pandemic has also limited the repertoire of ER strategies available to teens. Keeping active and busy with enjoyable activities can reduce anxiety, but school closures and recommendations to stay home whenever possible limit these opportunities. Our preliminary data shows that those teens showing a greater increase in anxiety since the onset of COVID-19 report greater use of relatively maladaptive coping strategies including denial (e.g. “I’ve been saying to myself ‘This isn’t real’”), disengagement (e.g. “I’ve been giving up the attempt to cope”), and self-blame (e.g. “I’ve been criticizing myself”), and less use of more positive coping strategies like acceptance (e.g. “I’ve been accepting the reality of the fact that it has happened”). Social distancing may decrease quality and quantity of face-to-face social support options. Indeed, 79% of our respondents selected ‘not seeing friends or family in person’ as the pandemic-related change that has affected their daily life in the most negative way.
There are critical community-based challenges including disproportionate effects for people of color, drastic financial pressures particularly for low income families, and barriers to accessing technological and health resources. As teen’s social and academic world has been forced largely online, reliable internet, mobile devices, and computers with webcams are essential resources to access social engagement and education. But these resources are not readily available to all, widening the divide and further entrenching socio-economic vulnerabilities.
COVID-19 has also placed additional stress on parents, who must manage their own anxiety in addition to balancing financial and health concerns with increased childcare hours due to school closures. A recent study showed that pandemic-related stress was associated with exacerbated internalizing symptoms in children and adolescence, and this link was stronger among lower income and single parent families. Pre-COVID, 35% of teens seeking mental health treatment did so through their schools. With these resources reduced or cut off, teletherapeutic options can provide alternate routes to seek care, but these modalities may be difficult to access by those who are most vulnerable.
Potential Silver Linings in the COVID-19 Storm Cloud
By identifying the positive consequences of the pandemic, however few they may be, we can potentially amplify these benefits. For example, with in-person peer contact limited, digital technologies provide alternative avenues to connect. Unsurprisingly, social media use has grown due to the pandemic, with our data showing a 13% increase in teens’ social media use. Since school closures in March and April 2020, 62% of our respondents said they talk with friends online every day or almost every day, 49% said they use social media to provide support for their friends, and 80% reported that online interactions help them cope with their own stress and anxiety related to COVID-19.
Time will tell whether this technology-mediated contact buffers against stress at the same level of in-person interactions. A particular focus may be what digital modalities provide maximal social-emotional support. Prior work on parental social buffering of stress in teens suggests that text-only interactions may lack physiological benefits, in the form of reduced hormonal stress response. Similarly, pilot data from my recent work showed that neurocognitive ER was bolstered among adolescent peer dyads following video chat, but not text-based interactions, indicating that seeing the faces and hearing the voices of our friends and family may be critical.
More good news is that the impact of school shutdowns has increased adolescents’ sleep duration and quality. Our own preliminary data is consistent with this pattern, with teens reporting a 14% increase in average daily sleep since the onset of the pandemic. Sleep problems have been implicated as precursors of anxiety symptoms, particularly among early and middle adolescents, suggesting that this boost in sleep could protect against some of the negative effects of the pandemic on mental health.
Conclusions and Recommendations
Adolescents’ specific vulnerabilities to the social-emotional consequences of the pandemic warrants targeted strategies to support our teens. A first step is simply acknowledging this vulnerability and giving a voice to those affected by involving teens in the conversation. Initiatives like Brave Teens (wellbeings.org) have done just that by creating a digital community through which teens can share their mental health struggles and triumphs. Researchers and medical experts should develop targeted communication geared towards teens and their parents. Successful ER takes effort, practice, social support, and the ability to acknowledge our regulatory shortcomings. When our attempts to regulate falter, we should forgive ourselves and persevere, resolving to try our best to manage our emotions better next time.
Finally, in our conversations we can highlight ways that anxiety can be healthy. Our anxiety is an evolutionarily adaptive signal that gets us to pay attention to threats and maintain our safety. Research from prior global health crises, like the 2009 H1N1 pandemic, showed that high anxiety was linked with greater likelihood to comply with preventative measures. The continued spread of COVID-19, spanning months after many thought this global event would be over, has taught us that restrictive measures, and honesty about threats to well-being, are the only way to stifle virus spread. We can aim to frame our negative emotions in terms of ‘optimistic anxiety,’ striking a balance between realistic anxiety and hope that diligent adherence to the advice of experts will eventually pay off.