For months, pediatricians and mental health experts have suspected that COVID-19 has had a significant negative impact on mental health for young people, especially adolescents.

Now a new study by the Centers for Disease Control and Prevention (CDC) suggests their fears may be well justified, particularly for adolescent girls. Researchers found that emergency room visits for suspected suicide attempts by adolescents have steadily increased throughout the pandemic, and the increase was most pronounced among girls ages 12-17.

At the same time, experts hasten to note, this doesn’t mean that deaths by suicide have actually increased. In fact, some data suggest otherwise. But the distress young people are experiencing is clear.

Researchers analyzed trends in emergency department visits between Jan. 1, 2019, and May 15, 2021, from the National Syndromic Surveillance Program, which included data from 71% of the country’s emergency departments. Compared with 2019, young people between 12 and 25 made fewer visits to emergency departments for suspected suicide attempts during the first two months of the pandemic (March and April of 2020), but by early May 2020, visits had begun to increase among adolescents ages 12 to 17, especially for girls. Between July and August, the average weekly number of ED visits for suspected suicide attempts for girls ages 12 to 17 was 26.2% higher than a year earlier. Weekly averages for February and March 2021 in this group were 51% higher than during the same months in 2019.

Philadelphia physicians were not surprised at the findings, noting that even before the pandemic, mental health issues among children were rising, and that trend likely was only exacerbated by COVID-19 lockdowns, isolation, and fear.

“We’ve seen significant increases in our volume of patients coming in for mental health reasons over the last year, by about 30%,” said Tami Benton, the psychiatrist-in-chief and executive director of the department of child and adolescent psychiatry at the Children’s Hospital of Philadelphia (CHOP). “There’s been a 24% increase for kids under 12 presenting with mental health symptoms. More kids have made attempts, and are expressing suicidality. It’s contributing to the increase in the number of kids we are recommending for residential treatment.”

Boys ages 12 to 17 reported a 3.7% increase in weekly average number of emergency department visits for suspected suicide attempts between February-March 2019 and February-March 2021. The reason for this discrepancy could be because girls are more likely than boys to self-report suicide attempts, researchers suggested.

The trend of increasing suicide attempts among teenage girls is “consistent with what was happening before the pandemic,” said Leah Orchinik, a pediatric psychologist at Nemours Alfred I. duPont Hospital for Children.

“Parents are more likely to be asking girls how they’re doing, knowing they have higher rates in general,” Orchinik said. “Plus, the way that boys and girls interact with peer groups are different. In my practice, teen boys are socializing virtually and doing a lot of online gaming. That may not have felt as drastically isolating as it did for girls.”

Early estimates from the CDC — which may fluctuate as records are updated — show a slight decrease in the suicide mortality rate nationwide across all ages between 2019 and 2020. Similarly, in Pennsylvania, for the months of July through September, the rate slid from 14.7 to 13 suicide deaths per 100,000 between 2019 and 2020.

Prior to the pandemic, data showed that suicide deaths in the 10-24 age group were increasing at a rate that outpaced the overall suicide death rate in Pennsylvania. Between 2007-2009 and 2017-2019, the suicide death rate increased by 29% overall, but by 52% among 10-24 year-olds. Women had lower death rates than men, but females ages 10 to 19 saw one of the largest increases, a 113% jump from 1.7 to 3.7 per 100,000. Rates among males in the same age range increased by 49% from 5.7 to 8.5.

The new CDC findings reinforce the need for more mental health services. Many emergency departments lack adequate crisis management resources for children and teens, said Susan Tellone, the clinical director of the Society for the Prevention of Teen Suicide. Crisis centers and hospitals in the Philadelphia area struggle to find beds in pediatric psychiatry wards for patients. For instance, at Abington Hospital-Jefferson Health, the average wait for a bed doubled from 100 hours in March 2020 to just under 200 hours by the end of the year.

“It’s very concerning,” Tellone said. “Our kids have been under enormous amounts of stress and uncertainty. And emergency rooms can be an incredibly stressful time for the family … it’s not necessarily the best place for the child. We’re concerned that when some kids finally do discuss that they’re feeling suicidal, and they end up in the ED, and it’s traumatic, they may not ask for help again.”

The Society for the Prevention of Teen Suicide has been working to educate parents on what warning signs for worsening mental health may look like for teens, Tellone said. By identifying those sooner, parents can get their teens help before they experience a mental health crisis.

Some of those signs might be if a child is “withdrawing from activities they used to love” or having anger outbursts, Tellone said.

“Know your baselines,” she said. “If they were a happy child and all of a sudden they’re not smiling, or if they were talkative and now they’re not, parents are the ones who can know that and talk to them about it. It’s also important to pay attention to what they’re saying … oftentimes they don’t say, ‘I’m feeling suicidal.’ They say things like, ‘I can’t do this anymore,’ or ‘No one would miss me if I was gone.’ ”

Benton said that increasing screenings at schools and primary care practices can help as well. CHOP has been working with schools ahead of the fall semester to develop an assessment to identify those most at risk for mental health crises. Those who need more help will be referred to CHOP behavioral care specialists. Benton is hoping this proactive approach will help more families and schools receive information and support.

“Contrary to popular belief, they’re not hiding it,” she said of young people suffering with mental health issues. “It’s the prolonged stress … there’s been at least a twofold increase [in anxiety and depression]. We’re going to have to prepare ourselves to address that.”

It’s impossible to know what the pandemic’s impact on mental health will look like in the long run, Orchinik said. But doctors — and parents — already know that transitions of all kinds are challenging, and now is the time to prepare for mental health concerns that may emerge as children and teens return to school.

“We don’t have a template for what this is going to look like, or how to handle it,” Orchinik said. “But we have a lot of great resources. Everyone should be listening to kids and looking for any risk factors and signs. We should be reporting those and talking about them.”

If you or someone you know is thinking of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text TALK to the Crisis Text Line at 741741.