Child and Youth Mental Health in Canada — Dr. Nicholas Chadi

This episode discusses suicide and self-inflicted wounds and may be upsetting to some listeners. You can get help at any time by calling 911 or your local emergency response centre. Please bear in mind that the opinions and comments of our guests do not necessarily reflect those of the Canadian Institute for Health Information.

Alya Niang

Hello and welcome to the Canadian Health Information Podcast. This is Alya Niang and I’m delighted to be back with you for the second episode from the Canadian Institute for Health Information, better known as CIHI. We analyze Canada’s health care systems and policies in depth by looking beyond the data and talking to experts, health care workers and patients. We will also discuss efforts to keep Canadians healthy.

In today’s podcast, we look at the effects of the pandemic on children and youths. While it is true that children are less likely to get sick from the coronavirus itself, the data shows us that the stressors associated with the pandemic, such as school closures, isolation and lack of family and friend gatherings, have had a negative impact on the mental health of children and youths. We will look at the numbers and how these disruptions have affected the children, their parents as well as the health care system, if these disruptions are just temporary or if there are ways to turn things around. With me is Dr. Nicholas Chadi, a pediatrician and clinical researcher.

Dr. Nicholas Chadi

I am a pediatrician and clinical researcher specializing in adolescent medicine and substance abuse. I have been working at the CHU Sainte-Justine for 3 years now in this role. In my practice, I specialize in the care of adolescents for different mental health issues, including eating disorders, gender diversity issues and various depressive or anxiety disorders linked to substance abuse. So, my research interests really revolve around these questions and I was very much solicited in the context of the COVID-19 pandemic, seeing a great increase in consultation requests at the CHU Sainte-Justine. I also took advantage of this opportunity to look into certain questions related to the mental health of adolescents.

Alya Niang

Hello, Dr. Chadi. How are you doing?

Dr. Nicholas Chadi

I’m doing well, thank you.

Alya Niang

So, we are dealing with a rather sensitive subject. Before I get into that, let me tell you a personal story. I had a baby at the beginning of the pandemic, and I had planned to spend my maternity leave out of the country to have help from my family, but I was not able to travel and was cut off from the world with a newborn. We know that this is a time when we need to be surrounded by loved ones. I went through a pretty tough time for 6 months, but my ability to reason and accept certain situations as an adult helped me get through it. I can’t imagine the state of mind of the children who have not yet achieved these abilities, how the pandemic may have affected them. It must have been really difficult. Let’s get to the point, Dr. Chadi.

A recent CIHI analysis shows that the pandemic has greatly affected the mental health of children and youths and that hospitalizations and emergency room visits have increased significantly. How is this possible?

Dr. Nicholas Chadi

Well, that question is actually very broad. As we know, for adults, children and teenagers, the pandemic has been a huge change and a great trauma for some. What we saw at the very beginning of the pandemic was that people stayed home a lot, kept  to themselves and avoided going to the emergency room. After a few months of lockdown, there was really an explosion in mental health–related emergency department visits. I think there are several factors that could help explain this. Children and teenagers get a lot of support at school. Socialization, contact with peers and extracurricular activities are very important for mental health and for maintaining a good balance, but all that has been completely disrupted by the pandemic. Add to that the stress to families, the uncertainty, the fear of being contaminated, the stress of a parent or a loved one falling ill and bad news in the media which can be very anxiety-provoking for many people.

So all of these things together, along with important lifestyle changes, may have caused an increase in distress. Also, several of the means that are normally available to help support youths were no longer available. We’re talking about educators, social workers and psychologists in schools who were available less or in a different way. Hospitals and emergency rooms became a key place, and sometimes the only place where people, parents and young people could go to get help. We think that several factors led to the increase in emergency department visits during this time, especially the fact that support services were greatly impacted by the pandemic.

Alya Niang

Would you say that school-related changes were a major factor?

Dr. Nicholas Chadi

Absolutely. Some children feel stressed about school, so not being at school may have been a relief initially. But I can tell you from a pediatrician’s perspective that after several months of lockdown and homeschooling, very few kids told me they wanted it to go on. Most said they needed to go back to class and to see their friends. It’s very difficult to maintain a routine and a healthy lifestyle when you’re at home. A lot of parents had to juggle working and taking care of children, which meant that the home environment, especially in smaller or crowded housing for example, could become quite difficult and even, at times, conducive to mental health issues.

We can also add to that the increased amount of screen time. Many children and teenagers increased their use of screen time, obviously to socialize, to keep in touch with their friends and to access their classes, but also to access certain social media and video games that could, in large amounts, have a potentially negative impact on their health and their general well-being.

Alya Niang

The same analysis shows that emergency room visits and hospitalizations for eating disorders increased in 2020, in particular among young women age 10 to 17 years. Can you explain this increase?

Dr. Nicholas Chadi

Absolutely. As a pediatrician specializing in adolescent medicine at the eating-disorder unit at CHU Sainte-Justine, I witnessed this increase first-hand. Hospitalization rates have doubled and even tripled during the pandemic, and there are several factors that can explain that. Among other things, as I mentioned earlier, spending a lot of time on social media can lead young people to feeling self-conscious and comparing themselves with others. Social media can convey to unattainable standards in terms of body image, beauty and weight, which may have been a trigger for many young people.

Because of this disruption in education, support systems and regular activities, some young people found themselves alone with more time to think about their bodies and their food intake. As a result, many tried to make changes like going on diets to lose weight, and lost control.

So, there are a number of factors that I think came into play. If community services, school supports, clinics, activities and community resources become scarce or hard to access, emergency rooms and hospitals become the place to go for care. Many young people went to the hospital with significant weight loss, which required them to be hospitalized in order to receive immediate help for their eating disorders. Why girls more than boys? This is something we are still trying to investigate. In general, eating disorders are more common in young girls than in young boys. Still, about 10% of teenage eating disorders affect boys. So it's not just girls, but the increase has been greater during the pandemic. Have girls been more affected by the different changes related to the pandemic? It is possible. Could it also be because girls seek help more than boys? There are many questions that remain to be answered, but the fact remains that this increase has been more pronounced in girls than in boys at Sainte-Justine.

Alya Niang

It is also apparent that the rate of medication use has increased over time, particularly among girls, who had the highest rates of mood and anxiety disorders. Why is this?

Dr. Nicholas Chadi

You mention an issue that is somewhat parallel to all of this. We're talking about an increase in emergency room visits and cries for help. We have also seen an increase in the rate of prescriptions of antidepressant medications among adolescents. It is very difficult right now across Canada to access psychological services, whether it's psychologists, social workers or specialized educators. It is very difficult. There are long waiting lists and given that many young people are experiencing an increase in distress and anxiety symptoms, it’s urgent that we focus our action on them. Parents want to know what they can do to help their kids. In some cases, it is easier or more accessible to go to the doctor. Medication can be prescribed without therapy if desired. Prescribing medication is not always necessary, but it can help alleviate symptoms of anxiety and depression under the circumstances, namely an increase in the rates of anxiety and depression disorders in young people, the lack of services and support, and the disruption in teenagers’ routines. All of these circumstances may have led to an increased rate of prescriptions for antidepressants among young people and especially among young girls.

This is definitely something that will be monitored in the coming years, so we can check if the young people who are prescribed these medications receive all the additional help they need, like psychological support, follow-ups, etc.

Alya Niang

The data also shows that the overall rate of mental health–related emergency room visits and hospitalizations was higher in children and youths living in low-income neighbourhoods. However, this pattern was reversed for eating disorders, with hospitalization rates increasing in higher-income neighbourhoods. Dr. Chadi, can you explain the link between mental health and where and how we live?

Dr. Nicholas Chadi

Mental health is obviously very complex and depends on many things. There are risk factors that can create a predisposition to mental health problems. Among these, we know that certain factors like poverty, less access to healthy food, unsanitary housing, experiencing adversity, being a victim of violence, for example, and being in contact with people or family members who have mental health or substance abuse problems can increase the rates of mental disorders. And that’s true regardless of whether we are in a pandemic or not. Why some people develop mental health disorders is a very complex question. It can depend on biological factors, which can be passed down from generation to generation; social and environmental factors; influences; lifestyle habits; and the different challenges experienced during one’s life.

Differences between socio-economic groups in relation to emergency room visits and access to services have been noted by various studies. Of course, the study you are referring to shows a higher number of visits in lower socio-economic groups. These findings are not consistent for all studies or mental health conditions. We know that certain mental health issues may be more prevalent in certain groups. We still see a lot of eating disorders in higher socio-economic categories as well. Then there is also the question of being able to access care. For people of lower socio-economic status, who may not have access to as many resources, a visit to the hospital or the emergency department, which is free, is the first solution. In contrast, people of higher socio-economic status may have access to more options, such as the private sector or other resources that are not available to all Canadians.

I think the question of how socio-economic status influences our mental health is a very complex one. We know that people of lower socio-economic status are more at risk of developing mental health problems and this can be further exacerbated in challenging times or during a pandemic, for example, where we lose the support systems that make it possible for us to maintain good mental health.

Alya Niang

Dr. Chadi, during the peak of the pandemic, how did you help your staff, both remote and frontline, through this really difficult time?

Dr. Nicholas Chadi

That’s a good question. The pandemic has been difficult for everyone, both for patients and caregivers. We had to increase the volume of medical consultations both at the hospital and at the clinic. We had to take care of ourselves, we had to find innovative solutions to continue to provide care without being overworked. One of the things we have been able to do is to introduce telemedicine and virtual care for certain patients and families who need it. Virtual consultations enable us to provide care to those who need it, while allowing more flexibility in terms of staff. So, there are advantages for physicians and health care professionals to be able to provide care both in person and virtually. More specifically, we had to think about which services we can offer at the hospital and how we should prioritize the increased demand. We also tried to expand our team and asked for support from our colleagues who are not necessarily specialized in mental health, but who have some training, like general pediatricians and family physicians. While they are not psychiatrists or experts in adolescent medicine like myself, they can help support young people who suffer from ongoing psychological distress and mental health issues because of the pandemic. Despite the fact that restrictions are being lifted and that we are getting back to a certain normality, the number of consultations for mental health issues is still higher than the pre-pandemic levels.

Alya Niang

How have you managed to keep your feet on the ground and maintain your own mental health?

Dr. Nicholas Chadi

It was certainly difficult. The fear of getting COVID and having to take time off from work was stressful for both me and my colleagues, knowing that our team was already weakened by the increased demand. But I think everyone found ways to self-care, whether it was taking time away from work, maintaining a balance, trying to stay active, making time for sleep and despite everything, trying to enjoy the little pleasures in life, and what was still accessible and open during the pandemic. Personally, I find that mindfulness meditation allows me to really be present in the moment and to accept what is happening, whether by doing short breathing or meditative exercises, or by being active throughout the day. It allowed me, among other things, to stay centred and to remain focused on the challenges, but also on the positive things that happened during the pandemic.

Alya Niang

Dr. Chadi, let's talk a bit about your article: “Mental Health–Related Emergency Department Visits in Adolescents Before and During the COVID-19 Pandemic: A Multicentric Retrospective Study.” Can you share with us a brief summary and some of the key findings of your research?

Dr. Nicholas Chadi

Certainly. So, as I mentioned, I am a pediatrician at Sainte-Justine Hospital in Montréal, which is one of the 2 largest pediatric centres in Quebec. At the beginning of the pandemic, there seemed to be an initial decrease in mental health–related emergency department visits in adolescents, but the situation quickly changed in mid-2020, a few months after the pandemic began. After talking with some of the emergency physicians who witnessed this increase first-hand, some of my colleagues and I decided we would like to have a clearer picture of the exact number of visits. Using data from Sainte-Justine Hospital and the Montreal Children’s Hospital, we compared hospital visits between the 2018–2019 pre-pandemic period and 2020. First, we wanted to know if there was a difference in the total rate of hospital visits related to mental health during both periods, and second, if there was a greater overall number of mental health–related visits after the pandemic versus before. We saw a clear increase in the rate of mental health–related emergency department visits. In terms of eating disorders, we saw an increase in the rate of visits, but also a significant surge in the overall number of visits: 60% more in 2020 versus the average for the 2018 and 2019 period. These numbers have been found in other studies, and have continued to rise beyond 2020.

This first study mainly looked at what was happening in the first months of the pandemic. Was it just an impression, or were more teens in fact using mental health–related services? But this increased rate wasn’t linked only to eating disorders. We also witnessed a surge in suicidal thoughts, anxiety disorders and depressive issues in 2 important pediatric centres in Quebec.

Alya Niang

You might say that the pandemic has really had a negative impact on children and youths.

Dr. Nicholas Chadi

Certainly. I am part of a group of researchers at the Observatoire pour l’éducation et la santé des enfants, based in Quebec, which is looking to determine what the short- and medium-term impacts of the pandemic are on the health, education and well-being of children. So, I continue to work on these issues with several colleagues. There are several research projects underway which demonstrate beyond doubt that several aspects relating to the health, well-being and development of children have been affected during the pandemic. These studies also highlight the opportunity to find innovative solutions to improve these components of health in the context of the pandemic, but also for years and for generations to come.

Alya Niang

That brings me to my next question. Are there any other initiatives being considered in this regard?

Dr. Nicholas Chadi

Yes, of course. In fact, I can tell you that we have completed a second analysis of emergency department visits, and this one should be published very soon. It compares visit-related data at the CHU Sainte-Justine from 2016 up to 2021. This time, using gender- and socio-economic–specific analysis, we were able to confirm that the number of emergency department visits was in fact higher among teenage girls. My colleagues and I will continue to analyze emergency department visits data to see how it evolves. I also take part in other studies in Quebec that focus on hospitalizations. It’s something that is of great interest for policy-makers, researchers and key stakeholders, meaning youths and families, who want to know what’s going to happen in the future. Will the rate of mental health issues remain high or will it return to its pre-pandemic level? In hindsight, mental health–related hospitalizations, problems and diagnoses among teens have been on the rise not only since the pandemic, but for the last 10 or 20 years. The increase in the number of mental health issues predates the pandemic.

So, it is important that we find sustainable solutions. Of course, the pandemic weakened our health care system, but it also highlighted the weaknesses that were already there. We need to think about how we can invest, change, improve and enhance our systems and services to better support youths. These are all questions of great interest to me, and I am part of several groups of researchers, collaborators and clinicians who are trying to work in this direction.

Alya Niang

Dr. Chadi, the question is, if children have mental health problems, will it affect them as adults? Are there any long-term consequences?

Dr. Nicholas Chadi

This is a very important question. We know that a large portion of mental health disorders begin in adolescence. Very often, when someone develops a mood disorder, an anxiety disorder or an eating disorder during the course of their life, there were early warning signs, or the disorders began during adolescence. In some cases, the problem will be short-lived. We will succeed in treating it, and the person will be able to have a fulfilling life. In other cases, the disease will be long-term, or the person will have relapses. There is no doubt in my mind that having mental health issues during adolescence, which is a time when the brain is developing, when we’re learning to grow, when we’re learning about ourselves, can have long-term effects, especially if it affects the way we function.

For example, if a person with a mental health issue misses school or has prolonged difficulties at school, lacks motivation and energy and experiences stress levels so great that their day to day is impaired, this can have an impact on their career path and possibly on their well-being and development. Adolescence is certainly an important period, because teenagers grow quickly and their brain creates the base for the rest of their life. The brain continues its maturation process until about our mid-twenties. So there can certainly be long-term repercussions, which is why it is important to prevent mental health problems, to try to treat them early when they are diagnosed and to offer support during adolescence and early adulthood, to ensure that we can function at our full potential and then eventually return to an optimal level of health.

Alya Niang

It can be said, then, that early management and appropriate support during this phase are key elements that can lead to a full recovery?

Dr. Nicholas Chadi

I think so. I think there are some kids who will bounce back very quickly, who will show resilience. And sometimes it’s also related to protective factors: if you’re getting support from your family and from the community and if you have access to certain resources, this can help you bounce back quickly. In some cases, no matter how much treatment is offered, the issue can continue for a prolonged period. Mental health issues can be difficult to deal with, but if they are treated quickly and if care is provided in a timely matter, we can improve the chances of a person regaining their health and becoming fully functional. So there are benefits there, for sure.

Alya Niang

Dr. Chadi, what is your message to doctors, parents or anyone who cares for a child? What can they do to mitigate the impact of the pandemic on children’s mental health and well-being? Do you think things will get better as the global pandemic subsides?

Dr. Nicholas Chadi

I do believe that things will get better. I am hopeful in that regard. I think the pandemic made us realize a lot of things, for example that we need to better support children and teens in terms of mental health, and I think some innovative solutions have been put forward. For example, the use of virtual services to provide care for those who live in remote areas or who have mobility issues brings us new possibilities.

To my fellow physicians and health care workers, I would like to say thank you for your contributions over the past few years. Don’t get discouraged, because it’s very important to support our young people. I think we can expect an improvement once we get back to normality and doing things that make us feel good.

For parents, community members and educators, I think an important message would be to keep an eye out for mental health issues. Try to ask questions, be curious about how kids and teens are doing, ask them in different ways how they are feeling, ask them if they need help or support, and show them you care. As I mentioned earlier, one thing that helps teens be healthier is to have a routine and a balanced life. This can include getting enough sleep, eating healthy and socializing. When you’re a parent or a teacher, it’s great to be able to offer those things to kids. When we notice issues, it’s important to recognize them early on and to seek help, whether from professionals, from resources in the community, from other family members or siblings.

I think being more aware of mental health issues is key. The pandemic clearly brought a focus on child and adolescent mental health. Many people have sounded the alarm, and I hope that we will continue to invest, to make efforts, to do research and to improve our services and systems to continue supporting children and teens in the years to come.

Alya Niang

Could we say, then, that proper guidance and being involved in all aspects of our children’s lives could help to avoid these problems?

Dr. Nicholas Chadi

Absolutely. Providing an environment that allows a person to grow requires certain boundaries or frameworks. Teenagers often want to test the limits. Sometimes they’ll be met with resistance. But frameworks allow us to meet their needs while promoting growth and all aspects of their health, whether physical or psychological.

Alya Niang

Do you have any final thoughts, Dr. Chadi?

Dr. Nicholas Chadi

We’ve talked about some very complex issues, which have stirred up a lot of emotions lately. I think that society as a whole has experienced a lot of stress because of the pandemic and it will probably leave scars. My hope is that we will be able to build on this and become more resilient. If we ever experience another pandemic or a similar event, we will be more prepared and have better resources and a stronger health system to overcome these crises.

Alya Niang

Thank you, Dr. Chadi, for shedding light on the issues surrounding the mental health of children and youths. It is such a sensitive and important subject. You have made an invaluable contribution to this podcast. Thank you again.

Dr. Nicholas Chadi

Thank you very much. You are most welcome.

Alya Niang

What we heard today was very concerning and we all believe that children and youth are the leaders of tomorrow. Thank you for listening, and hopefully this will spark a discussion about what we can and should do to protect the mental health of our children. Come back next time when we’ll be taking a close look at other interesting health topics. Our executive producer is Jonathan Kuehlein. I also want to thank Aila Goyette. To learn more about CIHI, please visit our website, www.cihi.ca. CIHI stands for Canadian Institute for Health Information. Don’t forget to subscribe to the Health Information Podcast and listen to it on the platform of your choice. Your host, Alya Niang. See you next time.