key: cord-0821298-n860fer4
authors: Hertz, Marci F.; Kilmer, Greta; Verlenden, Jorge; Liddon, Nicole; Rasberry, Catherine N.; Barrios, Lisa C.; Ethier, Kathleen A.
title: Adolescent Mental Health, Connectedness, and Mode of School Instruction During COVID-19
date: 2021-10-22
journal: J Adolesc Health
DOI: 10.1016/j.jadohealth.2021.10.021
sha: 0637de69ca5d156a78f5e07cf94bbd486ed5644b
doc_id: 821298
cord_uid: n860fer4

BACKGROUND: Since COVID-19 was declared a pandemic in March 2020, nearly 93% of US students engaged in some distance learning. These school disruptions may negatively influence adolescent mental health. Protective factors, like feeling connected to family or school may demonstrate a buffering effect, potentially moderating negative mental health outcomes. The purpose of the study was to test our hypothesis that mode of school instruction influences mental health and determine if school and family connectedness attenuates these relationships. METHODS: The COVID Experiences Survey was administered online or via telephone October –November 2020 to adolescents ages 13-19 using NORC’s AmeriSpeak Panel, a probability-based panel recruited using random address-based sampling with mail and telephone non-response follow-up. The final sample included 567 adolescents in grades 7-12 who received virtual, in person, or combined instruction. Unadjusted and adjusted associations among four mental health outcomes and instruction mode were measured, and associations with school and family connectedness were explored for protective effects. RESULTS: Students attending school virtually reported poorer mental health than students attending in-person. Adolescents receiving virtual instruction reported more mentally unhealthy days, more persistent symptoms of depression, and a greater likelihood of seriously considering attempting suicide than students in other modes of instruction. After demographic adjustments school and family connectedness each mitigated the association between virtual vs. in-person instruction for all four mental health indicators. CONCLUSION: As hypothesized, mode of school instruction was associated with mental health outcomes, with adolescents receiving in-person instruction reporting the lowest prevalence of negative mental health indicators. School and family connectedness may play a critical role in buffering negative mental health outcomes.

predicted by COVID-19 related worries, online learning difficulties, and increased conflict with 84 parents, and were reduced by feeling socially connected, defined as feeling connected to those 85 close to them, and society more broadly. The second study, conducted in China with baseline 86 collection in November 2019 (pre-pandemic) and follow-up data collection six months later 87 during the pandemic, found significant increases in non-suicidal self-injury, and suicidal 88 ideation, plans, and attempts. 10

In pre-pandemic research, protective factors, like feeling connected to family or school, have 90 demonstrated a buffering effect and moderated negative mental health outcomes, such as 91 depression and anxiety 11 and may present opportunities for building resilience during and 92 following the COVID-19 pandemic. School connectedness has been defined in a myriad of ways, 93 but generally includes the sub-constructs of student academic engagement; sense of belonging 94 and fairness; engagement in school activities; positive peer relations; feeling safe at school; and, 95 feeling supported by teachers. 12 Family connectedness, or feeling loved, cared for, valued, and 96 respected by one's parents or caregivers, is also critically important, and is similarly associated 97 with buffering against poor mental health. Youth who report feeling close to their parents are less 98 likely to experience depressive symptoms, suicidal ideation, non-suicidal self-injury, and 99 conduct problems. 13 Research has demonstrated the long-term benefits of both school and family Methods: 135 The COVID Experiences (CovEx) nationwide survey was administered online or via telephone 136 October 16-November 6, 2020, to adolescents ages 13-19 using NORC's AmeriSpeak Panel, a Measures: Four indicators of mental health challenges were assessed: 1) stress levels in four 165 areas (at school, home, work, and with friends) given response options low/moderate/high/very 166 high; responses were coded for high or very high stress in at least one area (hereafter "high/very 167 high stress"); 2) mental health-related quality of life, assessed by number of the past 14 days 168 (response options: 0, 1 or 2, 3 to 6, 7 to 14) with mental health not good, dichotomized with a 169 cutoff score of ≥7 days (hereafter, ≥7 days not good mental health); 3) seriously considering 170 attempting suicide (hereafter, considering suicide) in the past 12 months (response options: 171 yes/no); and, 4) persistent symptoms of depression over the past two weeks, assessed by the 9-172 item adolescent PHQ-9, 18 with students experiencing ≥3 symptoms on more than half of the past 173 14 days (response options: 0, 1 or 2, 3 to 6, 7 to 14) considered to have persistent symptoms of depression (hereafter, persistent symptoms of depression). Links to mental health resources and a toll-free national suicide prevention hotline were provided to all respondents.

Scales were used to assess both school connectedness and family connectedness. School Hispanic students (69.0%) compared to White students (48.1%). Table 1 . 207 All four mental health indicators were associated with mode of instruction (Table 2) . Students in 208 virtual learning were more likely than students attending school in-person to report high or very 209 high stress (44.7% vs. 25.0%). Students in virtual learning more frequently reported negative 210 mental health risk on three indicators than students receiving combined or in-person instruction: 211 ≥7 days not good mental health (14.5%, 7.6%, and 3.9%, respectively); considering suicide 212 (13.5%, 8.4%, and 3.8%, respectively); and persistent symptoms of depression (19.1%, 15.3%, 213 and 7.6%, respectively). When continuous variables for school and family connectedness were 214 dichotomized (lowest quartile compared to the three upper quartiles), low school connectedness 215 was more common for students attending virtually than those receiving combined or in-person 216 instruction (34.8%, 19.1%, and 13.3%, respectively) and the association was statistically 217 significant (p=0.006). Reported levels of family connectedness did not vary significantly by 218 mode of school instruction (27.4%, 21.2%, 17.6%, respectively) (p=0.212).

As shown in Model 1 (Table 3) , adjusting for demographics, students receiving virtual 220 instruction were more likely than those in-person to report: stress/high stress (aPR 1.78; CI 1.26-221 2.53); ≥7 days mental health not good (aPR 4.13; CI 1.61-10.55); seriously considering suicide 222 (aPR 3.52; CI 1.41-8.79); and persistent symptoms of depression (aPR 2.58; CI 1.13-5.88).

School connectedness (Model 2) and family connectedness (Model 3) ( Table 3) However, the need for mental health support resulting from the collective experience of COVID-296 19 32 for many students is so pervasive that services alone are necessary, but not sufficient, to 297 promote recovery and well-being. 33 School connectedness represents a public health approach to 298 mental health promotion 34 because of its potential to impact many students simultaneously and 299 evidence of its relationship to promoting positive student mental health outcomes and buffering were not able to assess the relationship between other school level characteristics (e.g., school 326 size, class-size, teacher-student ratio) and student mental health. Additional research exploring 327 school level characteristics that might influence school connectedness and student mental health 328 would be informative for educational policies and practices. incentivized, English-language survey. Second, self-reports are subject to social desirability and recall biases. Third, adolescents did not report the duration of in-person or virtual instruction or 335 whether they had a choice in instruction method. Fourth, the study did not adjust for all potential 336 confounders such as community COVID-19 transmission levels, some household characteristics 337 (e.g., urbanicity or rurality), and prior mental health status. Finally, neither causality nor 338 directionality (e.g., it is possible students with poor mental health were more likely to choose 339 virtual or hybrid instruction) between instruction mode and indicators can be inferred from this 

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