1
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
2021
Protecting
Youth
Mental Health
he U.S. urgeon eneral’s Advisory
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Table of Contents
INTRODUCTION FROM THE SURGEON GENERAL
ABOUT THE ADVISORY
BACKGROUND
WE CAN TAKE ACTION
What Young People Can Do
What Family Members and Caregivers Can Do
What Educators, School Sta, and School Districts Can Do
What Health Care Organizations and Health Professionals Can Do
What Media Organizations, Entertainment Companies, and Journalists Can Do
What Social Media, Video Gaming, and Other Technology Companies Can Do
What Community Organizations Can Do
What Funders and Foundations Can Do
What Employers Can Do
What Federal, State, Local, and Tribal Governments Can Do
Where Additional Research is Needed
CONCLUSION
ACKNOWLEDGMENTS
REFERENCES
3
5
6
12
14
16
19
21
23
25
29
31
33
35
38
40
41
42
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Every child’s path to adulthood—reaching developmental and
emotional milestones, learning healthy social skills, and dealing with
problems—is different and difficult. Many face added challenges
along the way, often beyond their control. ere’s no map, and the
road is never straight.
But the challenges today’s generation of young people face are
unprecedented and uniquely hard to navigate. And the effect these
challenges have had on their mental health is devastating.
Recent national surveys of young people have shown alarming
increases in the prevalence of certain mental health challenges—
in 2019, one in three high school students and half of female
students reported persistent feelings of sadness or hopelessness, an
overall increase of 40% from 2009. We know that mental health is
shaped by many factors, from our genes and brain chemistry to our
relationships with family and friends, neighborhood conditions, and
larger social forces and policies. We also know that, too often, young
people are bombarded with messages through the media and popular
culture that erode their sense of self-worth—telling them they are
not good looking enough, popular enough, smart enough, or rich
enough. at comes as progress on legitimate, and distressing, issues
like climate change, income inequality, racial injustice, the opioid
epidemic, and gun violence feels too slow.
And while technology platforms have improved our lives in
important ways, increasing our ability to build new communities,
deliver resources, and access information, we know that, for many
people, they can also have adverse effects. When not deployed
responsibly and safely, these tools can pit us against each other,
reinforce negative behaviors like bullying and exclusion, and
undermine the safe and supportive environments young people need
and deserve.
Introduction from
the Surgeon General
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
All of that was true even before the COVID-19 pandemic
dramatically altered young peoples’ experiences at home, at school,
and in the community. e pandemic era’s unfathomable number
of deaths, pervasive sense of fear, economic instability, and forced
physical distancing from loved ones, friends, and communities have
exacerbated the unprecedented stresses young people already faced.
It would be a tragedy if we beat back one public health crisis only
to allow another to grow in its place. at’s why I am issuing this
Surgeon General’s Advisory. Mental health challenges in children,
adolescents, and young adults are real, and they are widespread. But
most importantly, they are treatable, and often preventable. is
Advisory shows us how.
To be sure, this isn’t an issue we can fix overnight or with a single
prescription. Ensuring healthy children and families will take an all-of-
society effort, including policy, institutional, and individual changes
in how we view and prioritize mental health. is Advisory provides
actionable recommendations for young people and their families,
schools and health care systems, technology and media companies,
employers, community organizations, and governments alike.
Our obligation to act is not just medical—it’s moral. I believe that,
coming out of the COVID-19 pandemic, we have an unprecedented
opportunity as a country to rebuild in a way that refocuses our
identity and common values, puts people first, and strengthens our
connections to each other.
If we seize this moment, step up for our children and their families
in their moment of need, and lead with inclusion, kindness, and
respect, we can lay the foundation for a healthier, more resilient, and
more fulfilled nation.
Vivek H. Murthy, M.D., M.B.A.
Vice Admiral, U.S. Public Health Service
Surgeon General of the United States
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
A Surgeon General’s Advisory is a public statement that calls the American people’s attention to an urgent
public health issue and provides recommendations for how it should be addressed. Advisories are reserved
for significant public health challenges that need the nation’s immediate awareness and action.
is Advisory offers recommendations for supporting the mental health of children, adolescents, and
young adults. While many of these recommendations apply to individuals, the reality is that people have
widely varying degrees of control over their circumstances. As a result, not all recommendations will be
feasible for everyone.
at’s why systemic change is essential. e Advisory includes essential recommendations for the
institutions that surround young people and shape their day-to-day lives—schools, community
organizations, health care systems, technology companies, media, funders and foundations, employers, and
government. ey all have an important role to play in supporting the mental health of children and youth.
For additional background and to read other Surgeon General’s Advisories, visit SurgeonGeneral.gov.
ABOUT THE ADVISORY
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Youth Mental Health Prior to the
COVID-19 Pandemic
Mental health affects every aspect of our lives: how we feel about ourselves and the world; solve problems,
cope with stress, and overcome challenges; build relationships and connect with others; and perform in
school, at work, and throughout life. Mental health encompasses our emotional, psychological, and social
wellbeing, and is an essential component of overall health.
1
As described in the 1999 Surgeon General’s
Report on Mental Health, it is the “springboard of thinking and communication skills, learning,
emotional growth, resilience and self-esteem.”
2
Mental health challenges can be difficult to define, diagnose, and address, partly because it isn’t always
clear when an issue is serious enough to warrant intervention.
2
All of us, at all ages, occasionally
experience fear, worry, sadness, or distress. In most cases, these symptoms are short-lived and don’t affect
our ability to function. But, at other times, symptoms can cause serious difficulties with daily functioning
and affect our relationships with others, as in the case of conditions such as anxiety disorders, major
depressive disorder, schizophrenia, bipolar disorder, and eating disorders, among others.
3
Mental health conditions can be shaped by biological factors, including genes and brain chemistry,
and environmental factors, including life experiences. Some mental health disorders seem to cluster in
families, but they are often shaped by multiple genes, and whether an individual develops symptoms can
be further modified by their experiences and surrounding environment.
4, 5
Environmental factors can
range from exposure to alcohol or drugs during pregnancy, to birth complications, to discrimination and
racism, to adverse childhood experiences (ACEs) such as abuse, neglect, exposure to community violence,
and living in under-resourced or racially segregated neighborhoods.
6, 7, 8, 9, 10, 11, 12
ACEs can undermine a
child’s sense of safety, stability, bonding, and wellbeing.
13
Moreover, ACEs may lead to the development
of toxic stress. Toxic stress can cause long lasting changes, including disrupting brain development and
increasing the risk for mental health conditions and other health problems such as obesity, heart disease,
and diabetes, both during and beyond childhood as well as for future generations.
12, 14
Biological and environmental factors can also be interrelated, making it difficult to isolate unique “causes”
of mental health challenges. For example, if a child is genetically predisposed to depression, they might
be more affected by experiences such as bullying than other children.
15, 16
Figure 1 (next page) includes a longer list of factors that shape the mental health of young people.
BACKGROUND
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
FIGURE 1
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Even before the COVID-19 pandemic, mental health challenges were the leading cause of disability and
poor life outcomes in young people, with up to 1 in 5 children ages 3 to 17 in the US with a reported
mental, emotional, developmental, or behavioral disorder.
17
In 2016, of the 7.7 million children with
treatable mental health disorder, about half did not receive adequate treatment.
18
Unfortunately, in recent years, national surveys of youth have shown major increases in certain mental
health symptoms, including depressive symptoms and suicidal ideation. From 2009 to 2019, the
proportion of high school students reporting persistent feelings of sadness or hopelessness increased
by 40%; the share seriously considering attempting suicide increased by 36%; and the share creating
a suicide plan increased by 44%.
19
Between 2011 and 2015, youth psychiatric visits to emergency
departments for depression, anxiety, and behavioral challenges increased by 28%.
20
Between 2007 and
2018, suicide rates among youth ages 10-24 in the US increased by 57%.
21
Early estimates from the
National Center for Health Statistics suggest there were tragically more than 6,600 deaths by suicide
among the 10-24 age group in 2020.
22
Scientists have proposed various hypotheses to explain these trends. While some believe that the trends
in reporting of mental health challenges are partly due to young people becoming more willing to openly
discuss mental health concerns,
23
other researchers point to the growing use of digital media,
24, 25, 26
increasing academic pressure,
27, 28, 29
limited access to mental health care,
18, 30
health risk behaviors such as
alcohol and drug use,
31
and broader stressors such as the 2008 financial crisis, rising income inequality,
racism, gun violence, and climate change.
32, 33, 34, 35
It’s also important to acknowledge that the prevalence of mental health challenges varies across
subpopulations. For instance, girls are much more likely to be diagnosed with anxiety, depression, or an
eating disorder, while boys are more likely to die by suicide or be diagnosed with a behavior disorder,
such as attention deficit hyperactivity disorder (ADHD).
36, 37, 38
In recent years, suicide rates among Black
children (below age 13) have been increasing rapidly, with Black children nearly twice as likely to die by
suicide than White children.
39
Moreover, socioeconomically disadvantaged children and adolescents—
for instance, those growing up in poverty—are two to three times more likely to develop mental health
conditions than peers with higher socioeconomic status.
40
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
e COVID-19 Pandemic’s Impact on the
Mental Health of Children and Youth
During the pandemic, children, adolescents, and young adults have faced unprecedented challenges. e
COVID-19 pandemic has dramatically changed their world, including how they attend school, interact
with friends, and receive health care. ey missed first days of school, months or even years of in-person
schooling, graduation ceremonies, sports competitions, playdates, and time with relatives. ey and
their family may have lost access to mental health care, social services, income, food, or housing.
41
ey
may have had COVID-19 themselves, suffered from long COVID symptoms, or lost a loved one to the
disease—it’s estimated that as of June 2021, more than 140,000 children in the US had lost a parent or
grandparent caregiver to COVID-19.
42
Since the pandemic began, rates of psychological distress among young people, including symptoms
of anxiety, depression, and other mental health disorders, have increased. Recent research covering
80,000 youth globally found that depressive and anxiety symptoms doubled during the pandemic, with
25% of youth experiencing depressive symptoms and 20% experiencing anxiety symptoms.
43
Negative
emotions or behaviors such as impulsivity and irritability—associated with conditions such as ADHD—
appear to have moderately increased.
44
Early clinical data are also concerning: In early 2021, emergency
department visits in the United States for suspected suicide attempts were 51% higher for adolescent
girls and 4% higher for adolescent boys compared to the same time period in early 2019.
45
Moreover,
pandemic-related measures reduced in-person interactions among children, friends, social supports, and
professionals such as teachers, school counselors, pediatricians, and child welfare workers. is made it
harder to recognize signs of child abuse, mental health concerns, and other challenges.
46
During the pandemic, young people also experienced other challenges that may have affected their
mental and emotional wellbeing: the national reckoning over the deaths of Black Americans at the
hands of police officers, including the murder of George Floyd; COVID-related violence against Asian
Americans; gun violence; an increasingly polarized political dialogue; growing concerns about climate
change; and emotionally-charged misinformation.
47, 48, 49, 50, 51
Although the pandemic’s long-term impact on children and young people is not fully understood, there
is some cause for optimism. According to more than 50 years of research, increases in distress symptoms
are common during disasters, but most people cope well and do not go on to develop mental health
disorders.
52
Several measures of distress that increased early in the pandemic appear to have returned to
pre-pandemic levels by mid-2020.
53, 54
Some other measures of wellbeing, such as rates of life satisfaction
and loneliness, remained largely unchanged throughout the first year of the pandemic.
53, 55
And while
data on youth suicide rates are limited, early evidence does not show significant increases.
56, 57
In addition, some young people thrived during the pandemic: ey got more sleep, spent more quality
time with family, experienced less academic stress and bullying, had more flexible schedules, and
improved their coping skills.
44, 58, 59, 60
Many young people are resilient, able to bounce back from difficult
experiences such as stress, adversity, and trauma.
61
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
at said, the pandemic is ongoing, with nearly 1,000 Americans dying per day as of early December
2021.
62
And many millions of children and youth have faced and continue to face major challenges.
Importantly, the pandemic’s negative impacts, such as illness and death in families and disruptions in
school and social life, disproportionately impacted those who were vulnerable to begin with and widened
disparities.
63
For additional details, see Boxes 1 and 2. Box 1 discusses risk factors contributing to
children’s mental health symptoms during the pandemic. Box 2 discusses demographic groups at greater
risk of developing mental health problems during the pandemic.
BOX 1
Having mental health challenges before the pandemic
61, 64
Living in an urban area or an area with more severe COVID-19 outbreaks
65
Having parents or caregivers who were frontline workers
66
Having parents or caregivers at elevated risk of burnout (for example, due to parenting demands)
67, 68
Being worried about COVID-19
64
Experiencing disruptions in routine, such as not seeing friends or going to school in person
69, 70, 71
Experiencing more adverse childhood experiences (ACEs) such as abuse, neglect, community
violence, and discrimination
72, 73, 74
Experiencing more financial instability, food shortages, or housing instability
75, 76
Experiencing trauma, such as losing a family member or caregiver to COVID-19
77
Risk factors contributing to Youth mental health symptoms
During the pandemic
Note: Not a comprehensive list of risk factors
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Youth with intellectual and developmental disabilities (IDDs), who found it especially difficult to
manage disruptions to school and services such as special education, counseling, occupational, and
speech therapies
78, 79, 80, 81, 82
Racial and ethnic minority youth,
83
including:
American Indian and Alaska Native youth, many of whom faced challenges staying connected
with friends and attending school due to limited internet access
84
Black youth, who were more likely than other youth to lose a parent or caregiver to COVID-19
42
Latino youth, who reported high rates of loneliness and poor or decreased mental health during
the pandemic
85, 86
Asian American, Native Hawaiian, and Pacific Islander youth, who reported increased stress
due to COVID-19-related hate and harassment
87, 88
LGBTQ+ youth, who lost access to school-based services and were sometimes confined to homes
where they were not supported or accepted
89, 90
Low-income youth, who faced economic, educational, and social disruptions (for example, losing
access to free school lunches)
91
Youth in rural areas, who faced additional challenges in participating in school or accessing mental
health services (for example, due to limited internet connectivity)
92
Youth in immigrant households, who faced language and technology barriers to accessing health
care services and education
93
Special youth populations, including youth involved with the juvenile justice, or child welfare
systems, as well as runaway youth and youth experiencing homelessness
61, 94, 95, 96
Additional considerations:
Youth with multiple risk factors. Many young people are part of more than one at-risk group,
which can put at them at even higher risk of mental health challenges. For example, children with
IDDs who lost a parent to COVID-19, or Black children from low-income families, may require
additional support to address multiple risk factors.
97
Discrimination in the health care system. Some groups of youth and their families, such as
people of color, immigrants, LGBTQ+ people, and people with disabilities, may be more hesitant
to engage with the health care system (including mental health services) due to current and past
experiences with discrimination.
97, 98, 99
Risks of COVID-19 to children with mental health conditions. Children with mood
disorders, such as depression and bipolar disorder, as well as schizophrenia spectrum disorders, are
at elevated risk of severe COVID-19 illness.
100, 101, 102
Groups at higher risk of mental health challenges during the pandemic
Note: Not a comprehensive list of groups or risk factors
BOX 2
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
e good news is that, throughout the pandemic, many people have recognized the unprecedented
need to support youth mental health and wellbeing and have taken action to do so. Many young people
found ways to cope with disruption and stay connected.
103
Families helped children adjust to remote
learning.
104
Educators and school staff supported their students while facing unprecedented challenges
themselves.
105
Health care professionals rapidly shifted to telehealth.
106
Community organizations stepped
in to protect at-risk youth.
107
Employers helped employees adapt to remote work environments.
108
And
governments invested trillions of dollars to mitigate financial hardship for families, support COVID-19
testing and vaccination, provide health care and other social services, and support the safe reopening of
schools, among other policies.
109, 110, 111
But there is much more to be done, and each of us has a role to play. Supporting the mental health
of children and youth will require a whole-of-society effort to address longstanding challenges,
strengthen the resilience of young people, support their families and communities, and mitigate the
pandemic’s mental health impacts. Here is what we must do:
Recognize that mental health is an essential part of overall health. Mental health conditions are
real, common, and treatable, and people experiencing mental health challenges deserve support,
compassion, and care, not stigma and shame. Mental health is no less important than physical health.
And that must be reflected in our how we communicate about and prioritize mental health.
Empower youth and their families to recognize, manage, and learn from difficult emotions.
For youth, this includes building strong relationships with peers and supportive adults, practicing
techniques to manage emotions, taking care of body and mind, being attentive to use of social media
and technology, and seeking help when needed. For families and caregivers, this means addressing
their own mental health and substance use conditions, being positive role models for children,
promoting positive relationships between children and others as well as with social media and
technology, and learning to identify and address challenges early. Youth and families should know
that asking for help is a sign of strength.
Ensure that every child has access to high-quality, affordable, and culturally competent mental
health care. Care should be tailored to children’s developmental stages and health needs, and
available in primary care practices, schools, and other community-based settings. It’s particularly
important to intervene early, so that emerging symptoms don’t turn into crises.
WE CAN TAKE ACTION
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Support the mental health of children and youth in educational, community, and childcare
settings. is includes creating positive, safe, and affirming educational environments, expanding
programming that promotes healthy development (such as social and emotional learning), and
providing a continuum of supports to meet the social, emotional, behavioral, and mental health
needs of children and youth. To achieve this, we must also expand and support the early childhood
and education workforce.
Address the economic and social barriers that contribute to poor mental health for young
people, families, and caregivers. Priorities should include reducing child poverty and ensuring
access to quality childcare, early childhood services, and education; healthy food; affordable health
care; stable housing; and safe neighborhoods.
112, 113
Increase timely data collection and research to identify and respond to youth mental health
needs more rapidly. e country needs an integrated, real-time data infrastructure for understanding
youth mental health trends. More research is also needed on the relationship between technology
and mental health, and technology companies should be more transparent with their data and
algorithmic processes to enable this research. We also need to better understand the needs of at-risk
youth, including youth facing multiple risk factors. Governments and other stakeholders should
engage directly with young people to understand trends and design effective solutions.
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
What Young People Can Do
Since many of the challenges young people face are outside of their control, we need a whole-of-society
effort to support children’s mental health and wellbeing from birth to adulthood. at said, below are
important steps children and young people themselves can take to protect, improve, and advocate for
their mental health and that of their family, friends, and neighbors:
Remember that mental health challenges are real, common, and treatable. Struggling with your
mental health does not mean you are broken or that you did something wrong. Mental health is
shaped by many factors, including biology and life experiences, and there are many ways mental
health challenges can be addressed.
Ask for help. Find trusted adults, friends, or family members to talk to about stressful situations. For
example, if you or someone you know is being bullied, tell a trusted adult. If you are struggling to
manage negative emotions, reach out to a school nurse or counselor, a teacher, a parent or caregiver,
a coach, a faith leader, or someone else you look up to and trust. Look into therapy or counseling
resources to get support when something causes distress and interferes with your life. Reaching out to
others can be hard and takes courage, but it is worth the effort and reminds us we are not alone.
Invest in healthy relationships. Social connection is a powerful buffer to stress and a source of
wellbeing. But too often in our fast-paced lives, quality time with people gets crowded out. Make
space in your life for the people you love. Spend time with others regularly, in-person and virtually.
114
Find people who support and care about you and have open and honest conversations with them
about your feelings. Get involved in group activities, such as recreation and outdoor activities, after-
school programs, and mentorship programs.
115
Find ways to serve. Volunteering in your community and helping others can be a great way to
connect with people, build a sense of purpose, and develop your own sense of self-worth.
116
Helping
others when you are the one struggling can seem counterintuitive. But service is a powerful antidote
to isolation, and it reminds us that we have value to add to the world.
Learn and practice techniques to manage stress and other difficult emotions. Try to recognize
situations that may be emotionally challenging for you, and come up with strategies to manage those
emotions. For example, if you find it stressful to look at COVID-related news, try to check the news
less often, take a break for a day or a week at a time, keep notifications off throughout the day, and
avoid looking at negative stories before bed.
51
WE CAN TAKE ACTION
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Take care of your body and mind. Stick to a schedule, eat well, stay physically active, get quality
sleep, stay hydrated, and spend time outside.
117, 118, 119
And avoid substances that can ultimately make
you feel tired, down, or depressed, such as alcohol, marijuana, vaping, and tobacco.
120
Be intentional about your use of social media, video games, and other technologies. Here are
some questions to help guide your technology use: How much time are you spending online? Is it
taking away from healthy offline activities, like exercising, seeing friends, reading, and sleeping? What
content are you consuming, and how does it make you feel? Are you online because you want to be,
or because you feel like you have to be?
Be a source of support for others. Talk to your family and friends about mental health, listen
and be a source of support to them, and connect them to the right resources.
121
Advocate for and
contribute your ideas at the local, state, or national levels. For example, look into joining Youth
Advisory Councils or mental health peer support programs in your community.
122
If you’re in crisis, get immediate help: Call the
National Suicide Prevention Lifeline at 1-800-273-
8255, chat with trained counselors 24/7, or get
help in other ways through the Lifeline
How Right Now (Centers for Disease Control and
Prevention): Resources for coping with negative
emotions and stress, talking to loved ones, and
nding inspiration
Youth Engaged 4 Change: Opportunities for
youth to make a dierence in their lives and in
the world around them
Supporting Emotional Wellbeing in Children
and Youth (National Academies of Medicine):
Tools for children, teens, and parents to learn
how to cope with challenges
Mental Health Resource Center (JED
Foundation): Information about common
emotional health issues and how to overcome
challenges
Youth Wellbeing Initiatives (National Council
for Mental Wellbeing): Collection of initiatives to
improve mental wellbeing in youth and young
adults
Kids, Teens, and Young Adults (National Alliance
on Mental Illness): Resources for young people to
get mental health support
One Mind PsyberGuide: A guide to navigating
mental health apps and digital technologies
FindTreatment.gov (SAMHSA): Information on
substance use and mental health treatment
Trevor Project: Suicide prevention and crisis
intervention resources for LGBTQ+ young people
AAKOMA Mental Health Resources (The
AAKOMA Project): Resources to support the
mental health of youth of color and their
caregivers
Mental Health for Immigrants (Informed
Immigrant): Tips for managing the mental health
of yourself and others
Resources for Young People
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Families and caregivers play a critical role in providing the safe, stable, and nurturing environments and
relationships young people need to thrive. Below are recommendations for how families and caregivers
can engage with children and youth on mental health topics, help them become more resilient, and
address emerging mental health challenges:
Be the best role model you can be for young people by taking care of your own mental and
physical health. Young people often learn behaviors and habits from what they see around them. You
can model good habits by talking to children about the importance of mental health, seeking help when
you need it, and showing positive ways you deal with stress so children learn from you. Additional
ways to take care of your own mental health include taking breaks, getting enough sleep, exercising,
eating balanced meals, maintaining regular routines, obtaining health insurance coverage, staying
connected with family and friends, and taking time to unplug from technology or social media.
123
Help children and youth develop strong, safe, and stable relationships with you and other
supportive adults. Research shows that the most important thing a child needs to be resilient is a
stable and committed relationship with a supportive adult.
124
Spend time with children on activities
that are meaningful to them, show them love and acceptance, praise them for the things they do well,
listen to them, and communicate openly about their feelings. Encourage children to ask for help and
connect them with other adults who can serve as mentors.
125
Encourage children and youth to build healthy social relationships with peers. is can be done
through self-directed play and structured activities such as school, after school programs, sports,
and volunteering.
126
Since peers can play a major role (both positive and negative) in children’s
development, it’s important to help children learn how to deal with peer pressure. Have open
conversations with your child about their values and teach them to be confident and comfortable in
expressing their needs and boundaries.
Do your best to provide children and youth with a supportive, stable, and predictable home and
neighborhood environment. A lot may be outside of your control, and there will be trial and error
as you figure out what works best for your child. at said, try to help children stick to a regular and
predictable daily schedule, such as regular dinnertime and bedtime.
117, 126, 127
Be thoughtful about
whether and how to discuss stressful topics such as financial and marital problems. e American
Psychological Association offers tips on how to talk with your child about difficult topics.
128
It’s also
important to minimize children’s exposure to violence, which puts them at risk of mental health and
substance use challenges.
129
What Family Members and
Caregivers Can Do
WE CAN TAKE ACTION
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Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Try to minimize negative influences and behaviors in young people’s lives. Talk to children early
about the risks of alcohol and other drugs, both short-term (such as car crashes and other accidents)
and long-term (such as reduced cognitive abilities). e earlier a child or adolescent begins using
substances, the greater their chances of developing substance use problems.
131
Mental health and
substance use problems can also occur at the same time. For example, some young people struggling
with stress or difficult feelings turn to alcohol or drug use.
132
And alcohol and other drugs can also
affect mental health, for example by altering mood or energy levels.
133
Ensure children and youth have regular check-ups with a pediatrician, family doctor, or other
health care professional. Health care professionals can help you monitor your children's health,
give you advice on how to prevent problems, and diagnose and treat physical and mental illnesses.
Obtaining health insurance coverage for your children can help. To learn more about enrolling
in Medicaid, the Children’s Health Insurance Program (CHIP), or a Marketplace plan, go to
HealthCare.gov or InsureKidsNow.gov.
Look out for warning signs of distress, and seek help when needed. Signs of distress in children
can show up in a number of ways, such as irritability, anger, withdrawal, and other changes in their
thoughts, appearance, performance at school, sleeping or eating patterns, or other behaviors.)
134
If
you notice concerning changes in your child, let them know you’re there and ready to support them
however they need. Don’t be afraid to ask for help by talking to a doctor, nurse, or other professional or
looking into other available resources in your community. For example, schools often have counseling
services and additional accommodations (e.g., for students enrolled in special education programs).
Minimize children’s access to means of self-harm, including firearms and prescription
medications. Dispose of unused or expired prescriptions and keep medications out of reach for
children and youth. If you choose to keep firearms in the home, ensure that they are stored safely:
unloaded and locked up (e.g., in a lock box or safe). Having firearms in the home increases the
likelihood of firearm-related death.
135, 136
In fact, firearms are by far the most lethal means of suicide:
90% of attempted suicides with a firearm result in death, compared to less than 10% of attempted
suicides overall.
137
Be attentive to how children and youth spend time online. Digital technology can help young
people connect with friends and family, learn about current events, express themselves, and access
telehealth and other resources.
138
At the same time, children can have negative experiences online,
such as being bullied, finding harmful information, and negatively comparing themselves to others.
139
Box 3 has a list of questions you can ask yourself about your child’s use of technology.
Be a voice for mental health in your community. ere are many ways to do this, from talking
openly with friends and family about the importance of mental health, to going to school board
meetings or a town hall, to volunteering with an advocacy group, to promoting greater funding and
awareness of mental health programs in schools and local organizations, such as churches, libraries,
parks and recreation, or sports teams.
18
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
BOX 3
Technology and youth mental health: Questions for families to consider
Time
How much time is my child spending online? Is it taking away from healthy offline activities,
such as exercising, seeing friends, reading, and sleeping?
Are there healthy limits I can set on my child’s use of technology, such as limiting screen time
to specific times of the day or week, or limiting certain kinds of uses?
Content
Am I aware of what devices and content my child has access to?
Is my child getting something meaningful and constructive out of content they are looking
at, creating, or sharing? How do I know?
Are there healthier ways my child could engage online? (Examples: Finding meal recipes,
researching options for a family outing, video chatting with a relative, etc.)
Is being online riskier for my child than for some other children? For example, does my child
have a mental health condition that might make them react more strongly to certain kinds of
stressful or emotional content?
Impact
How does my child feel about the time they spend online?
Is my child engaging because they want to, or because they feel like they have to?
How can I create space for open conversations with my child about their experiences online?
How do I feel about my own use of technology? Can I be a better role model for my child?
Resources for Families
Children’s Mental Health and COVID-19
Parental Resources Kit (CDC): Resources for
supporting children’s social, emotional, and
mental health
HealthyChildren.org (American Academy of
Pediatrics): Parenting tips and other resources
What’s On Your Mind? (UNICEF): Guide for
talking to children about mental health
Family Resource Center (Child Mind Institute):
Family resources on child mental health,
including Media Guidelines for Kids of All Ages
NetSmartz (National Center for Missing and
Exploited Children): Online platform to teach
children online safety in age-appropriate ways
Parents’ Ultimate Guides (Common Sense Media):
Information about the safety of current media and
technology trends and apps for your children
HealthCare.gov or InsureKidsNow.gov: Infor-
mation on enrolling in health insurance coverage
MentalHealth.gov: What to look for, how to talk
about mental health, and how to get help
Aging and Disability Networks (ACL): Connect
with advocacy and caregiver resources
19
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
e experiences children and young people have at school have a major impact on their mental health.
At school, children can learn new knowledge and skills, develop close relationships with peers and
supportive adults, and find a sense of purpose, fulfillment, and belonging. ey can also find help to
manage mental health challenges. On the other hand, children can also have highly negative experiences
at school, such as being bullied, facing academic stress, or missing out on educational opportunities (for
example, due to under-resourced schools). Mental health challenges can reveal themselves in a variety
of ways at school, such as in a student having trouble concentrating in class, being withdrawn, acting
out, or struggling to make friends. In light of these factors, below are recommendations for how schools,
educators, and staff can support the mental health of all students:
Create positive, safe, and affirming school environments. is could include developing
and enforcing anti-bullying policies, training students and staff on how to prevent harm (e.g.,
implementing bystander interventions for staff and students), being proactive about talking to
students and families about mental health, and using inclusive language and behaviors.
140, 141
Where
feasible, school districts should also consider structural changes, such as a later start to the school day,
that support students’ wellbeing.
142, 143
Expand social and emotional learning programs and other evidence-based approaches that
promote healthy development. Examples of social, emotional, and behavioral learning programs
include Sources of Strength, e Good Behavior Game, Life Skills Training, Check-In/Check-Out,
and PATHS.
144, 145, 146, 147
Examples of other approaches include positive behavioral interventions and
supports and digital media literacy education.
Learn how to recognize signs of changes in mental and physical health among students,
including trauma and behavior changes. Take appropriate action when needed.
148
Educators
are often the first to notice if a student is struggling or behaving differently than usual (for example,
withdrawing from normal activities or acting out). And educators are well-positioned to connect
students to school counselors, nurses, or administrators who can further support students, including
by providing or connecting students with services.
149
Provide a continuum of supports to meet student mental health needs, including evidence-
based prevention practices and trauma-informed mental health care. Tiered supports should
include coordination mechanisms to get students the right care at the right time.
150
For example,
the Project AWARE (Advancing Wellness and Resilience in Education) program provides funds for
state, local, and tribal governments to build school-provider partnerships and coordinate resources to
support prevention, screening, early intervention, and mental health treatment for youth in school-
based settings.
151
School districts could also improve the sharing of knowledge and best practices.
What Educators, School Staff, and
School Districts Can Do
WE CAN TAKE ACTION
20
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
For example, districts could dedicate staff at the district level to implementing evidence-based
programs across multiple schools). Districts could also implement mental health literacy training for
school personnel (e.g., Mental Health Awareness Training, QPR training).
Expand the school-based mental health workforce.
152
is includes using federal, state, and local
resources to hire and train additional staff, such as school counselors, nurses, social workers, and
school psychologists, including dedicated staff to support students with disabilities. For example, a lack
of school counselors makes it harder to support children experiencing mental health challenges. e
American School Counselor Association (ASCA) recommends 1 counselor for every 250 students,
compared to a national average of 1 counselor for every 424 students (with significant variation by
state).
153
e American Rescue Plan's Elementary and Secondary School Emergency Relief funds can
be used for this purpose and for other strategies outlined in this document.
154
Support the mental health of all school personnel. Opportunities include establishing realistic
workloads and student-to-staff ratios, providing competitive wages and benefits (including health
insurance with affordable mental health coverage), regularly assessing staff wellbeing, and integrating
wellness into professional development.
155
In addition to directly benefitting school staff, these
measures will also help school personnel maintain their own empathy, compassion, and ability to
create positive environments for students.
156
Promote enrolling and retaining eligible children in Medicaid, CHIP, or a Marketplace plan, so
that children have health coverage that includes behavioral health services. e Connecting Kids to
Coverage National Campaign also has outreach resources for schools, providers, and community-based
organizations to use to encourage parents and caregivers to enroll in Medicaid and CHIP to access
important mental health benefits. Families can be directed to HealthCare.gov or InsureKidsNow.gov.
Schools can use Medicaid funds to support enrollment activities and mental health services.
157
Protect and prioritize students with higher needs and those at higher risk of mental health
challenges, such as students with disabilities, personal or family mental health challenges, or other
risk factors (e.g., adverse childhood experiences, trauma, poverty).
158
Resources for Educators, School
Staff, and School Districts
Supporting Child and Student Social,
Emotional, Behavioral, and Mental Health
Needs (Dept. of Education): Guidance for schools,
school districts, and education departments
National Center for School Mental Health:
Resources to promote a positive school climate
StopBullying.gov: Learn about what bullying is,
who is at risk, and how you can help
Turnaround for Children Toolbox: Tools to drive
change towards a more equitable, whole- child
approach to school
Design Principles for Schools: Framework for
redesigning schools with a focus on supporting
students’ learning and social and emotional
development
Safe Schools Fit Toolkit (National Center for
Healthy Safe Children): Resources and guides to
build safe and healthy schools
Mental Health Technology Transfer Center
Network: School mental health resources
21
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Our health care system today is not set up to optimally support the mental health and wellbeing of children
and youth. In addition to changing government policy (see recommendations for Governments on page 33),
we must reimagine how health care organizations and health professionals prevent, identify, and address mental
health challenges. Below are some steps health care organizations and health professionals can take:
Recognize that the best treatment is prevention of mental health challenges. Implement trauma-
informed care (TIC) principles and other prevention strategies to improve care for all youth,
especially those with a history of adversity.
In addition to working in the clinic, for example to
educate families on their role in healthy child development, health care professionals should work
with other sectors (e.g., schools, child care, justice, social services, public health) on prevention
strategies. For instance, health care professionals can refer patients to resources such as economic
supports, school enrichment programs, and legal supports.
12
Routinely screen children for mental health challenges and risk factors, including adverse
childhood experiences (ACEs).
159
Screenings can be done in primary care, schools, emergency
departments, and other settings. For example, primary care providers can conduct screenings
during well-visit appointments, annual physicals, or routine vaccinations using principles of trauma-
informed care. Screenings should account for the diverse ways in which mental health challenges can
manifest, such as changes in physical health, sleep patterns, and behaviors. It’s critical that screening
services link to appropriate follow-up care. e American Academy of Pediatrics offers tools and
resources for screening processes. California’s ACEs Aware initiative offers ACEs screening tools for
children, adolescents, and young adults.
Identify and address the mental health needs of parents, caregivers, and other family members.
e mental health of children and youth is closely linked to the mental health and wellbeing of
their families. Screening parents and caregivers for depression, intimate partner violence, substance
use, and other challenges can be combined with broader assessments of food insecurity, housing
instability, and other social determinants of health.
160
Combine the efforts of clinical staff with those of trusted community partners and child-serving
systems (e.g., child welfare, juvenile justice). For example, hospital-based violence intervention
programs (HVIPs) identify patients at risk of repeat violent injury and link them to hospital- and
community-based resources to address risk factors for violence.
161, 162, 163, 164
Another example
initiative is school-hospital partnerships, such as behavioral health urgent care clinics supported by
schools.
165
New payment and delivery models, such as the Centers for Medicare & Medicaid Services
Innovation Center’s Integrated Care for Kids (InCK) Model, can be used to support the mental
health-related needs of children across settings.
166
What Health Care Organizations and
Health Professionals Can Do
WE CAN TAKE ACTION
22
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Build multidisciplinary teams to implement services that are tailored to the needs of children
and their families. Enlist children and families as partners and engage them in all stages of decision-
making, from screening to treatment.
167
Recognize that a variety of cultural and other factors shape
whether children and families are able or willing to seek mental health services. Accordingly, services
should be culturally appropriate, offered in multiple languages (including ASL), and delivered by a
diverse mental health workforce. Additionally, support the wellbeing of mental health workers and
community leaders, building their capacity to support youth and their families.
Mental Health Initiatives (American Academy
of Pediatrics): Information and guidance on
supporting the healthy mental development of
children, adolescents, and families. For example,
see here for information on developing age-
appropriate screening processes.
HealthySteps Model (Zero to Three): A
primary care model that brings together child
development experts, specialists, and pediatric
primary care providers to promote healthy child
development
Evidence-Based Practices Resource Center
(Substance Abuse and Mental Health Services
Administration): Information to incorporate
evidence-based practices into communities and
clinical settings
Behavioral Health Integration Compendium
(American Medical Association): Steps for
integrating behavioral health care into a clinical
practice
Telemental Health Resource Center (Western
Regional Children’s Advocacy Center): Information
and tools to set up telehealth programs for
mental health
ACEs Screening Tools (California’s ACEs Aware
Initiative): Oers tools to screen children,
adolescents, and adults for ACEs
Trauma Screening Tools (Childhood Trauma
Toolkit, Centre for Addiction and Mental Health):
ACEs questionnaire and developmental trauma
symptom screening checklist
Resources for Health Care Organizations and
Health Professionals
23
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Note: See next section for recommendations specic to technology platforms such as social media companies.
Media organizations, entertainment companies, and journalists can have a powerful impact on young
people. In some cases, this impact can be positive. For example, television programs can keep children
and adolescents informed about current events and teach them valuable lessons.
168
On the other hand,
false, misleading, or exaggerated media narratives can perpetuate misconceptions and stigma against
people with mental health or substance use problems.
169, 170
In addition, media coverage of traumatic
events, such as bombings and natural disasters, can contribute to psychological distress among
consumers.
171, 172, 173, 174, 175
Particularly in times of global crisis, such as the COVID-19 pandemic, people
can come away from news stories feeling anxious and powerless.
176
Below are steps media organizations
can take to protect the mental health of viewers while staying true to their role in informing the public:
Recognize the impact media coverage of negative events can have on the public’s mental health.
e solution isn't to hide or downplay negative news, but rather to avoid misleading consumers, and
to be more attentive to how stories are framed. Example best practices include:
Being fact-based in reporting and avoiding language that shocks, provokes, or creates a sense of
panic.
Being more cautious about showing distressing content, particularly graphic images or video,
without context or warnings for viewers. Help viewers decide whether they want to engage with
the content.
177
Giving audiences context, including highlighting uncertainties and conflicting reports. When
discussing preliminary research—such as papers that have not yet been peer-reviewed—outlets
should be forthright about the preliminary nature of the findings, get independent experts to
weigh in, and identify areas of uncertainty.
Offering the public ways to make a positive difference (for example, ways to donate funds or
supplies to victims of a natural disaster).
Including positive messages and stories of hope and healing (particularly when covering
pandemics, natural disasters, and incidents of mass violence).
What Media Organizations,
Entertainment Companies, and
Journalists Can Do
WE CAN TAKE ACTION
24
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Normalize stories about mental health and mental illness across all forms of media, taking care
to avoid harmful stereotypes, promote scientifically accurate information, and include stories of
help, hope, and healing. Example best practices
178
include:
Avoiding harmful stereotypes about mental illness, such as the idea that people who have a
mental illness are prone to violence or that mental illness causes violence.
Research shows this is not the case.
179
Avoiding demeaning language (e.g., “crazy,” “psycho,” “looney,” “wacko”, “nut,” “junkie”). is
includes using person-centered language, or language that focuses on the person rather than a
disease label.
180
For example, instead of referring to someone as a “schizophrenic,” refer to them
as a “person living with schizophrenia.”
Include stories of people seeking help, getting treatment, and successfully recovering. ese can
also include examples of people getting help from friends, family neighbors, or even strangers
(not just mental health professionals).
181
Direct consumers to mental health resources (as part of any mental health-related TV episode,
movie, news story, podcast, or other media).
Craft more authentic stories by consulting with subject matter experts and people with personal
experience of mental illness or mental health challenges.
Whenever depicting suicide or suicidal ideation, adhere to best practices such as the National
Recommendations for Depicting Suicide.
182
For example:
Convey that suicide is complex and often caused by multiple factors, not a single event.
Show that help is available. For example, in TV shows or movies, show characters reaching out to health
professionals, talking to supportive peers, friends, or family, or calling or texting a crisis hotline.
Mental Health Media Guide: A guide to mental
health storytelling developed by a coalition of
mental health experts and entertainment industry
leaders
National Center on Disability and Journalism
Resources: Eective, sensitive ways to talk about
disability in the media
National Recommendations for Depicting
Suicide (National Action Alliance): Guidance
for content creators to tell more balanced and
authentic stories involving suicide
Resources for Media Organizations,
Entertainment Companies, and Journalists
25
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Over the past two decades, more and more of our lives have moved onto social media platforms and
other digital public spaces. e COVID-19 pandemic has rapidly accelerated this trend. During the
pandemic, the time teenagers spent in front of screens for activities not related to school more than
doubled, from 3.8 to 7.7 hours per day.
183
In 2020, 81% of 14- to 22-year-olds said they used social
media either “daily” or “almost constantly.”
138
In these digital public spaces, which privately owned and tend to be run for profit, there can be tension
between what’s best for the technology company and what’s best for the individual user or for society.
Business models are often built around maximizing user engagement as opposed to safeguarding users’
health and ensuring that users engage with one another in safe and healthy ways.
184, 185
is translates to
technology companies focusing on maximizing time spent, not time well spent.
In recent years, there has been growing concern about the impact of digital technologies, particularly
social media, on the mental health and wellbeing of children and young people.
186, 187, 188
Part of the
challenge with research on this topic is that digital technology involves a vast range of devices, platforms,
products, and activities, so it’s hard to generalize. Researchers also have limited access to data to inform
potential research.
Many researchers argue that digital technologies can expose children to bullying, contribute to obesity
and eating disorders, trade off with sleep, encourage children to negatively compare themselves to others,
and lead to depression, anxiety, and self-harm.
139, 187, 189, 190, 191, 192
Several studies have linked time spent
on social media to mental health challenges such as anxiety and depression.
26, 193, 194, 195, 196, 197
Meanwhile,
others have cast doubt on the idea that technology or social media use is a major factor in youth
wellbeing.
198, 199, 200, 201, 202, 203
Importantly, the impact of technology almost certainly varies from person to person, and it also matters
what technology is being used and how.
204
So, even if technology doesn’t harm young people on
average, certain kinds of online activities likely do harm some young people.
For example, some
research has linked “passive” social media use (such as scrolling through posts and auto-play video) to
declines in wellbeing (versus more “active” use such as commenting on posts or recording videos).
205
ere can also be benefits to certain online activities, such as connecting meaningfully with friends and
family, learning a new skill, or accessing health care, and these also vary from person to person.
206
For
example, LGBTQ+ young people may be more vulnerable than other young people to cyberbullying but
also more likely to consider social media important for feeling less alone, expressing themselves, finding
inspiration, and getting support.
138, 207
What Social Media, Video Gaming, and
Other Technology Companies Can Do
WE CAN TAKE ACTION
26
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
ere is a clear need to better understand the impact of technologies such as social media on
different kinds of users, and to address the harms to users most at risk. We need more research using
strong data and research methods, such as longitudinal and experimental designs, behavioral (as opposed
to self-reported) measures of time spent online and types of content engaged with, as well as data on
subgroups of users (e.g., boys vs. girls).
208, 209
Most importantly, technology companies must step up and take responsibility for creating a safe
digital environment for children and youth. Today, most companies are not transparent about the
impact of their products, which prevents parents and young people from making informed decisions and
researchers from identifying problems and solutions. At a minimum, the public and researchers deserve
much more transparency. More broadly, below are specific recommendations for how these companies
can prioritize the wellbeing of users above monetizing those users for profit:
Prioritize user health and wellbeing at all stages of product development.
210
Elevate user safety, health, and wellbeing in the culture and leadership of technology
companies. Senior technology executives should acknowledge that their products can harm some
young people and take material and measurable steps to prevent and mitigate these harms, even
at the expense of engagement, scale, and profit. Leaders should be accountable for creating a safe,
accessible, and inclusive digital environment for their users and designing safe products.
Assess and address risks to users at the front end of product development. Build products and
services using a precautionary approach that focuses on making them safe for youth before they
are deployed. Company employees at all levels, especially those involved in product development,
should be expected to prioritize user health and wellbeing in their day-to-day work. For example,
consider how to align performance incentives for product developers to measures of user wellbeing.
Develop consistent procedures for receiving input on proposed products from youth, parents,
health and youth development professionals, and civil society, for example through advisory
groups. Create ways for employees to voice concerns about products without fear of retaliation.
Continually measure the impact of products on user health and wellbeing and share data
with the public. Supplement traditional product success metrics, such as monthly active users,
with dedicated metrics for user health and wellbeing. In addition to relying on user-reported
data (e.g., surveys), consider using behavioral data (e.g., analysis of user inputs such as typed
keywords). Make results publicly available. Take corrective action to address harms.
Recognize that the impact of platforms and products can vary from user to user, and
proactively ensure that products designed for adults are also safe for children and
adolescents. Consider many kinds of users, including users of different ages and developmental
stages, when developing new products and features. Talk to those users and collect data to
identify subgroups who may be harmed by certain products or ways of engaging. Use this data to
inform product design and research.
27
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Be transparent and allow for independent researchers and the public to study the impact of
company products on user health and wellbeing.
Allow users to provide informative data about their online experience to independent
researchers. is should be a fully consented process that allows users to individually request
personal data about their use to transfer to researchers (e.g., timestamps of when and how long
use takes place; type of content seen and engaged with; whether, when, and how interactions
with others took place). Companies should also allow third-party researchers to request data on
behalf of users if evidence of full user consent is provided and facilitate the automated transfer of
data to third-party researchers (e.g., through application programming interfaces or APIs).
Directly provide researchers with data to enable understanding of (a) subgroups of users
most at risk of harm and (b) algorithmic design and operation. Data on algorithmic design
and operation should be of sufficient granularity to allow researchers to understand when, why,
and how users are shown different types of content.
Partner with researchers and experts to analyze the mental health impacts of new products
and features in advance of rollout. Regularly publish findings. Where possible, design
evaluations in ways that enable causal inference (for example, using randomized interventions).
Allow a broad range of researchers to access data and previous research instead of providing
access to a privileged few. Make research results publicly available and do not bind researchers
to non-disclosure agreements. Avoid conflicts of interest that cast doubt on researchers’
independence.
Build user-friendly tools that help children and adolescents engage online in healthy ways.
Take a holistic approach to designing online spaces hospitable to young people. For example,
support the creation of industry-wide safety standards for online health and wellbeing, in
partnership with civil society groups. Just as we have safety standards for offline activities, such as
driving, we should also consider standards for online activities.
211, 212
Private organizations, such
as video game companies, have already begun sharing best practices and developing a common
framework for protecting users.
213
Limit children’s exposure to harmful online content. is can involve a mix of limiting
access for younger users, reducing content amplification, prohibiting data collection of and
targeted advertising to children, ensuring privacy settings are maximized by default, removing
content quickly if it violates company policies, tightening age verification requirements and
audits, enabling independent algorithm audits, and imposing consequences for users found to
be circumventing age restrictions or other policies.
227
Companies should conduct research to
evaluate whether these measures work. For example, children today can easily get around age
limits by claiming to be older than they really are. To address this, some companies have required
users to upload an ID and a selfie to verify identity and age (without storing the underlying ID
or selfie data).
214
28
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Give users opportunities to control their online activity, including by opting out of
content they may find harmful. For example, some companies have built in “frictions,” such
as notifications that remind people to take breaks and limit screen time.
215
Other examples of
frictions could include banning auto-play” functions on videos or limiting scrolling capabilities
for youth users. Also consider allowing users to opt out of content they believe may harm their
mental health, such as ads involving violence, alcohol, or gambling, or content related to eating
disorders.
216
Develop products that actively safeguard and promote mental health and wellbeing. New
technologies create opportunities to reach large numbers of youth with educational interventions,
such as directing youth to mental health tips and resources.
217
ere are also emerging digital
technologies—often referred to as “digital therapeutics”—that prevent, manage, and treat health
conditions. More and more of these technologies are gaining clinical validation and regulatory
approval.
218, 219
Promote equitable access to technology that supports the wellbeing of children and youth. For
example, donate digital technology and remote services (e.g., internet access) to under-resourced
populations.
Safety by Design (Australia’s eSafety
Commissioner): Ways technology companies can
minimize online threats and harms before they
occur
Toolkit For Technologists (Center for Humane
Technology): Principles to help create value-
driven and humane technology environments
The Children’s Code (UK’s Information
Commissioner): Standards for online services to
protect children’s safety, rights, and privacy online
The Unseen Teen (Data & Society): A report with
challenges and recommendations on improving
digital wellbeing for adolescent users
The U.S. Access Board: U.S. federal agency
providing technical assistance for content
creators and developers
Resources for Social Media, Video Gaming, and
Other Technology Companies
29
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
ousands of community organizations are doing heroic work every day to support the mental health of
children and young people. While different groups address different parts of the problem, serve different
youth populations, and implement different solutions, all community organizations can keep the
following recommendations in mind as they continue their work:
Educate the public about the importance of mental health, and reduce negative stereotypes,
bias, and stigma around mental illness. Community groups can play a key role in fostering
open dialogue about mental health at the local level and correcting misconceptions and biases.
For example, community groups can partner with trusted messengers such as faith leaders and
health care professionals to speak to community members about youth mental health needs. It’s
particularly important to address misconceptions in populations that have an outsized influence over
young people, such as families, educators, health care professionals, juvenile justice officials, online
influencers, and the media.
Implement evidence-based programs that promote healthy development, support children,
youth, and their families, and increase their resilience. Examples include youth enrichment
programs (e.g., mentoring, after-school programs), skill-based parenting and family relationship
approaches, and other efforts that address social determinants of youth health such as poverty,
exposure to trauma, and lack of access to education and health care. A few respected programs
include e Incredible Years,
220
Strengthening Families,
220
e Martinsburg Initiative,
221
and the
Drug-Free Communities (DFC) Support Program.
222
Ensure that programs rigorously evaluate mental health-related outcomes. For example, track
outcomes around anxiety, depression, and suicide (including ideation, plans, and attempts), as well
as around upstream risk and protective factors (e.g., social connectedness, coping skills, economic
supports).
223
Address the unique mental health needs of at-risk youth, such as racial and ethnic minorities,
LGBTQ+ youth, and youth with disabilities. Youth-serving organizations should think
intentionally about how and to whom program services are offered. For example, actively recruit and
engage populations who have historically been prevented from equal access to opportunities and may
benefit the most from services. Engage with youth to understand what unique barriers prevent them
from accessing mental health services. Recruit program staff directly from communities being served.
Build program staff capacity to recognize personal biases, as well as structural challenges in these
communities. For example, provide training on cultural and linguistic competence and related topics.
What Community Organizations Can Do
WE CAN TAKE ACTION
30
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Elevate the voices of children, young people, and their families. Youth are experts on their own
lives, so it is important to engage youth in community-based mental health efforts. Explore youth
advisory councils and other ways to involve young people in all phases of programming, from
ideation to implementation. Gather feedback to understand what is and isn’t working. Include youth
and families directly in delivering services, for example by creating peer support programs.
Having conversations in your community
(MentalHealth.gov): Provides a toolkit to help
communities and groups plan and facilitate
dialogues about mental health.
Preventing Adverse Childhood Experiences
(ACEs) (CDC): Guidance to equip communities
with the best available evidence for the
prevention of ACEs
A Comprehensive Technical Package for
the Prevention of Youth Violence and
Associated Risk Behaviors (CDC): Strategies
to help communities sharpen their focus on
prevention activities to stop youth violence and its
consequences
Preventing Suicide: A Technical Package
of Policy, Programs, and Practices (CDC):
Strategies to help communities sharpen their
focus on activities to prevent suicide
The Community Guide on Mental Health
(Community Preventive Services Task Force,
or CPSTF): Evidence-based ndings to select
community interventions to improve mental
health
Mentoring for Youth with Mental Health
Challenges (National Mentoring Resource
Center): Research on mentoring for youth (ages
18 and younger) experiencing mental health
challenges
Resources for Community Organizations
31
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Philanthropic and other funding organizations play a critical role in supporting the mental health of
children and young people across the full continuum of need. For example, they can make bets on
promising but untested technologies or programs for which government funding may not be available.
ey can also serve as reliable partners to community-based organizations across the country, and
promote and build cross-sector partnerships. Below are some recommendations for how funding
organizations can support youth mental health:
Create sustained investments in equitable prevention, promotion, and early intervention.
Prioritize interventions that address social and economic factors known to affect children’s healthy
development and mental health, such as poverty, discrimination, and inequality, among others.
224
Incentivize coordination across grantees and foster cross-sector partnerships to maximize reach
and bring together a diversity of expertise. e scale and complexity of mental health issues among
young people require collaborative approaches. Consider leveraging resources across sectors to advance
practices, policies, and research that support the mental health of children, youth, and families. And
support grantees in developing and sharing meaningful mental health outcome measures.
Scale up evidence-based interventions, technologies, and services. Use a structured process to
assess an intervention’s readiness to scale and support high-quality implementation at a community
level.
225
Share information and convene stakeholders to provide education and consultation to spread
innovation.
Invest in innovative approaches and research on mental health. For example, fund participatory
research that involves young people in understanding their online experiences. Develop and test
new solutions, including digitally enabled solutions that can reach young people at scale and in
underserved communities. Consider different kinds of funding models, such as incubators and
accelerators, that can drive funding toward promising projects at very early stages.
226, 227
Elevate and amplify the voices of youth and families in all stages of funding and evaluation.
Listening to young people is critical to understanding what kinds of solutions will work and what
communities need to scale successful interventions. Bring young people, parents, and caregivers to
the table to identify their needs and create ongoing meaningful opportunities to inform grantmaking
strategies and decision-making. Engage youth from different identities and backgrounds—
particularly those that come from vulnerable communities.
What Funders and
Foundations Can Do
WE CAN TAKE ACTION
32
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Grantmakers in Health: Resources for health
funders to learn, connect, and grow
Incorporating Youth Voice and the Lived
Experience in Research (NAM): Seminar
examining the importance of including youth
voices in research
Health in Mind: A Philanthropic Guide for
Mental Health and Addiction (UPenn Center for
High Impact Philanthropy): Guidance for funders
on mental health and addiction
COVID-19 Pandemic: Supporting Mental Health
(UPenn Center for High Impact Philanthropy):
Guidance for funders on how to help individuals
and communities struggling with the stress of
COVID-19
The Promise of Adolescence (NAM): Report
supported by the Funders for Adolescent
Science Translation (FAST) Collaborative with
recommendations for funders and other
adolescent-serving systems on supporting young
people’s development
Disability & Philanthropy Forum: Resources to
advance disability inclusion in philanthropy
Resources for Funders and Foundations
33
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Employers can play an outsized role in supporting the mental health of children and young people. ey
can directly help younger employees, such as high school students working part-time jobs or young
adults starting out in the labor force after high school or college. For example, employers can provide
affordable health insurance that covers mental health needs.
Employers can also support children and youth indirectly. For example, they can offer insurance
coverage for employees’ dependent children, offer parent-friendly benefits such as family leave and
childcare, and promote work-life balance and a positive culture at work to reduce family stress.
Below are some recommendations for how employers can support the mental health of young people:
Provide access to comprehensive, affordable, and age-appropriate mental health care for all
employees and their families, including dependent children. Research shows that parental mental
health challenges not only impact their productivity in the workplace, but can also affect the mental
health of their children.
228, 229
Employers should offer health insurance plans that include no or low
out-of-pocket costs for mental health services, and a robust network of high-quality mental health
care providers.
Implement policies that address underlying drivers of employee mental health challenges,
including both home and workplace stressors. Employers should:
Offer paid family leave and sick leave where feasible. Consider additional employee benefits such
as respite care for caregivers and mental health and wellness tools.
Help caregivers secure affordable childcare, or offer more flexible work arrangements. is can
reduce stress and improve productivity.
230, 231
Ensure employees are aware of and can easily make use of these benefits. For example, include
information on mental health benefits in emails, webinars, and during onboarding and training
for all new hires.
Create a workplace culture that affirms the importance of the mental health and wellbeing of all
employees and their families.
Create space for employees to speak up about how they are feeling and encourage company leaders
to serve as role models for discussing mental health and modeling healthy behaviors. For example,
ensure that senior leaders take advantage of benefits such as paid leave and vacation days.
What Employers Can Do
WE CAN TAKE ACTION
34
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Solicit ideas from employees about how to support their mental health and wellbeing as well as
that of their children and families.
Adopt clear messaging that promotes mental health awareness and addresses common
misconceptions about mental health (for example, that mental health issues are not a sign of
weakness).
Provide managers and supervisors with training to help recognize negative mental health
symptoms in themselves and colleagues and encourage employees to seek help.
232
Mental
health employee resource groups, for example, can help increase mental health awareness, build
community, and offer peer support.
Regularly assess employees’ sense of wellbeing within the workplace. Tools such as employee
surveys can help employers understand the wellbeing of employees across demographic groups (e.g.,
gender, race, sexual orientation), levels of seniority, business units, and geographies, and to identify
opportunities for improvement. Employers should make sure to assess the wellbeing of young adults
just starting out in the workforce, as well as of parents with young children.
Center for Workplace Mental Health (American
Psychiatric Association Foundation): Resources
to help employers create a more supportive
workplace environment
Work and Wellbeing Initiative (Harvard-MIT
Collaboration): Employer toolkit to help improve
workplace conditions and list of employee
assessment tools
What Works Wellbeing (UK): UK’s independent
body for wellbeing evidence, policy, and practice.
For example, see example employee wellbeing
snapshot survey.
Employer’s Guide to Digital Tools and Solutions
for Mental Health (One Mind PsyberGuide):
Information for employers on digital mental
health solutions for employees
Generation Work (Annie E. Casey Foundation):
Research briefs, blogs, and tools to help
employers of youth better understand and
integrate positive youth development approaches
Mental Health Toolkit (Employer Assistance
and Resource Network on Disability Inclusion):
Background, tools and resources to help
employers learn more about mental health
and cultivate a welcoming and supportive work
environment
Oce of Disability Employment Policy
(Department of Labor): Resources for disability-
related workplace policies and practices
Resources for Employers
35
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Note: For actions taken by the Biden Administration from January to October 2021 to support youth mental health, see
Fact Sheet: Improving Access and Care for Youth Mental Health and Substance Use conditions.
Ultimately, youth mental health challenges cannot be addressed solely by the efforts of youth, their
families, local communities, and private organizations. Federal, state, local, and tribal governments all
have a role to play. While the below recommendations are not comprehensive, their implementation
would mark an enormous step forward in supporting youth and their families:
Address the economic and social barriers that contribute to poor mental health for young
people, families, and caregivers. Priorities should include reducing child poverty and ensuring
access to quality childcare, early childhood services, and education; healthy food; affordable health
care; stable housing; and safe neighborhoods with amenities such as parks and playgrounds. Recent
federal investments in child poverty reduction, safe school reopening, and other pandemic-related
measures represent historic progress on this front, but additional investments are needed at all levels
of government.
233
Emphasis should be placed on preventing adverse childhood experiences (ACEs),
which are strong risk factors for mental health challenges.
12
Take action to ensure safe experiences online for children and young people. Example
opportunities include but are not limited to increasing investment in research on the role of
social media and technology in youth mental health; educating consumers about potential mental
health risks online; requiring companies to be more transparent with researchers and the public
(e.g., disclosing meaningful data for research purposes, enabling systemic auditing of social media
algorithms), and developing safety standards for online services (e.g., standards for data collection,
age verification, user engagement techniques such as ‘nudges’, and advertising aimed at kids and
teens). For instance, the United Kingdom’s Age appropriate design code has led companies including
Instagram, TikTok, and YouTube to announce product changes to protect their users’ safety, rights,
and privacy.
234, 235
In addition, the Australian government’s Safety by Design initiatives have resulted
in a set of principles for user safety, tools for companies to assess their safety practices, resources for
investors and financial entities to manage online safety risks, and a pilot program with universities to
embed Safety by Design materials into curricula.
236
What Federal, State, Local, and
Tribal Governments Can Do
WE CAN TAKE ACTION
36
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Ensure all children and youth have comprehensive and affordable coverage for mental health
care. Example opportunities include strengthening public and private insurance coverage for
children and young adults (e.g., by promoting enrollment), ensuring adequate payment for pediatric
mental health services, investing in innovative payment models for integrated and team-based care,
increasing the participation of mental health professionals in insurance networks, and ensuring
compliance with mental health parity laws.
237
Local, state, and tribal governments can access outreach
and enrollment resources to help enroll and retain eligible children in Medicaid and CHIP at
InsureKidsNow.gov.
Support integration of screening and treatment into primary care. For example, continue
expanding Pediatric Mental Health Care Access programs, which give primary care providers
teleconsultations, training, technical assistance, and care coordination to support diagnosis,
treatment, and referral for children with mental health and substance use needs.
238, 239, 240
Expanding
screening for ACEs is also critical. For instance, California recently enacted a law that will
significantly expand coverage for ACEs screening.
241
Provide resources and technical assistance to strengthen school-based mental health programs.
Example opportunities include improving education about mental health, increasing screening of
students for mental health concerns, investing in additional staff (e.g., school counselors) to support
student mental health needs, improving care coordination, and financing school-based mental health
services. As mentioned in the earlier section with recommendations for educators, the American
Rescue Plan's Elementary and Secondary School Emergency Relief funds can be used for these
purposes, along with Project AWARE (Advancing Wellness and Resilience in Education) program
funds, which provide support for state, local, and tribal governments in building school-provider
partnerships and coordinating resources to support prevention, screening, early intervention, and
mental health treatment for youth in school-based settings.
242
In California, a recent law will ensure
that all middle and high school students learn about mental health in health education classes.
243
And, in New Jersey, a recent program will provide funding for school districts to screen students for
depression.
244
Invest in prevention programs, such as evidence-based social and emotional learning. Example
opportunities include implementing developmentally appropriate social and emotional learning
standards and programs, supporting professional development for educators, and providing funding
for teachers and school leaders to work with families to support student health needs. For example,
the CDC’s Legacy for Children program, which promotes positive parenting among low-income
mothers, has been found to improve children’s behavioral, social, and emotional health.
245
Expand the use of telehealth for mental health challenges. Example opportunities include
addressing regulatory barriers (such as limits on provision of telehealth across state lines), ensuring
appropriate payment, and expanding broadband access. For instance, Colorado recently established
the “I Matter” program, offering young people three free behavioral health sessions, primarily via
telehealth.
246
37
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Expand and support the mental health workforce. Example opportunities include investing in
training and hiring individuals from a broader set of disciplines (e.g., peer supports, community
health workers, family counselors, care coordinators), accelerating training and loan repayment
initiatives, supporting the mental health and wellbeing of health workers, and recruiting a diverse
workforce that reflects local communities. In the school setting, governments should invest in
building a pipeline of school counselors, nurses, social workers, and school psychologists.
253
Expand and strengthen suicide prevention and mental health crisis services. Example
opportunities include providing flexible funding to fund crisis care needs, increasing access to
intensive outpatient and other "step-down" programs, supporting access to trauma-informed services
for traumatized children, implementing the 988 mental health crisis and suicide prevention hotline,
and promoting public awareness of crisis hotlines and other resources. Governments should also
collaborate with the private sector and local communities to reduce access to firearms and other lethal
means of suicide and promote best practices such as safe storage.
Improve coordination across all levels of government to address youth mental health needs.
One example is to ensure households eligible for social services and supports are receiving them.
For instance, states can align renewal processes across Medicaid and the Supplemental Nutrition
Assistance Program (SNAP), use data from SNAP files to complete Medicaid renewal, and allow
qualified entities like schools to make presumptive eligibility determinations.
247
Support continued reduction in biases, discrimination, and stigma related to mental health.
Example opportunities include enforcing laws that support the needs of at-risk youth (e.g., students
with disabilities), identifying and improving policies and programs that inappropriately target or
harm youth with mental health needs, and conducting targeted education campaigns to address
stigma, promote new cultural norms, and increase safety and trust in local communities.
Support the mental health needs of youth involved in the juvenile justice system. Example
opportunities include investing in alternatives to incarceration (e.g., school, probation, and police-
based diversion models for youth with mental health needs
248
), expanding mental health training
for staff, supporting high-quality and trauma-informed mental health care inside these systems, and
improving coordination across different youth-serving agencies.
249
Support the mental health needs of youth involved in the child welfare system. Example
opportunities include expanding family-centered mental health services to prevent unnecessary
entry and increase reunification;
250
ensuring youth and caregivers are informed about medications;
investing in peer support services; providing mental health services before, during, and after new
placements and when emancipating from foster care;
251
ensuring youth have access to mental health
services in community settings whenever possible; and avoiding unnecessary placements in non-
family settings. Coordination should be improved across different youth-serving agencies.
See “Where Additional Research is Needed” section for recommendations specific to research and data on
youth mental health
38
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Despite the evidence that millions of young people are suffering and in crisis, there is still a lot we
don’t know. Below are recommendations for the kinds of research questions and studies that should be
prioritized to better understand and address youth mental health needs:
Improve mental health data collection and integration to understand youth mental health
needs, trends, services, and evidence-based interventions.
Today, data on youth mental health are collected and analyzed by multiple agencies and often
take months or years to be released. e federal government should strengthen research and
data integration across governments, health systems, and community organizations to ensure
regular, longitudinal surveillance of national mental health trends across the age continuum.
Data collection and data linkages should be improved to enable real-time surveillance (e.g., at the
census tract level).
Data should be able to be disaggregated to enable analysis of trends (by age, gender, race,
ethnicity, disability status and type, sexual orientation, socioeconomic background, family
characteristics, insurance status, etc.)
252
Foster public-private research partnerships. For example, academic partners, community-based
organizations, technology companies, health care companies, and others can partner to conduct novel
studies using nontraditional data sources (e.g., data from wearables and online platforms) to better
understand needs, track outcomes, and evaluate risk and protective factors for youth mental health.
Increase investments in basic, clinical, and health services research to identify treatment targets
for mental health conditions and develop innovative, scalable therapies. For example, conduct
research to optimize stepped-care approaches to treatment for youth populations (e.g., different
kinds of cognitive-behavioral therapy such as self-guided, computerized, and group-based vs. solely
individual therapy).
253
Prioritize data and research with at-risk youth populations, such as racial, ethnic, and sexual
and gender minority youth, individuals from lower socioeconomic backgrounds, youth with
disabilities, youth involved in the juvenile justice system, and other groups.
254
Researchers
and research sponsors should ensure that these populations are represented in basic, translational,
effectiveness, and services research studies. is will help improve understanding of disparities in risk
and trajectories for mental illnesses, responsiveness to interventions, and access to, and engagement
with, quality mental health services.
WHERE ADDITIONAL
RESEARCH IS NEEDED
39
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
Advance dissemination and implementation science to scale up and improve compliance with
evidence-based mental health practices in systems that serve children, youth, and their families.
For example, appropriate funding agencies can prioritize demonstration projects of effective evidence-
based interventions in and across schools or other systems (e.g., primary care offices, clinics, treatment
facilities, family services, child welfare settings, juvenile justice settings). Translate findings into
actionable policy proposals and disseminate them effectively to improve adoption of best practices.
Conduct research to expand understanding of social media and digital technology’s impact
on youth mental health and identify opportunities for intervention. For example, explore the
impact of frequent exposure to social comparisons, hateful speech, and graphic content on children
and youth, and which groups are most- and least-affected. Also, identify opportunities for families
to engage with youth around social media as a means of connection, and offer guidance in handling
difficult interactions and content. Explore how pre-existing mental health status and environmental
conditions in young people’s lives inform how they engage with and experience content online, and
empower young people with effective strategies (e.g., mood management) to actively manage their
online experiences.
40
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
CONCLUSION
As we learn the lessons of the COVID-19 pandemic, and start recovering and rebuilding, we have an
opportunity to offer a more comprehensive, more fulfilling, and more inclusive vision of what constitutes
public health. And for a generation of children facing unprecedented pressures and stresses, day in and
day out, change can’t come soon enough.
It won’t come overnight. Many of the recommendations offered in this Advisory require structural buy-in
and change.
But everyone has a role to play in combating this mental health pandemic. Without individual
engagement, no amount of energy or resources can overcome the biggest barrier to mental health care:
the stigma associated with seeking help. For too long, mental and emotional health has been considered,
at best, the absence of disease, and at worst, a shame to be hidden and ignored.
If we each start reorienting our priorities to create accessible space in our homes, schools, workplaces,
and communities for seeking and giving assistance, we can all start building a culture that normalizes and
promotes mental health care.
is is the moment to demand change—with our voices and with our actions.
Only when we do will we be able to protect, strengthen, and support the health and safety of all children,
adolescents, and young adults—and ensure everyone has a platform to thrive.
41
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
ACKNOWLEDGMENTS
is Advisory was prepared by the Office of the Surgeon General (OSG) with contributions from the
following interagency partners:
Department of Health and Human Services
Administration for Children and Families (ACF)
Administration for Community Living (ACL)
Behavioral Health Coordinating Council Subcommittee on Children and Youth
Centers for Disease Control and Prevention (CDC)
National Center for Injury Prevention and Control (NCIPC)
National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP)
Division of Adolescent and School Health (DASH)
Centers for Medicare and Medicaid Services
Center for Medicaid and CHIP Services
Food and Drug Administration (FDA)
Office of Pediatric erapeutics
Health Resources and Services Administration (HRSA)
Maternal and Child Health Bureau (MCHB)
Indian Health Service (IHS)
National Institutes of Health (NIH)
National Institute of Mental Health (NIMH)
National Institute on Drug Abuse (NIDA)
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
Office of the Assistant Secretary for Health (OASH)
Office of Minority Health (OMH)
Office of the Assistant Secretary for Planning and Evaluation (ASPE)
Office of Human Services Policy (HSP)
Office of Behavioral Health, Disability, and Aging Policy (BHDAP)
Substance Abuse and Mental Health Services Administration (SAMHSA)
Additional Partners
Department of Education
Office of Special Education and Rehabilitative Services (OSERS)
Department of Justice (DOJ)
Office of Justice Programs (OJP)
White House Domestic Policy Council (DPC)
White House Office of Science and Technology Policy (OSTP)
Note: Examples and external resources in this advisory are provided for informational purposes only, and their
inclusion does not constitute an endorsement by any government office or agency.
42
Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory
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