About two years ago, Suzanne noticed that her daughter was getting thinner and thinner. The Ottawa resident suspected that her daughter, then 14, had developed bulimia. By December 2019, she was struggling to get out of bed and looked gravely ill. Her parents were worried about her heart: purging — a symptom of bulimia that can involve self-induced vomiting, laxative misuse, and other behaviours — can cause imbalances of the electrolytes that help maintain a regular heart rhythm.
In January 2020, Suzanne’s daughter agreed to go on a wait-list for an eating-disorder clinic at the Children’s Hospital of Eastern Ontario. About two months later, as COVID-19 began upending the world, their family doctor instructed her to go to the emergency room immediately. She was admitted to the hospital’s inpatient eating-disorder program later that day.
Suzanne says that, because of the pandemic, group therapy and recreational programming weren’t running at the time, and the eating-disorder unit had been temporarily relocated to the mental-health ward, which, she says, had stricter regulations. Her daughter saw clinicians regularly, but because of physical-distancing protocols, she was not allowed contact with other patients. Either Suzanne or her husband would stay with their daughter during the day — if they hadn’t been able to, she says, their daughter would have mostly sat alone in her room.
“It was terrible. With no structured programming, my daughter was basically in prison. She was confined to her room for the whole day,” Suzanne tells TVO.org via email. About a week later — after her daughter’s vital signs had stabilized — she was discharged. Six weeks later, she was re-admitted, this time for almost four weeks. “Still with no programming in place,” Suzanne writes. “Still a prison.”
Leanna Isserlin, medical director for CHEO’s eating-disorders program, tells TVO.org in an email that the hospital merged its eating-disorder and mental-health units in spring 2020, allowing it to retain staff, “who were then redeployed to meet community needs.” She also writes that CHEO was not able to run group programming during the start of the pandemic, as “at that time much was still unknown about the safety of bringing patients together, and what we did know was that mental health units are particularly vulnerable to outbreaks because patients often move around and interact differently than patients on medical floors.”
Since being discharged, Suzanne’s daughter has returned to the hospital every two or three weeks for weigh-ins and bloodwork. But her behavioural therapy and other appointments are provided virtually. Suzanne says this is “torture” for her daughter, because she has developed body dysmorphia — a condition marked by an intense focus on perceived defects in one’s appearance — and struggles to look at herself on video. “The people we work with are amazing; they are genuinely concerned and very conscious of her situation,” Suzanne says in an interview. “But what I have to remember is that we see them an hour every week or two, and there’s hundreds of other people just like my daughter who they’re seeing. It’s a big workload for them.”
For this story, TVO.org spoke with 25 experts and family members and heard from 12 Ontario hospitals: what they had to say suggests that the pandemic has increased the need for mental-health services among children and youth, most dramatically among those with eating disorders. And, clinicians say, young people are showing up to emergency rooms in more serious condition than before.
The pandemic is further straining a system that was already overwhelmed. As of January 2020, Children’s Mental Health Ontario estimates, 28,000 children and youth were waiting for mental-health care in the province; some had been waiting as long as two and a half years. Experts say the pandemic will only widen the gaps in the system, leaving youth and families in desperate need of care with few options.
“We are an under-resourced sector, and now we’re seeing the stress of that,” says Peter Szatmari, chief of the Child and Youth Mental Health Collaborative, which involves the Centre for Addiction and Mental Health, the Hospital for Sick Children (SickKids), and the University of Toronto. “And, yes, the wait-lists are growing. And the longer the wait-list, the more difficult it is to ensure that these kids have a good long-term outcome.” (According to research published in The Canadian Journal of Psychiatry, “major mental disorders such as major depression, bipolar disorder, and psychotic disorders that begin early mostly continue through adult life. Given their age at onset of such disorders, delays and missed opportunities for intervention are alarming.”)
Over the past year, the Ontario government has allocated some funding to the sector. In October 2020, the Ministry of Health announced $24.3 million to hire additional staff, increase access to counselling and therapy, create new programs, and address eating disorders. A ministry spokesperson tells TVO.org via email that the funding will include $3.7 million in 2020 for an eating-disorder-prevention and early intervention program and $800,000 for the creation of Eating Disorders Ontario, which they describe as a new entity “in development.” This funding is meant to “fill a total lack of services for eating disorders prevention and early intervention in the province,” they write.
And in February of this year, the ministry announced up to $10.5 million to expand secure mental-health treatment — intensive inpatient care for children who are at risk of self-harm or of causing harm to others — at such facilities as Oakville’s Syl Apps Youth Centre. (Less than a week later, the Ministry of Children, Community and Social Services cut funding for the centre’s intensive mental-health program for youth in custody or detention, leaving advocates “confused.”)
“Any time funding is sprinkled provincially, it’s usually in the form of arbitrary pilot projects and photo-ops for provincial governments to sprinkle here and there at politically convenient times,” says Javeed Sukhera, a child and adolescent psychiatrist in London and past president of the Ontario Psychiatric Association. “But we’re in a funding desert in child and youth mental health. It is so parched and dry that if you throw a thimbleful — or even a cupful — of water, it’s going to quickly absorb and stay dry.”
Kim Moran, CEO of the advocacy group Children’s Mental Health Ontario, says that, on the whole, the system is still failing to provide adequate care for children: “It’s akin to somebody who has stage-four cancer, and you’re just providing Tylenol. It’s just wrong.”
In the 14 months since COVID-19 first closed schools to in-person learning, youth have missed graduations, summer jobs, and sports competitions. They’ve had to go without family visits, after-school programs, and playdates. They’ve had to confront uncertainty and a loss of routine. And some have been forced to contend with heightened poverty, violence in the home, or the death of a loved one.
Sarah Hudson, who leads the Orangeville chapter of Parents for Children’s Mental Health, a provincewide family-support network, says that the pandemic has been “catastrophic” for the mental health of her 12-year-old daughter, who has selective mutism (an anxiety disorder), autism, and other special needs.
School has been a challenge for her daughter due to a lack of support staff and changing teachers, says Hudson, a single mother and front-line worker. Her daughter has switched between different online-learning schedules and in-person classes. She was “breaking down every day,” Hudson says. “A lot of kids with special needs or mental-health issues don’t adapt that easily; it’s months and months of working on things and a lot of meltdowns and anguish within the families to try to get this stuff organized. This is hard on everybody, but as adults, we can at least try to understand and cope. But kids have no clue — they just know things are chaotic.” Hudson also says that her younger daughter, who is seven years old, has become depressed and angry because of the pandemic.
Hudson’s children are not alone. In 2020, children across Canada reached out to Kids Help Phone for mental-health support 4.5 million times, up from 1.9 million in 2019. (In 2020, there were about 6 million children aged five to 19 living in Canada.) In Ontario last year, the most commonly discussed issues on the service’s text line were relationships, anxiety and stress, depression, suicide, and isolation.
“If you look at some of our younger callers, they’re talking about missing friends, not having that typical structure of school, and not being able to do after-school activities,” says Kate May, a counselling manager at Kids Help Phone. “For teenage or high-school-age callers, they’re not able to have the same rites of passage and developmental milestones.”
In a paper released in February 2021, SickKids researchers found that most of the Ontario children surveyed reported worse mental health during initial lockdown measures last year — and that those with pre-existing mental-health diagnoses reported the most significant deterioration.
Christina Bartha, executive director of the Brain and Mental Health Program at SickKids, says that, early in the pandemic, data showed “an unusual dip” in the number of kids presenting in the emergency room, possibly because situational stressors that might lead to mental-health challenges had lessened: “There wasn’t the pressure of exams; there wasn’t the pressure of social dynamics that they might have been dealing with.” But as the fall came around, Bartha says, more kids needed help: the longer children and youth stayed at home, the more their socialization was disrupted. Several hospitals told TVO.org that fear of the virus, particularly in the first wave, also kept many people away.
That fear is reflected in the data: in the first seven months of the pandemic, childhood visits to emergency rooms in Ontario — for all reasons — plummeted by 44 per cent compared to the same period the year before, according to figures provided to TVO.org by the Canadian Institute for Health Information. Mental-health-related visits and hospitalizations, however, dropped just 32 and 23 per cent, respectively. The Children’s Hospital of Eastern Ontario saw an even starker pattern: total emergency-room visits dropped by 41 per cent between March 2020 and January 2021 compared to the same period the year before, but mental-health-specific visits declined just 26 per cent and self-harm-related visits 4 per cent.
Some hospitals have, however, recorded increases in mental-health patients. The Children’s Hospital at the London Health Sciences Centre, for instance, recorded a “significant increase” in mental-health-related emergency-room visits. In Toronto, Sunnybrook Hospital’s Family Navigation Project, a program that helps youth and their families navigate the mental-health system, opened more than 1,100 new files in 2020, up from around 600 the year before. Several hospitals also said that, despite initial dips, their numbers are trending upward again.
And hospitals and clinicians say that the number of children and youth seeking treatment for eating disorders this year is surging. SickKids is reporting a 55 per cent increase in eating-disorder admissions. Southlake Regional Health Centre, in Newmarket, has seen a 39 per cent increase in referrals to its outpatient eating-disorder program for young people. In Sudbury, the wait time for Health Sciences North’s outpatient eating-disorder program for children and adults has grown to 204 days this year, up from 114 in 2018-19.
David Murphy, director of the Children’s Hospital of Eastern Ontario’s mental-health program, says the hospital has seen a “frightening surge” in eating-disorder cases: inpatient admissions are up 63 per cent since the pandemic started, as compared to the same period last year. “It also speaks to the medically compromised state that many of these young kids are showing up in our emergency department — unfortunately, many are requiring inpatient services as that first step,” he says. “We want to be getting to these kids much earlier.” Medically compromised patients, he notes, can have a resting heart rate of fewer than 45 beats per minute; the average for a child over the age of 10 is between 60 and 100.
According to Bartha, one reason for the steep rise in eating disorders could be the social isolation and loss of routine youth faced at the onset of the pandemic. Increased access to the internet, where they are “watching various videos that are reinforcing preoccupation with body image, dieting, and exercise,” could also be a contributing factor, she says. “For kids with pre-existing vulnerability to some of these issues, this became a real risk.”
Several other clinicians also told TVO.org that children are showing up to their care in more serious condition. Sarosh Khalid-Khan, a child and adolescent psychiatrist at the Kingston Health Sciences Centre, says that the patients coming in now often require “more in-depth care.” For instance, more eating-disorder patients now also need treatment for co-existing anxiety and depression, she says. “Everybody is on high alert.”
COVID-19 has also paused in-person group therapy and made virtual care the primary delivery method in many mental-health-care settings. Sukhera, the past president of the Ontario Psychiatric Association, says that, while the “explosion” in virtual care has improved access in some ways — such as for those who lacked adequate transportation — many young people lack access to private spaces, internet, and devices.
The fact that many services are delivered over the phone, says Toula Kourgiantakis, an assistant professor at U of T’s Factor-Inwentash Faculty of Social Work, also presents a challenge. “For mental health, that doesn’t cut it,” she says. “We need to actually see the person to be able to do a proper assessment.”
According to Cynthia Weaver, chief operating officer of the community-based mental-health provider Kinark Child and Family Services, a number of the children the organization works with haven’t managed well virtually. “For some youth who have fairly significant and complex mental-health issues, they really need to connect in person,” she says. “And when they get into crisis, they really do need that individual support within the same room as them.”
COVID-19 created “the perfect storm” for Amber to relapse, her parents say. The 18-year-old dealt with anorexia five years ago. Until December 2019, she’d been doing well, Amber tells TVO.org, but she then began experiencing a slow relapse. In February, she broke her foot, meaning she had to miss the rest of her volleyball season. By the time COVID-19 arrived in March, what had seemed like a temporary setback had escalated into something more. “COVID didn’t start, but intensified, my relapse,” Amber says. (TVO.org has changed Amber’s name and those of her family members to protect their identities.)
Last March, the family, who live in Burlington, began seeking care at McMaster Children’s Hospital. A pediatrician started monitoring Amber’s health and, after a few virtual appointments, suggested that she be admitted. Between May and September, she was admitted four times.
The family looked for treatment programs in the community, but they were told that the average wait time was about four months. Although the hospital offered psychotherapy and some social-work services, they became primarily responsible for maintaining Amber’s health.
“While you’re on wait-lists, you just really are waiting, with nothing,” says Hannah, Amber’s mother. According to Amber’s father, Tom, hospital admission seemed like the only option, even though the family knew it was not a sustainable one. Some residential programs told them that Amber could not be admitted until she had reached a higher body-mass index and her health was less at risk. “It’s a bizarre concept,” says Tom. “You have to be sick but not too sick,” Hannah says. And in hospital, Tom adds, “you can only be sick until you’re just well enough.”
According to Moran, the CEO of Children’s Mental Health Ontario, this pattern reflects the lack of specialized eating-disorder-treatment programs in the community: “All the resources are really located in hospitals. If you’re a parent, you want to get [your child] help before they are acutely ill, but all the resources are focused around being acutely ill … We wait until kids are critically ill until we act.”
During one admission over the summer, Amber says, she was not given the option to stay in the hospital after she was medically stable to further her recovery — although she had been given that option in the past. A staff member came into her room to tell her that she was going to be discharged, she says: “They just needed my bed. And so they sent me home that day. It was kind of scary because it happened so fast.” A spokesperson for McMaster Children’s Hospital tells TVO.org via email that its inpatient unit has been “managing an unprecedented volume of children and youth requiring admission” and that, because of the enormous demand for beds in recent months, the program has had to discharge patients as soon as they are medically stable. They note, however, that resource information and a recommendation for follow-up are always provided.
After Amber turned 18, in October 2020, becoming ineligible for treatment at the children’s hospital, the family found itself in and out of the emergency room at the Oakville Trafalgar Memorial Hospital. During one admission, Amber waited three days in the emergency department, then spent six weeks on the hospital’s cardiac floor. (Oakville Trafalgar does not have an inpatient eating-disorder unit.) In March, Amber was admitted to an inpatient program at Toronto General Hospital, where she stayed for almost a month.
She’s been “a trouper through all of this,” Tom says. “But it’s extremely emotionally exhausting for her because it’s physical and mental.” The family says they are grateful for the care Amber has received but that more needs to be done for their daughter and for families like theirs. “There’s some hope,” Tom says. “There are just a bunch of gaps.”
To close such gaps, CMHO in January 2020 called for $150 million in additional annual funding for community child and youth mental-health services to facilitate the hiring and training of 1,400 front-line professionals and ensure that no child or young person has to wait longer than 30 days for counselling or psychotherapy.
Sukhera says that the human cost of the lack of investment is “staggering” and can have lasting effects. “If you’re someone who struggles and is suffering and you’ve built up all the courage in the world to ask for help — in a system that you’re afraid might shame you or blame you for being vulnerable — and you don’t get it, that is disastrous in so many ways.”
Difficulties accessing treatment during the pandemic has taken a toll on both Michelle and her 12-year-old daughter, who live in Vaughan. Last March, Michelle noticed her daughter’s increasing desire to work out. At first, it didn’t seem like an issue. But then, she says, “You start seeing the weight loss and seeing the face chiselled, and then family members would make comments about it, too. And then you realize this is serious; it’s not in my head. This has become something extremely unhealthy.”
Michelle sought guidance from a pediatrician, who ordered bloodwork and an electrocardiogram. After the results came in, Michelle says, the doctor told her to rush her daughter to the emergency room. They went to Southlake Regional Health Centre and waited for two hours, she says, and then an emergency-room doctor told her that her daughter was within the normal weight range. “The fact that [Southlake] sent us home validated to my daughter that she didn’t have an eating disorder. It made things worse.” A spokesperson tells TVO.org via email that, for privacy reasons, Southlake cannot comment on the care that individual patients receive. They note that the centre has seen a significant increase in the need for inpatient and outpatient eating-disorders care and that there are on average four to five patients waiting on the pediatric unit for inpatient eating-disorder treatment.
A few months later, the pediatrician again told Michelle to go to the emergency room. This time, Michelle says, her daughter’s weight was not considered healthy — when her husband took their daughter to North York General Hospital, she was admitted on the spot.
Hamilton resident Ashley Keats fought for almost a decade to get treatment for her 15-year-old daughter, who’s experienced mental-health issues since she was six. After a combination of publicly and privately funded assessments, her daughter was diagnosed with ADHD, disruptive mood dysregulation disorder, oppositional defiant disorder, a learning disability, and other challenges.
About a year and a half ago, Keats was running out of options to keep her daughter at home: her daughter’s school expressed concern about comments her daughter had made about harming Keats and herself. She lived for a short while with her grandparents, who eventually brought her to the McMaster Children’s Hospital. Upon her daughter’s discharge — which coincided with the start of the COVID-19 pandemic — Keats signed a temporary care agreement with the Children’s Aid Society, which took responsibility for her. After that, her daughter ping-ponged between a foster home, where she was kicked out for throwing a boot at a staff member; the children’s hospital; a hotel room, where she was watched by support staff; and several residential facilities.
In April, Keats’s daughter finally found a spot at the Child and Parent Resource Institute — a specialized treatment facility in London. “If I didn’t go through the steps that I did, in giving up completely, we would never have gotten to where we are now,” Keats says. The Ministry of Children, Community and Social Services is seeking a residential placement for her daughter, but, so far, no facility has been willing to accept her. “I’ve tried everything that you’ve got to offer, and here we are,” she says. “So what do we do? What’s the next step? Because at the end of the day, my kid is not any better for it.”
Michelle Dermenjian, director of child and youth services at Hands, a provider of mental-health treatment in northern Ontario, says that in the past six months, her organization has been working to prevent 18 cases of so-called family breakdown, a level it hasn’t seen before. “It’s parents saying, ‘I can’t parent my child anymore,’” she explains.
In the north, Dermenjian says, resources are especially limited. (The Ministry of Health spokesperson says that the government invested over $12.8 million in “community-based mental health supports and services by collaborating with Indigenous partners,” including $1 million for the expansion of a child- and youth-psychiatry program based in Thunder Bay.) Hands needs at least 10 more therapists but can’t afford to hire them, and its wait-lists are growing: “In the past, families would have waited three to six months. They’re now waiting nine to 12 months or more for therapy, unless they are priority pick-up,” meaning they’re suicidal, have a life-threatening eating disorder, or have witnessed violence. “And what does that do to the capacity of a youth and a youth’s family as they sit by — and in the isolation of COVID?”
Since the pandemic began, the Parents’ Lifeline of Eastern Ontario has fielded more and more calls to its peer-support line for families of children with mental-health challenges, says Elyse Schipper, the organization’s executive director. Callers and participants in its now-virtual support groups, she notes, often start by saying that they feel “isolated, stressed, and alone” — but peer support helps ease those feelings. “The thing that is not solved quickly is that they feel like they are out of capacity and resilience, which is a harder thing to build in a pandemic.”
While clinical support is still available, Schipper says, the pandemic has disintegrated families’ informal support systems — including after-school programs, neighbours, and family. “A lot of the supports that were keeping kids and families okay are gone,” she says. “When you need to go into crisis mode, you do, and you’re kind of run by adrenaline. But when it’s gone on for a year, your system just can’t take it anymore.”
Back in Ottawa, Suzanne says that her daughter continues to struggle and that she spends much of the day in her darkened bedroom on her phone, not engaging much with online school. Her daughter has continued online therapy and in-person check-ins at their local children’s hospital and is on wait-lists for both a virtual day program and an inpatient bed, but Suzanne says she doesn’t know when either will become available. A CHEO representative tells TVO.org that the wait for the virtual day program has typically been about two to four weeks over the past year.
“I feel like she’s being monitored. I don’t feel like she’s slipped through the cracks,” Suzanne says. “But I feel like it’s just keeping her head above the water — it’s not giving her anything to stand on. It’s just, ‘Let’s keep her alive.’”
If you’re a young person struggling with your mental health, you can reach a counsellor with Kids Help Phone 24/7 by calling 1-800-668-6868 or by texting CONNECT to 686868. People of any age who are experiencing thoughts about suicide or know someone who is can call the Canada Suicide Prevention Helpline 24/7 at 1-833-456-4566 or text 45645 between 4 p.m. and midnight for support.
Ontario Hubs are made possible by the Barry and Laurie Green Family Charitable Trust & Goldie Feldman.
The authors speak to Jeyan Jeganathan on The Agenda, May 7, 2021.
This story has been updated with comment from the Ministry of Health.
Correction: An earlier version of this article indicated that the Ministry of Health cut funding for the intensive mental-health program at the Syl Apps Youth Centre; in fact, the Ministry of Children, Community and Social Services was responsible for the funding decision. TVO.org regrets the error.