Triple Threat

By Stephen Gray Wallace

COVID-19 has wrought so many unforeseen consequences for youth mental health that it’s almost hard to quantify them. Some were recently noted by the Centers for Disease Control and Prevention (CDC), which stated that mental-health related emergency room visits for children aged 12 to 17 increased by 31 percent from April through October 2020. These included reports of increased anxiety, depression, schizophrenia, self-harm, and substance abuse (SOS Children’s Villages, 2021).

And those are the ones we’ve come to expect from this pandemic going on endemic.

Buried beneath those threats to young people are a few other COVID-related maladies: eating disorders, tic disorders, and fentanyl overdoses.

According to the CDC, teenage girls had an increased risk of developing eating disorders during the pandemic. In fact, the CDC states that the proportion of emergency room visits due to eating disorders doubled. And diagnoses of tic disorders tripled. Tic disorders are characterized by repeated twitches, movements, or sounds that people do involuntarily (CDC, 2022).

Dr. Neha Chaudhary, a child psychiatrist at Harvard Medical School, told ABC News, “‘The results of the report are unsurprising … This is quite in line with what I’m seeing in my clinical practice and what I’m hearing from teens directly. Many teens with preexisting conditions like depression or anxiety noted worsening of their symptoms since the pandemic, while others without previously diagnosed conditions noted having symptoms for the first time’” (Aboubakr and Salzman, 2022).

It appears that stress can be a trigger for these conditions, and we already know there’s no shortage of that to go around.

Chaudhary continued, “‘Teens everywhere have been hit harder than most groups by the stress of the pandemic … It’s no wonder that their mental health has been declining when their usual supports — like structure, routine and peer connections — have been ripped out from under them for the past two years.’”

Some good news can be found in a December 2021 report from the National Institute on Drug Abuse (NIDA). It reflected new Monitoring the Future data from the University of Michigan and stated, “In line with continued long-term declines in the use of many illicit substances among adolescents previously reported by the Monitoring the Future survey, these findings represent the largest one-year decrease in overall illicit drug use reported since the survey began in 1975” (NIDA, 2022). Beyond the good news, however, are mounting concerns that have appeared about youth opioid use and related deaths among children. That use includes middle school students, according to CNN, which reported on the death of fourteen-year-old Alexander Neville. He was described as “a Boy Scout who enjoyed getting outdoors and camping. He played with Legos and liked to skateboard. He slept with a stuffed Iron Man figure and still snuggled with a teddy bear he’d had since he was much younger” (Christensen, 2022).

Like many young adolescents, Alexander reported experimenting with oxycodone, a prescription pain killer. What Alexander didn’t know is that many of the prescription medications used experimentally or recreationally by children are mixed with fentanyl. According to the Drug Enforcement Administration, “Fentanyl is a synthetic opioid that is 80-100 times stronger than morphine. Pharmaceutical fentanyl was developed for pain management treatment of cancer patients, applied in a patch on the skin. Because of its powerful opioid properties, Fentanyl is also diverted for abuse. Fentanyl is added to heroin to increase its potency, or be disguised as highly potent heroin. Many users believe that they are purchasing heroin and actually don’t know that they are purchasing fentanyl – which often results in overdose deaths. Clandestinely produced fentanyl is primarily manufactured in Mexico” (DEA, 2022).

The American Academy of Child and Adolescent Psychiatry notes that drug use among youth often begins with alcohol before morphing into more dangerous behaviors (AACAP, 2018).

Using alcohol and tobacco at a young age has negative health effects. Some teens will experiment and stop, or continue to use occasionally without significant problems. Others will develop a dependency, moving on to more dangerous drugs and causing significant harm to themselves and possibly others. It is difficult to know which teens will experiment and stop and which will develop serious problems. Teenagers at risk for developing serious alcohol and drug problems include those:

  • with a family history of substance use disorders
  • who are depressed
  • who have low self-esteem, and
  • who feel like they don’t fit in or are out of the mainstream

Teenagers abuse a variety of drugs, both legal and illegal. Legally available drugs include alcohol, prescribed medications, inhalants (fumes from glues, aerosols, and solvents) and over-the-counter cough, cold, sleep, and diet medications. The most commonly used illegal drugs are marijuana (pot), stimulants (cocaine, crack, and speed), LSD, PCP, opiates or opioid pain killers, heroin, and designer drugs (Ecstasy). The use of illegal drugs is increasing, especially among young teens. The average age of first marijuana use is 14, and alcohol use can start before age 12. The use of marijuana and alcohol in high school has become common.

By now it’s no surprise that any drug use is linked to adverse youth outcomes, including falling grades, impaired driving, unsafe sexual behavior, and suicide.

The Institute for Behavior and Health (IBH), a collaborator at the Center for Adolescent Research and Education, notes that not only are not all youth using illicit drugs and in many cases the rates are falling. Recognizing that too many youth still use these substances, IBH has developed an important prevention initiative: “One Choice: no use of any alcohol, nicotine, marijuana, or other drugs for reasons of health (IBH, 2022).

And an IBH study revealed three “gateway drugs” for youth – alcohol, nicotine and marijuana – and the correlation of each to the others.

Compared to their peers who did not use marijuana, youth aged 12-17 who used marijuana in the past month were:

  • 7.9 times more likely to binge drink,
  • 9.9 times more likely to use other illegal drugs, including opioids,
  • 8.9 times more likely to smoke cigarettes.

The close association is also true for alcohol use: compared to their peers who did not binge drink, youth aged 12-17 who engaged in binge drinking in the past month were:

  • 9.9 times more likely to use marijuana,
  • 8.1 times more likely to use other illegal drugs,
  • 7.6 times more likely to smoke cigarettes.

Similarly, compared to their peers who did not use cigarettes, youth aged 12-17 who used cigarettes in the past month were 

  • 6.1 times more likely to binge drink,
  • 7.7 times more likely to use other illegal drugs,
  • 7.0 times more likely to use marijuana.

Since alcohol is often the gateway drug to other destructive behaviors, including addiction, it is critical for parents and other caring adults to talk with young people about how alcohol will affect their bodies, their brains, their safety, and their likelihood of setting and meeting meaningful life goals (Wallace, 2008).

And in alliance with the approach of IBH, it is important to point out that perceived social norms (how many kids are believed to be doing this, that, or the other thing) are often dangerously incorrect.

In reality, the threats to youth are many. Way beyond COVID-19.

Stephen Gray Wallace, M.S. Ed., is a doctoral candidate in the Institute for Ethical Leadership at St. Thomas University in Miami. He is also an associate research professor and president and director of the Center for Adolescent Research and Education (CARE). Stephen has broad experience as a school psychologist and adolescent/family counselor. He is a member of the professional development faculties at the American Academy of Family Physicians and American Camp Association and a parenting expert at, NBC News Learn, and WebMD. He is also an expert partner at RANE (Risk Assistance Network & Exchange) and was national chairman and chief executive officer at SADD for 16 years. Stephen is an award-winning writer and author of the books Reality Gap and IMPACT. Additional information about Stephen’s work can be found at


AACAP. (2018). Teens: alcohol and other drugs. American Academy of Child and Adolescent Psychiatry. No. 3: Updated March 2018. (16 Mar. 2022).

Aboubakr, A. and S. Salzman. (2022). Teenage girls had increased risk of developing eating disorders during pandemic: CDC. ABCNews. February 18, 2022. (16 Mar. 2022).

CDC. (2022). New reports on health and well-being of children during COVID-19 pandemic. Centers for Disease Control and Prevention. CDC Newsroom. February 18, 2022. (16 Mar. 2022).

Christensen, J. (2022). Middle-school children fall prey to fatal fentanyl overdoses. CNN. February 18, 2022. (16 Mar. 2022).

DEA. (2020). Fentanyl. U.S. Drug Enforcement Administration. (16 Mar. 2022).

DOJ/DEA. (2020). Fentanyl. What is it? Department of Justice/Drug Enforcement Administration. (16 Mar. 2022).

IBH. (2022). Prevent teen drug use: One Choice for Health. Institute for Behavior and Health. (16 Mar. 2022).

NIDA. (2021). Percentage of adolescents reporting drug use decreased significantly in 2021 as the COVID-19 pandemic endured. National Institute on Drug Abuse. December 15, 2021. (16 Mar. 2022).

SOS Children’s Villages. (2021). Teen mental health: a vulnerable stage of life. SOS Children’s Villages Illinois. (16 Mar. 2022).

Wallace, S. Reality Gap: Alcohol, Drugs, and Sex – What Parents Don’t Know and Teens Aren’t Telling. New York: New York. Union Square Press/Sterling Publishing Company. 2008.

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