Introduction
Mental health — encompassing emotional, psychological, and social well-being — has been declining in American children over time.[1] Although the American Academy of Pediatrics declared a pediatric mental health emergency due to the rapid worsening of mental health during the COVID-19 pandemic, the crisis was likely an acceleration of a pre-existing trend.[2] Before the pandemic, from 2009 to 2019, the proportion of high school students reporting persistent sadness or hopelessness increased by 40% and those seriously considering suicide increased by 36%.[3] More alarmingly, suicide rates among people aged 10–24 increased by 57% between 2017 and 2018.[4] These trends are likely to persist as young people transition into adulthood, potentially leading to future adult anxiety disorders, substance abuse, decreases in health and social functioning, and increased criminality.[5]
This issue brief examines the mental health findings from a 2018–2019 survey of Houston area high school students. Evidence suggests that while the Houston region experienced an increase in mental health concerns during that period, impacts varied across different communities and sociocultural backgrounds.
Key Findings
Compared to the general population surveyed, children who reported higher depression-related scores:
- Identified as female, transgender, or white.
- Were higher grade levels.
- Experienced high absenteeism or behavioral problems.
The following sections explain the methodology employed in the survey and explore the outcomes in terms of demographics, absenteeism, and school-related behavioral issues.
Survey Methodology
The survey of 8,868 high school students in the Houston Independent School District was conducted by Rice University between 2018 and 2019. It asked a wide-ranging array of questions on themes such as mental health, food insecurity, school belonging, neighborhood characteristics, and more. Points to note about the survey and the results presented in this brief:
- The survey was open to all students at participating schools. It was up to the principal and wraparound services to distribute the survey once the school decided to participate.
- Students were given the opportunity to respond or skip each question, resulting in different response rates for each individual question.
- Any proportions were calculated as a proportion of the total number of students who answered the question.
- All data was self-reported by the individual students.
Mental Health
The first two questions regarding mental health came from the Patient Health Questionnaire-2 (PHQ-2), a measure designed to screen for depression (Figure 1).[6] Two other indirect questions about depression — related to functional problems — were also included and assessed. From the answers, the authors created a composite score as an indicator of clinically significant depression.
Figure 1 — Mental Health Questions
Note: Each PHQ-2 question is scored on a 0–3 scale for a maximum score of 6. The PHQ-2 is used as a screening measure — it is not a full diagnostic assessment. If an adolescent scores a 3 or higher on the PHQ-2 it is recommended that a mental health provider conducts a more thorough diagnostic evaluation.
* A YES to those two questions indicates that major depressive disorder is likely.
Demographics and Depression
Outcomes by Race
The population studied was 76.6% Hispanic, 12% Black, 3.3% Asian, and 1.5% white. White students scored higher in all depression metrics compared to Asian, Hispanic, and Black students (Figure 2). The 99 white students averaged 0.9 points higher on the PHQ-2 than the lowest group. This is consistent with research on growing mental health disparities between white and minority youth, though questions remain about underreporting of depression in minority groups.[7] Though income data was not collected, their reported rates of food insecurity and lack of health insurance suggest that the white students surveyed were economically disadvantaged compared to the Hispanic respondents.
Figure 2 — What Is Your Race?
Note: Total respondents in parentheses.
Findings Categorized by Gender
The 28 transgender students had the most concerning scores of any of the groups surveyed (Figure 3), with half reporting that they felt they needed to speak to a mental health professional. Additionally, the transgender youth had a mean PHQ-2 score of 3, suggesting that most screened positive for depression, a finding that aligns with research on this high-risk population.[8] Females also scored worse than males, though not as poorly as transgender youth.
Figure 3 — How Would You Describe Yourself (Female, Male, Transgender, Other)
Note: Total respondents in parentheses.
Grade Level
The data reveals a pattern of worsening mental health markers as students advance through high school (Figure 4). Ninth graders had the lowest PHQ-2 average (1.31), while 12th graders scored highest suggesting that depression rates rise through adolescence, peaking in the late teens. As well as developmental changes, this could be attributed to older students being subject to mounting academic pressure and gaining a heightened understanding of their internal distress.[9] The worsening trajectory highlights the need for appropriate mental health resources at all grade levels.
Figure 4 — What Grade Are You In?
Note: Total respondents in parentheses.
Missed School
We found a correlation between students who self-reported missed days of school and all depression screening metrics, consistent with national level data (Figure 5).[10] Of those that missed:
- 10 or more days of school, over 30% attributed some of the missed days to their mental health or emotions.
- 15 or more days of school, nearly 30% felt that they needed to see a mental health professional.
Overall, almost 20% of the students who missed some school days likely met the criteria for clinical depression — this is over twice the rate of the general population surveyed.
Figure 5 — About How Many School Days Did You Miss Last Year?
Note: Total respondents in parentheses.
Unwanted School Behavior
Similarly, the more likely a student was to report that they “got in trouble” at school, the higher their depression metrics (Figure 6). Over 30% of children who reported that they “often got in trouble” in the past month said they felt like they would benefit from seeing a mental health professional and 24% reached our metric that approximates depression.
Figure 6 — How Has Your Behavior Been at School in the Past Month?
Note: Total respondents in parentheses.
Conclusions
This survey on pediatric, pre-COVID-19 depression in Houston area high school students finds that the children most at risk for mental health issues are older, female, white, or transgender. Additionally, those who frequently miss school and have disciplinary issues have higher depression scores than students in general. This is a call to action for involved stakeholders to provide focused, targeted interventions to those most at risk. Helping children with potential mental health issues may also improve school attendance rates and reduce disruptive behavior.
Podcast For a more recent take on the issues outlined in this brief, please listen to our podcast, Baker Briefing: America’s Youth Mental Health Crisis. Discussants include brief co-authors Lilian Dindo, Ph.D., and Jan Lindsay, Ph.D.
Notes
[1] Nirmita Panchal et al., “Mental Health and Substance Use Considerations among Children during the COVID-19 Pandemic,” KFF, May 26, 2021, https://www.kff.org/coronavirus-covid-19/issue-brief/mental-health-and-substance-use-considerations-among-children-during-the-covid-19-pandemic/; “Reducing the Economic Burden of Unmet Mental Health Needs,” The White House: Council of Economic Advisers, May 31, 2022, https://www.whitehouse.gov/cea/written-materials/2022/05/31/reducing-the-economic-burden-of-unmet-mental-health-needs/; and “Hospitalizations for Mental Health Issues Were Rising before Pandemic,” KidsData News, May 4, 2021, https://www.kidsdata.org/blog/?p=9688.
[2] “AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health,” American Academy of Pediatrics, October 19, 2021, https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/.
[3] “Youth Risk Behavior Surveillance Data Summary & Trends Report: 2009–2019,” Centers for Disease Control and Prevention: Dear Colleague letter, October 23, 2020, https://www.cdc.gov/nchhstp/dear_colleague/2020/dcl-102320-YRBS-2009-2019-report.html.
[4] Sally C. Curtin, “State Suicide Rates among Adolescents and Young Adults Aged 10–24: United States, 2000–2018,” National Vital Statistics Reports 69, no. 11 (September 2020), https://stacks.cdc.gov/view/cdc/93667.
[5] William E. Copeland et al., “Associations of Childhood and Adolescent Depression With Adult Psychiatric and Functional Outcomes,” Journal of the American Academy of Child & Adolescent Psychiatry 60, no. 5 (May 2021): 604–11, https://doi.org/10.1016/j.jaac.2020.07.895.
[6] “Instrument: Patient Health Questionnaire-2 (PHQ-2),” National Institute on Drug Abuse, accessed April 9, 2024, https://cde.nida.nih.gov/instrument/fc216f70-be8e-ac44-e040-bb89ad433387. An adolescent’s score on the PHQ-2 is an indicator that a student is likely to be experiencing major depressive disorder, but it does not alone confirm a diagnosis of clinical depression. Effective screening tools like the PHQ-2 are essential to support early detection and intervention, which is crucial in mitigating its long-term impact. Implementing a school-wide, standardized screening for depression can help reduce stigma associated with mental health concerns by normalizing conversations about struggles with mental health.
[7] Nirmita Panchal, Heather Saunders, and Nambi Ndugga, “Five Key Findings on Mental Health and Substance Use Disorders by Race/Ethnicity,” >KFF, September 22, 2022, https://www.kff.org/racial-equity-and-health-policy/issue-brief/five-key-findings-on-mental-health-and-substance-use-disorders-by-race-ethnicity/.
[8] Kurt Kroenke, Robert L. Spitzer, and Janet B.W. Williams, “The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener,” Medical Care 41, no. 11 (2003): 1284–92, https://doi.org/10.1097/01.MLR.0000093487.78664.3C; Jason Rafferty et al., “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents,” Pediatrics 142, no. 4 (October 2018): e20182162, https://doi.org/10.1542/peds.2018–162.
[9] Anita Thapar et al., “Depression in Adolescence,” The Lancet 379 (March 2012): 1056–67, https://doi.org/10.1016/S0140-6736(11)60871-4.
[10] Consistent with the CDC report “Mental Health Surveillance Among Children — United States, 2013–2019,” we found a correlation between depression and school absenteeism, showing that students experiencing feelings of sadness or hopelessness were more likely to miss school: Bitsko RH et al., “Mental Health Surveillance Among Children — United States, 2013–2019,” Morbidity and Mortality Weekly Supplement 71, Suppl-2 (February 2022): 1–42, http://dx.doi.org/10.15585/mmwr.su7102a1.
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