The COVID-19 pandemic has caused widespread disruptions and significant stress for millions of people, including children and adolescents (Hertz et al., 2021; Krause et al., 2022; McKnight-Eily et al., 2021; Meade, 2021). In 2020, the American Psychological Association (APA) warned about the potential long-term physical and mental health impact of pandemic-related stress, reporting that adolescents and young adults were showing unprecedented stress levels (American Psychological Association, 2020). Vulnerabilities of young populations during public health emergencies, such as natural disasters and significant outbreaks of infectious disease, have been previously identified (Fothergill & Peek, 2021; Lori, 2008; Masten & Narayan, 2012). However, little research has investigated the pre-pandemic factors that might intensify pandemic-related stressors, such as parental job loss, household illness, and worsened relationships, resulting in negative mental health outcomes (Stinson et al., 2021). To address this gap, we examine the impact of exposure to adverse childhood experiences (ACEs), together with pandemic-related stressors, on symptoms of depression among adolescents ages 13 to 19 to inform prevention and intervention strategies accordingly.

Risk for Children and Adolescents during and after Public Health Emergencies

Children and adolescents have specific developmental needs and characteristics that can place them at unique and heightened risk for negative health outcomes during public health emergencies. These can include, for example, differences from adults in physiology; behavioral, cognitive, and emotional development; and dependence on others for basic needs provision (Fothergill & Peek, 2021; Krug et al., 2015; Lai & La Greca, 2020; Lori, 2008; Masten & Narayan, 2012). Additional contextual and situational factors can contribute to negative outcomes for children and adolescents during public health emergencies, including the degree of exposure and proximity to crisis; extent of community disruption; family stressors, such as job, housing, and food insecurity; and experience with personal loss, including loss of life, property, or routines (Briere & Scott, 2015; Furr et al., 2010; Kinner & Borschmann, 2017; Osofsky et al., 2015).

Some subpopulations already disproportionately experience poor mental health outcomes due to the structural and social inequities that influence the quality and safety of where they live, work, and play (Braveman, 2014; Compton & Shim, 2015; Cooper et al., 2018; Harris et al., 2020). These inequities are often exacerbated by public health emergencies, creating compounded inequities and amplifying risks for some children and adolescents, including those who identify as sexual and gender minorities; are from historically marginalized racial and ethnic groups; have a disability; or live in poverty (Hoffman & Kruczek, 2011; Kronenberg et al., 2010; Okonkwo et al., 2020; Shim, 2020; Shim & Starks, 2021). This suggests that children and adolescents who have experienced inequities prior to a public health emergency may be at increased risk for poor mental health-related outcomes following an emergency.

Risks to Mental Health

Many children and adolescents who have experienced public health emergencies show emotional adjustment reactions including regression of behaviors from a prior developmental stage, somatic symptoms, and bereavement; many are also at increased risk for experiencing chronic mental health symptoms (Fothergill & Peek, 2021; Masten & Osofsky, 2010). Stress exposures caused by public health emergencies have been consistently linked to elevated depression, anxiety, and traumatic-stress-related pathology in children and adolescents, especially in situations where there is a significant loss of life (Fothergill & Peek, 2021; Furr et al., 2010; Mills et al., 2020; Osofsky et al., 2015; Tang et al., 2014).

Public health emergencies can also result in disruptions to support systems (e.g., school, community, peer, family), which can erode feelings of safety and impact the psychological functioning of children and adolescents (Fothergill & Peek, 2021; Lai & La Greca, 2020). Since the outbreak of the novel coronavirus and subsequent declaration of COVID-19 as a global pandemic, many children and adolescents have directly experienced an array of disruptions, including widescale school closures, loss of health services, social isolation, and deaths of family members, any of which might result in increased risk for negative mental health outcomes (Krause et al., 2022; Meade, 2021; Verlenden et al., 2021).

Elevated risks due to Previous Adversity

Previous exposure to ACEs can exacerbate the risk for poor mental health outcomes during public health emergencies (Oldfield et al., 2018; Whaley et al., 2020). ACEs are preventable, potentially traumatic events that occur in childhood (aged 0–17 years), such as neglect, experiencing or witnessing violence, and having a family member attempt or die by suicide (Ports et al., 2020). ACEs may also include aspects of a child’s environment that can undermine their sense of safety, stability, and bonding, such as growing up in a household with substance use or mental health problems, or instability due to parental separation or incarceration of a parent, sibling, or other members of the household (Ford et al., 2014; LeMoult et al., 2020; Merrick et al., 2018; Ports et al., 2020).

Unfortunately, ACEs are common. Approximately two-thirds of adults in the general US population have had at least one type of ACE; one in six had 4 or more ACEs (Merrick et al., 2018). ACEs often occur together (Brown et al., 2019; Bussemakers, et al., 2019) and are associated with a range of less optimal health, behavioral, and social outcomes across the lifespan (Merrick et al., 2019; Mills et al., 2020). For example, individuals who have ACEs have higher rates of anxiety and depression symptoms (Sheffler et al., 2020), and a cumulative dose–response relationship exists between the number of ACEs and lifetime prevalence of depressive disorders (Clements-Nolle et al., 2018; LeMoult et al., 2020; Merrick et al., 2019). Exposure to ACEs may also exacerbate inequities in health, social, and economic outcomes across generations (Dominguez & Brown, 2022; Lensch et al., 2021; Shonkoff et al., 2021).

Depression in Adolescence

Depression is a serious condition that negatively affects how a person feels, thinks, and acts (American Psychiatric Assocation, 2022; Malhi & Mann, 2018). Symptoms of depression can vary from mild to severe and can include having a depressed mood, loss of interest in activities, appetite changes, fatigue, agitation or fidgetiness, feelings of unworthiness and guilt, difficulty concentrating, and thoughts of suicide (American Psychiatric Assocation, 2022). Depression is a leading mental health concern for adolescents. It is associated with a range of adverse outcomes, including increased risk for substance use problems, suicidality, academic difficulties, poor physical health, as well as other mental disorders (Bethell et al., 2019; Bitsko et al., 2022; Jones et al., 2016, 2022; Katon et al., 2010). According to 2020 data examining past year depression, approximately 17% of U.S. adolescents had at least one major depressive episode during the past year (2019) with prevalence higher among adolescent females (25.2%) compared to males (9.2%; Substance Abuse & Mental Health Services Administration, 2020). Other national data have also indicated that the prevalence of depression among adolescents had risen significantly in the years before the pandemic (Lebrun-Harris et al., 2022). See Mental Health Surveillance Among Children — United States, 2013–2019 | MMWR (cdc.gov) for a comprehensive overview of children and adolescent mental health surveillance and for prevalence estimates from before the pandemic (Bitsko et al., 2022).

Research suggests that symptoms and rates of depression among adolescents have increased during the pandemic (Chaabane et al., 2021; Zolopa et al., 2022). For example, a cohort study of adolescents that assessed changes in symptoms of mental disorders from before and during the pandemic identified increases in depression from July 2019 to May 2020, especially among females (Hawes et al., 2021). Additionally, a national syndromic surveillance data analysis found increases in emergency department visits related to depressive disorders in 2021 compared to 2019 among adolescent females aged 12–17 years (Radhakrishnan et al., 2022).

Considering evidence of the rising rates of depression among adolescents before and during the pandemic, as well as the long-term health risks associated with depression, it is important to understand factors that may contribute to increases in depression during the pandemic to guide public health response to the ongoing children’s mental health crisis (Shim et al., 2022). Specifically, the identification of potential causal pathways can inform the development of programming to ameliorate or reduce risk and facilitate more positive trajectories and support; guide allocation of needed resources for early intervention to allay symptoms; and facilitate implementation of mental health promotion and prevention initiatives (Mendelson & Tandon, 2016; Morina et al., 2017; Tang et al., 2014).

Examining Effects of Public Health Emergencies on Adolescent Mental Health

Public health emergencies influence the proximal and distal systems within which adolescents exist and interact, including home, schools, jobs, neighborhoods, society, and social support networks (Hoffman & Kruczek, 2011; Layne et al., 2010; Pynoos et al., 2014). As such, understanding the impact of a public health emergency on adolescent mental health involves consideration of direct and indirect effects as well as contexts particularly relevant to adolescent development (Bronfenbrenner & Morris, 2007; Hoffman & Kruczek, 2011; Spencer et al., 1997; Stern et al., 2021). Amidst the COVID-19 pandemic, for example, education, employment, health, safety, and travel mandates resulted in disruptions that may have amplified stress and adversity in some ways, yet reduced them in others (Brown et al., 2020; Krause et al., 2022; Prime et al., 2020). As such, the impact of a public health emergency such as the COVID-19 pandemic on adolescent mental health must be assessed in terms of social and community contexts, factoring in appraisals of stress and support and considering unfolding effects across time (Fothergill & Peek, 2021; Lori, 2008; Masten & Narayan, 2012).

To date, limited research has attempted to investigate the mental health impact of the pandemic on adolescents by considering contexts, systems, phenomenological perspectives, and compound effects (Shim et al., 2022). To address this need, we use longitudinal data from a nationwide sample of adolescents ages 13 to 19 to develop an index of pandemic-related stress experiences, identifying temporal-specific, episodic stressors. We then use the index to examine direct and indirect relationships among adolescent reports of ACEs, pandemic-related stress experiences, and depressive symptomology. We also consider the extent to which sex at birth and race/ethnicity influence associations and risk of depression.

Methods

Setting, Procedures, and Participants

The COVID Experiences Study (CovEx) included the administration of longitudinally designed surveys to adolescents 13–19 years of age (at Wave 1) using the National Opinion Research Center’s (NORC) at the University of Chicago AmeriSpeak® Panel, a probability-based panel of approximately 40,000 households. Two waves of survey data were collected to capture the experiences of adolescents during the COVID-19 pandemic and to examine the impact of COVID-19 on their health and well-being over time. Surveys were administered online or via telephone, with Wave 1 surveys fielded October 16—November 6, 2020 and Wave 2 surveys fielded April 2—May 7, 2021. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy; see 45 C.F.R. part 46; 21 C.F.R. part 56; 42 U.S.C. Section 241(d), 5 U.S.C. Section 552a, 44 U.S.C. Section 3501 et seq. 45 C.F.R. part 46; 21 C.F.R. part 56. The study was also reviewed and approved by the Institutional Review Board of NORC at the University of Chicago.

Adolescents were recruited for participation in the study using three AmeriSpeak sources: 1) adolescents ages 18–19 were recruited from the NORC AmeriSpeak® Panel, 2) adolescents ages 13–17 who had been previously recruited from AmeriSpeak® Panel households to join the AmeriSpeak® Teen Panel, and 3) adolescents ages 13–17 living in AmeriSpeak® Panel households who had not joined the AmeriSpeak® Teen Panel. A parent or legal guardian provided consent for adolescents 13–17 years of age, and each adolescent participant assented. Adolescents ages 18–19 years consented for themselves. Only one adolescent per household was eligible for selection (random within household sampling). All adolescents that completed the Wave 1 survey (NW1 = 727) were invited to participate in the follow-up Wave 2 survey (78.3% completion rate, NW2 = 569) resulting in an attrition rate of 21.7%. All adolescents re-assented before beginning the follow-up survey. We found no significant demographic differences between Wave 1 and 2 participants. After restricting to participants responding at both waves, the final analytical sample size is 569. Path analyses were conducted with list-wise deletion. See Table 1 for characteristics of the analytic sample.

Table 1 Demographic characteristics of study sample and properties of main study variables (N = 569)
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Measures

Demographic Covariates

Considering empirical support of differences by sex in the prevalence of internalizing conditions among youth and in the manifestation of effects of ACEs and stress on mental health, we included sex at birth as a covariate (Hogye et al., 2022; Merrick et al., 2018). Adolescents reported sex at birth in response to the survey question: “What sex were you assigned at birth on your original birth certificate?” Gender identity and sexual orientation were not included as covariates in this study. Although differences in experiences of adversity and stress across gender and sexual orientation are salient, especially among adolescents who identify as transgender and among adolescents who identify as lesbian, gay, or bisexual (Brown et al., 2019; Craig et al., 2020), investigating such differences was outside the scope of the analysis conducted.

Adolescent race/ethnicity was also included as a covariate. Race/ethnicity was based on information gathered during the initial recruitment of adolescent participants into the AmeriSpeak® and AmeriSpeak Teen® national panels. Adolescents self-reported their Hispanic ethnicity and race, which were categorized as White, non-Hispanic; Black, non-Hispanic; Hispanic/Latinx; or another race non-Hispanic inclusive of Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, some other race, or selection of more than one race category.

Adverse Childhood Experiences (ACEs)

We used eight Wave 1 survey items to assess exposure to ACEs, which are broadly aligned with the core ACEs constructs included in the Behavioral Risk Factor Surveillance System (BRFSS) ACEs module (Merrick et al., 2019), and the Youth Risk Behavior Survey (YRBS; Anderson et al., 2022). Similar ACEs questions have been used in other research involving adolescents (Clements-Nolle et al., 2018; Lensch et al., 2021). For this study, each adolescent respondent identified whether they experienced any of the following at any point since they were born: (1) physical abuse by any perpetrator; (2) emotional abuse by a household member; (3) sexual violence by any perpetrator; (4) witnessing intimate partner violence; (5) parental divorce; (6) family member serving time in jail; (7) family member with a mental health condition; (8) family member with a substance use problem. Sum scores ranging from 0 to 8 were used to indicate ACEs exposure to date (Wave 1).

Pandemic-Related Stress Index (PRSI)

We developed the pandemic-related stress index (hereafter PRSI) to assess stressors experienced within the timeframe of the COVID-19 pandemic at Wave 1. While creating the PRSI, we evaluated all Wave 1 survey items from the CovEx survey of adolescents (ni = 92) for their potential as indicators of pandemic-related stress exposure in the following domains: material, relational, social/societal, health services, education, COVID-19, and stress appraisal. Items that did not measure experiences related to pandemic-related stress were omitted from consideration (ni = 68), as were items with high missingness and skip** patterns (ni = 7), items that did not align with the specified timeframe (ni = 3), and items with relatively low principal component loadings and Cronbach’s alphas (ni = 12). As part of the index development process, we implemented a principal components analysis (PCA) to reduce the number of variables in the index while preserving as much information as possible. Since most of our index items were binary, we conducted a logistic PCA, which does not require a matrix factorization but instead uses projections of the natural parameters from the saturated model (Landgraf, 2016; Landgraf & Lee, 2015). Figure A1 illustrates the process of item selection and exclusion.

The final PRSI includes 7 items assessing stress exposure during the pandemic in the following areas: (1) family/parent job loss, (2) economic insecurity, (3) worsened family/household relationships, (4) lack of support from friends, (5) COVID-19 personal illness, (6) COVID-19 family member illness, and (7) missed health care when needed. Responses are dichotomized with a sum score calculated (range = 0 to 7). A higher sum score indicates accumulation of more pandemic-related stress experiences at Wave 1. See Appendix A for supplementary information related to PRSI development.

Patient Health Questionnaire for Adolescents (PHQ-A)

The PHQ-A is a nine-item mental health screening instrument validated for use among adolescents to identify risk for depression (Johnson et al., 2002). Criteria align with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®) diagnosis of depressive disorders. As a screening instrument for depression, the PHQ-A has demonstrated satisfactory specificity, sensitivity, diagnostic agreement, and overall diagnostic accuracy (i.e., positive and negative predictive power) when compared to comprehensive diagnostic interview tools (e.g., Diagnostic Interview Schedule for Children) and has been used widely in research and health care settings (Kroenke et al., 2009). Adolescent responses to PHQ-A items at Wave 2 of survey administration were used to assess depressive symptomology, measuring the number and frequency of symptoms experienced in the past 14 days (response options: 0 days; 1 or 2 days; 3–6 days; 7–14 days); the scale showed good internal consistency (α = 0.92). Sum scores ranged from 0 to 18.

Analysis

Descriptive statistics, Pearson correlations, and Cronbach’s alpha estimates were obtained for all variables, using SAS version 9.4. For the hypothesized model (Fig. 1), path analysis was used to examine the associations between ACEs (Wave 1), pandemic-related stress (PRSI, Wave 1), and depressive symptoms (PHQ-A, Wave 2). Covariates included sex assigned at birth (male as referent) and race/ethnicity (White as referent). For the goodness of fit analyses, the model chi-square (χ2), the comparative fit index (CFI), and the root mean square error of approximation (RMSEA) were used (Kline, 2015). The χ2 assesses overall fit and the discrepancy between the sample and the fitted covariance matrices, with non-significant χ2 values (p > 0.05) indicating good model fit. The CFI values range from 0 to 1, with higher values indicating better fit. The RMSEA values range from 0 to 1, with smaller values indicating better model fit. The CFI ≥ 0.95 and the RMSEA ≤ 0.08 are generally recommended as cut-off points indicating acceptable model fit (Hu & Bentler, 1999).

Fig. 1
figure 1

Conceptual model depicting hypothesized relationships of Adverse Childhood Experiences (ACEs) and Pandemic-Related Stress Index (PRSI) reported at Wave 1(W1), and symptoms of depression at Wave 2 (W2) (PHQ-A). The conceptual model depicts hypothesized relationships and directionality of relationships among predictor variables and the outcome of outcome of interest. W1 ACEs reflects adolescent reported exposure to experiences of early adversity. W1 PRSI reflects adolescent reported pandemic-related stress exposures. W2 PHQ-A reflects depression symptoms reported by adolescents. Wave 1 data were collected October—November 2020 and Wave 2 data were collected April—May 2021. Covariates include sex (i.e., sex assigned at birth) and race/ethnicity (i.e., Black non-Hispanic, Hispanic/Latinx, White non-Hispanic, and all Other Races including Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, some other race, or selected more than one race category). Variables drawn from the nationwide, longitudinal COVID Experiences Study (CovEx) of Adolescents 13–19 years of age using the National Opinion Research Center’s (NORC) at the University of Chicago AmeriSpeak® and AmeriSpeak Teen® panels

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Results

Descriptives

Table 1 describes unweighted demographic characteristics of the analyzed sample based on Wave 1 data, including adolescents’ sex assigned at birth, age, race and ethnicity, sexual identity, and annual household income. The participant sample was evenly distributed by sex with 52.7% indicating sex at birth as female. Most participants (54.8%) were between the ages of 15 and 17 years, 28.5% were 13–14 years of age, 16.7% were 18–19 years. Over half (54.1%) of the sample identified as White non-Hispanic, 21.3% as Hispanic/Latinx, 12.3% Black non-Hispanic, and 12.3% another race non-Hispanic.

Table 2 provides item-level frequencies reported at Wave 1 for ACEs and for the pandemic-related stress index (PRSI). For ACEs, percentages ranged from 3.5% (“sexual violence”) to 30.0% (“parental divorce”); for the PRSI percentages ranged from 14.5% (“worsened family/household relationships”) to 40.6% (“family/parent job loss”). Table 3 provides item-level frequencies for the PHQ-A at Wave 2 that indicate the presence of depressive symptoms in the past 14 days. The percentage of adolescents indicating persistence of depressive symptom for 7–14 days ranged from 6.7% (“thoughts that you would be better off dead, or of hurting yourself”) to 21.3% (“feeling tired or having little energy”). Table 4 provides Pearson correlations, means, and standard deviations for all variables and covariates in the model. The three model variables (i.e., ACEs, PRSI, PHQ-A) were positively and significantly correlated. They were also correlated with the sex covariate, with women more likely to report ACEs and pandemic-related stressors at Wave 1 and depressive symptoms at Wave 2. See supplemental tables in Appendix A for additional bivariate results, including associations among demographic characteristics and each of the three model variables.

Table 2 Descriptive Statistics of Wave 1 Adverse Childhood Experiences (ACEs) and Pandemic-Related Stress Index (PRSI) Items (N = 569)
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Table 3 Descriptive statistics of wave 2 patient health questionnaire for adolescents (PHQ-A) item responses (N = 569)
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Table 4 Zero-order correlations for study variables
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Path Analysis

Overall, tests of the measurement model demonstrated a good fit to the data, χ2(5) = 6.62 p = 0.03, CFI = 0.96, RMSEA = 0.05 (90% CI = 0.01, 0.09). While the χ2 was statistically significant, research shows that the χ2 is highly sensitive to changes in sample size and tends to be statistically significant for models with larger sample sizes, or more than 300 cases. Also, the relatively high CFI (≥ 0.95) and low RMSEA (≤ 0.08) indicated acceptable model fit.

Figure 2 depicts the path analysis model with standardized estimates. ACEs were positively and significantly related to PRSI scores (b = 0.31, SE = 0.03, p < 0.001), meaning that a 1-standardized unit increase in ACEs was associated with a 0.31-standardized unit increase in PRSI scores. PRSI scores were positively and significantly related to subsequently reported depressive symptoms on the PHQ (b = 0.29, SE = 0.14, p < 0.001), meaning that a 1-standardized unit increase in PRSI scores was associated with a 0.29-standardized unit increase in PHQ scores at Wave 2. The direct association between ACEs and depressive symptoms on the PHQ remained statistically significant (b = 0.23, SE = 0.12, p < 0.001), even after accounting for the indirect effect of PRSI scores (b = 0.09, SE = 0.05, p < 0.001). Therefore, the total effect of ACEs on depressive symptoms was 0.32. The Pandemic-related stress, therefore, partially explained the relationship between ACEs and depressive symptoms.

Fig. 2
figure 2

Path analysis model illustrating relationships among Adverse Childhood Experiences (ACEs), Pandemic-Related Stress Index (PRSI) reported at Wave 1 (W1), and symptoms of depression (PHQ-A) at Wave 2 (W2) with Standardized Estimates. The path model describes the tested direct and indirect relationships and directionality of relationships among predictor variables and the outcome of interest with * indicating p < 0.01 and ** indicating p < 0.001. W1 ACEs reflects Adverse Childhood Experiences reported by adolescents at Wave 1. W1 PRSI reflects adolescent reported pandemic-related stress based on scores on the Pandemic-Related Stress Index and reported by adolescents at Wave 1. Wave 1 data were collected October—November 2020 and Wave 2 data were collected April—May 2021. Covariates include sex (i.e., sex assigned at birth) and race/ethnicity. Sex was modeled as a bivariate variable (female vs. male). Race/ethnicity was modeled twice: first as Black non-Hispanic vs. White non-Hispanic, second as White non-Hispanic vs. all Other races/ethnicities. As both models had similar nonsignificant results, only White non-Hispanic vs. all Other race/ethnicities results are reported in Fig. 2. Variables drawn from the nationwide, longitudinal COVID Experiences Study (CovEx) of Adolescents 13–19 years of age (at Wave 1, October—November 2020) using the National Opinion Research Center’s (NORC) at the University of Chicago AmeriSpeak® and AmeriSpeak Teen® panels

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Regarding the covariates, sex assigned at birth was significantly associated with ACEs (b =—0.15, SE = 0.14, p < 0.001), PRSI scores (b =—0.10, SE = 0.11, p < 0.01), and PHQ scores (b =—0.23, SE = 0.39, p < 0.001). In other words, we found that adolescent females were more likely to report ACEs, pandemic-related stressors, and depressive symptoms, and that these sex differences contributed significantly to the model. Race/ethnicity was not significantly associated with any variables in the model.

Discussion

To our knowledge, this is the first study to examine associations between ACEs, pandemic-related stress exposures, and symptoms of depression among a nationwide cohort of adolescents ages 13 to 19. We also expand the literature to date in develo** and applying a pandemic-related stress index (PRSI). The findings strongly support hypothesized causal relationships between ACEs, pandemic-related stress, and subsequent report of depressive symptoms. Path models revealed significant direct effects of pandemic-related stress and of ACEs reported at Wave 1 on depressive symptoms reported at Wave 2, suggesting the possibility of a causal association. ACEs also have a significant indirect effect on depressive symptoms via pandemic-related stress. In addition, we found that females reported higher rates of ACEs, pandemic-related stress, and depressive symptoms than males. Overall, the findings highlight a synergistic effect on depressive symptoms produced by pandemic-related stress and ACEs directly and indirectly.

Our findings align with a body of research showing associations between exposure to acute, episodic stress during public health emergencies and increased risk for children and adolescents to experience the symptoms of mental health conditions, including depression (Kronenberg et al., 2010; Masten & Osofsky, 2010; Osofsky et al., 2015; Rubens et al., 2018; Tang et al., 2014). When youth experience acute stress events (e.g., conflict, instability, illness) in developmentally relevant contexts (e.g., peer, family), depression can ensue via the main effect of stress or via various vulnerabilities interacting with the rise in stress through stress amplification processes (Furr et al., 2010; Masten, 2021; Masten & Narayan, 2012; Tang et al., 2014). Using path analysis, we identified a strong temporal relationship between pandemic-related stressors, including family/parent job loss, economic insecurity, worsened family/household relationships, lack of support from friends, personal or family COVID-19 illness, and absence of needed health care and depressive symptomology. This finding also supports current research pointing to the potential negative impact of pandemic-related stress on adolescent mental health (Hertz et al., 2021; Jones et al., 2022; Krause et al., 2022; Leeb et al., 2020) with disruptions in schooling and family situations precipitating rapid accumulation of stress events for many adolescents.

Our findings also demonstrate the mental health vulnerabilities of adolescent populations who have experienced ACEs; there was a direct association between the accumulation of ACEs and depressive symptoms. This finding aligns with previous literature suggesting that ACEs are associated with poor mental health across the lifespan (Merrick et al., 2019; Nurius et al., 2015). Moreover, results show a synergistic effect between ACEs and pandemic-related stress that may increase the risk for depressive symptoms among adolescents during the pandemic. This finding indicates longitudinal compounding risks due to pandemic-related stress for adolescents who have experienced ACEs. While the literature on ACEs, episodic stress, and depressive symptomology is limited, a pre-pandemic study of college students found not only that ACEs predicted worsening mental health over a semester, but also that stressors accrued during the semester mediated the relationship between ACEs and mental health and suicide-related outcomes (Karatekin, 2018; Osofsky et al., 2015; Tang et al., 2014).

In this study, female adolescents had higher reported ACEs, pandemic-related stress, and depressive symptoms, and these sex differences contributed significantly to the tested path model. Sex differences in adolescent depression have been identified previously with females having a higher incidence of major depressive disorder (MDD) and a more chronic course of depression than males (Avenevoli et al., 2015; Jones et al., 2016; Lewis et al., 2020). Likewise, there is evidence of sex differences in exposure to different types of ACEs with females reporting more complex and varied history of childhood adversities and a greater incident of sexual violence than males (Haahr-Pedersen et al., 2020). Our findings suggest the possibility that at least some effects on depressive symptoms may be attributable to sex differences; however, further research is needed to understand differential experiences of adversity and pandemic-related stress by sex as well as different symptomology reported by females and males in adolescence, especially following public health emergencies.

We did not find any racial/ethnic differences in the analysis, indicating that the observed associations between ACEs, pandemic-related stress, and depressive symptoms were similar across these subpopulations. This finding suggests that ACEs and pandemic-related stress may have a universal impact on depression symptomatology regardless of race and ethnicity. However, this does not preclude the possibility that individuals in different racial and ethnic groups may experience ACEs, pandemic-related stress, and depressive symptomatology differently, and that some groups may be at greater risk for these challenges because of the social and structural conditions in which people live, work, and play (Merrick et al., 2018; Ports et al., 2020; Vanderminden et al., 2019). Our relatively small sample size possibly prevented us from detecting differences across racial and ethnic minority subgroups. For the same reason, we could not incorporate social determinants of health such as experiences of racism and discrimination into this analysis. However, we recognize that the presence of ongoing adversities and stress for adolescents who have historically experienced (and may continue to experience) marginalization, stigma, and discrimination amidst the pandemic needs further investigation. Racial/ethnic minorities, LGBTQI + youth, American Indian/Alaska Native youth, and youth with disabilities often face a disproportionate burden of stress, have less access to healthcare, and experience environmental and attitudinal barriers to accessing supports, which can adversely affect mental health (Compton & Shim, 2015; Shim, 2020; Shim & Starks, 2021).

Limitations

The findings of the present study are not without limitations. First, ACE exposures could vary in intensity, frequency, duration, and developmental timing. Each ACE was also given equal weight in creating a summed score; while this is a standard approach, it is not without limitations (Holden et al., 2020; Ports et al., 2020). Second, we retrofitted PRSI items using existing survey items. Thus, items included in the PRSI might not be theoretically exhaustive. We were also limited to binary items and used a logistic PCA, an innovative but not yet fully developed methodology, to develop the index. Some items had suboptimal logistic PCA loadings (see Appendix for details) and were excluded during the dimension reduction process of the index development. As such, the current form of the PRSI will likely benefit from additional use and testing to better ascertain its applicability outside this study. Third, information biases such as social desirability, recall, and/or self-report biases might exist. For example, previous studies have identified gender differences in patterns of self-reporting on traits associated with internalizing disorders, including depression, which can lead to overestimation of sex differences (Lindsey et al., 2017; Navarro et al., 2020; Van Beek et al., 2012). Fourth, loss to follow-up between waves, survey skip** patterns, and item-level missingness leads to potential selection bias and low data power for including more covariates. However, the significant and theory-aligned relationships found between ACEs, pandemic stress, and depressive symptoms, are sufficiently robust to be interpreted for practical implications. Finally, due to the methodological approach, the data used in this study were unweighted. Although participants were sampled from a nationwide, probability-based panel, the sample was predominately white and heterosexual, findings may not be generalizable to the broader adolescent population.

Implications

Deleterious effects of pandemic stress on adolescents call for urgent action, particularly for adolescents with higher pandemic-related stress and the presence of ACEs. This need may also be particularly salient for females. One immediate need is to identify adolescents needing clinical treatment and ensure linkage to developmentally and culturally relevant services for depression and high stress. Clinical screening might occur during primary care wellness visits and check-ups, sports physicals, or other health care appointments, supporting the ability of clinicians to make timely referrals to cognitive-behavioral therapy (CBT), trauma-focused CBT, and interpersonal psychotherapy as needed (American Psychological Association, 2019; Kairys et al., 2020; Stanley et al., 2009).

However, mental and behavioral health services are not equitably distributed across demographic subpopulations and may not be available for those with disproportionate need (Hodgkinson et al., 2017; Kairys et al., 2020). A robust and comprehensive infrastructure across all youth-serving systems that incorporates developmental monitoring and appropriately used screening processes could facilitate more equitable and transparent identification of adolescents in need of services with the ultimate goal of the provision of needed services (Harris et al., 2020; Vaivada et al., 2022). Schools play a critical role in providing social support, universal mental health programming, early intervention services, and mental health care (Hoover & Bostic, 2021). Application of a comprehensive, multi-tiered system of supports that incorporates trauma-informed approaches; health education inclusive of social-emotional learning and mental health education; early intervention programming; and linkage to health services has shown promise as a framework for supporting the mental health of children and adolescents in school and in facilitating connection to needed supports (Herbers et al., 2021). However, providing schools with adequate resources to facilitate comprehensive mental health programming is imperative for initiatives to be effective (Cummings et al., 2022; U.S. Department of Education, 2021).

Foundationally, establishing safe and supportive environments in child-serving spaces may help assuage the negative impact of pandemic stress while also benefiting those who have experienced ACEs by establishing an environment for healthy recovery and development (Kataoka et al., 2018; Overstreet & Chafouleas, 2016). In particular, connectedness to family and school has been identified as an important buffer to stress, and school-based initiatives that promote connectedness and family engagement have shown promise for supporting and protecting adolescent mental health (Areba et al., 2021; Blackwell et al., 2022; Hertz et al., 2021; Steiner et al., 2019). School-based approaches to creating safe and supportive environments, fostering connectedness, and preventing and mitigating the harms of ACEs are available, as are trainings to help improve understanding of ACEs and ACEs prevention for others who work with youth; see Preventing ACEs (Centers for Disease Control and Prevention, 2019a, b; Filia et al., 2021). Likewise, community-based mentoring, bystander training, and community initiatives that promote prosocial relationships and reduce stigma around help-seeking for mental health challenges or substance use disorders are among the strategies that offer a venue for the community to be a source of connection and resilience for young people (Li et al., 2021; Mendelson & Tandon, 2016; Pfefferbaum et al., 2019).

Finally, ongoing surveillance of the impact of stress due to public health emergencies is critically important to understand both immediate and long-term effects and to elucidate factors related to emotional adjustments extending over time (Pfefferbaum et al., 2012). Grounded in frameworks for research on children’s reactions to public health emergencies, factoring in the role of family challenges, parental and peer relationships, and proximity of exposures, the development of the PRSI might serve as a foundation for on-going assessment of stressors experienced by adolescents amidst the COVID-19 pandemic and for future public health emergencies, with the goal of identifying needed services, supports, and interventions.

Conclusion

The current study is among the first to examine specific longitudinal pathways between pandemic stress, ACEs, and mental health among U.S. adolescents, using nationwide samples collected between 2020 and 2021. Overall, our findings highlight the utility of examining pandemic-related stress among adolescents to better understand the degree of its negative impact on mental health. This work lays a solid foundation for further research by revealing an important mechanism linking ACEs and pandemic stress to subsequent depression among adolescents, both directly and synergistically. Findings point to the critical importance of tailoring and scaling up primary, tertiary, and secondary prevention for reducing risks for mental disorder as well as treatment interventions for mental illness to accommodate new challenges brought on by the pandemic, which were compounded by existing adversities. Systems that work to prevent and mitigate the harms of ACEs and other forms of stress at the family, community, and societal level are needed to reduce the adolescent mental health crisis and build strong, healthy communities where youth and families can thrive.