The Epidemic of Internalizing Problems Among Latinx Adolescents Before and During the Coronavirus 2019 Pandemic

ABSTRACT

Objective

Latinx youth exhibit disproportionately higher internalizing symptoms than their peers from other racial/ethnic groups. This study compares depression and anxiety symptoms between referred students of Latinx and non-Latinx backgrounds before and during the COVID-19 pandemic and examines key determinants within the Latinx sample.

Method

Data are analyzed from four academic years – two before and two during the pandemic – from 1220 5^th through 8^th grade students (M_age = 12.1; 59.6% female; 59.9% Latinx or mixed-Latinx) referred for services across 59 Chicago Public School District (CPS) elementary schools. Using the Children’s Depression Inventory (CDI) and the Revised Child Anxiety and Depression Scale (RCADS), mean scores and risk levels for depression, social anxiety, and generalized anxiety are examined.

Results

Higher internalizing risk and comorbidity rates were found in the second year of the pandemic, compared to pre-pandemic levels. Latinx students reported higher depression, social anxiety, and generalized anxiety symptoms than non-Latinx students. During the pandemic, more Latinx students were classified as having comorbid depression and anxiety, and scored in the clinical range for depression, generalized anxiety, and social anxiety than non-Latinx students. Within the Latinx sample, girls and gender non-conforming students reported the highest maladjustment.

Conclusions

Results highlight the pressing need to examine the long-term impact of COVID-19 on the mental health of Latinx children and adolescents, and to address their internalizing problems.

RESUMEN

Objectivo: Los jóvenes Latinx presentan niveles desproporcionadamente elevados de síntomas de internalización comparado con de otros grupos raciales/étnicos. Este estudio compara síntomas de depresión y ansiedad entre estudiantes de ascendencia Latinx y no Latinx antes y durante la pandemia de COVID-19 y examina determinantes claves dentro de la muestra de jóvenes Latinx.

Método: Se analizaron los datos de cuatro años escolares – dos antes y dos durante la pandemia – de 1220 estudiantes del 5° a 8° grado (M_edad = 12.1; 59.6% niñas; 59.9% Latinx o mestizos Latinx) referidos para servicios en 59 escuelas del Distrito de Escuelas Públicas de Chicago. Utilizando el Children’s Depression Inventory (CDI) y el Revised Child Anxiety and Depression Scale (RCADS), se analizaron puntuaciones medias y tasas de riesgo de depresión, ansiedad social, y ansiedad generalizada.

Resultados: Se encontraron riesgos de internalización y niveles de comorbilidad más altos en el segundo año de la pandemia en comparación con los niveles prepandemia. Los estudiantes Latinx reportaron más síntomas de depresión, ansiedad social, y ansiedad generalizada comparados a los estudiantes no Latinx. Durante la pandemia, más estudiantes Latinx fueron clasificados con comorbilidad de depresión y ansiedad y dentro de los puntajes en el rango clínico de depresión, ansiedad generalizada y ansiedad social que estudiantes no Latinx. Dentro de la muestra Latinx, las niñas y los estudiantes de género no conforme reportaron el mayor desajuste.

Conclusiones: Los resultados indican la necesidad de examinar el impacto a largo plazo de COVID-19 en la salud mental de los niños y adolescentes Latinx con un enfoque en sus problemas de internalización.

Since the beginning of 2020, the world has been dramatically affected by the Coronavirus Disease 2019 (COVID-19) pandemic, which has caused millions of deaths and has been associated with immeasurable disease burden in every part of the world (Wang et al., 2022). Uncertainty and widespread misinformation have existed regarding the nature, course, and lethality of the COVID-19 illness, as well as about the best approaches to protect individuals (Loomba et al., 2021). Months of lockdowns, restrictions, and other measures to mitigate transmission have created high levels of fears, frustrations, and social isolation, particularly as regions are struck with waves of high infections and hospitalizations (Panchal & Jack, 2022). Studies documenting the effects of COVID-19 show that mental health is an area of particular concern. A meta-analytic review estimated an additional 53.2 million cases of major depressive disorder, and an additional 73.2 million cases of anxiety disorders globally resulted from the pandemic (Santomauro et al., 2021). The pandemic increased the incidence of symptoms of panic disorder, post-traumatic stress disorder, and generalized anxiety disorder (Koch et al., 2022).

Among children and adolescents, multiple cross sectional and longitudinal reports have also emerged revealing high rates of anxiety and depression, and significant mental health problems have been consistently documented in multiple countries (DeFrance et al., 2022; Guazzelli Williamson et al., 2022). Brasso et al. (2022) summarized data from over 80 studies across the world on the mental health impact of the pandemic on children and adolescents and concluded that depressive and anxiety symptoms and disorders have shown the greatest increases in incidence, particularly among girls. It is estimated that, among those ages 18 and under, 25.2% experienced clinically elevated depression symptoms and 20.1% experienced clinically elevated symptoms of anxiety globally (Racine et al., 2021).

In the U.S. alone, there have been nearly 100 million cases of COVID-19, and the death toll has surpassed one million people since the pandemic began (Centers for Disease Control and Prevention [CDC], 2022). Death rates have disproportionately affected underrepresented groups and U.S. Latinx, in particular. Estimated age-adjusted death rates for Latinxs were 494 per 100,000, a rate that is 70% higher than that of European Americans and the highest of all major racial/ethnic groups except for Indigenous Americans (American Public Media Research Lab, 2022). A survey by the Centers for Disease Control and Prevention (CDC) during the early months of the pandemic indicated that, among U.S. adults, 28.6% were experiencing depression, 8.4% endorsed suicidal thoughts or ideation, and 18.2% indicated initiation or increase in substance use (McKnight-Eily et al., 2021). Latinx adults in this survey reported higher stress related to not having enough food or housing, and reported significantly higher depression, suicidal ideation, and initiation and increase of substance use than European American and African American adults (McKnight-Eily et al., 2021). In a large national online survey, Latinx adults reported significantly higher depression, anxiety, and moderate to severe psychological distress, compared to non-Latinx adults (Khubchandani et al., 2021). Similarly, in a report comparing the survey results from 2018 and 2020 among U.S. adults, Latinx respondents reported the highest increases and highest levels of mental health problems and depression (McGinty et al., 2020).

The results of a large U.S. study show the mental health impact of the pandemic among young people (Murata et al., 2021). In online surveys completed between April and July of 2020, adolescents reported significantly higher rates of major depressive disorder (55% vs. 29%) and generalized anxiety disorder (48% vs. 29%) symptoms than adults. There is also emerging evidence that Latinx youth have been disproportionately affected. A school-based study conducted in the first three months of the pandemic with over 14,000 students from 49 schools showed decreases in clinical depression, compared the previous year. The decreases were largest and significant among Asian American, European American, and African American students, while Latinx youth did not show a parallel pattern of decreases (Luthar et al., 2021). Only a few studies have identified factors to help understand the well-being and adjustment of Latinx youth during the pandemic. In one study with a predominantly Latinx adolescent sample, higher COVID-19 media exposure predicted higher engagement in safety behaviors, which in turn impacted quality of life and future depression and anxiety symptoms (Trucco et al., 2022).

As noted, studies of both youth and adult samples have uncovered mental health disparities associated with COVID-19 and point to Latinx in the U.S. as a group that has been particularly negatively affected. Much of the data have been drawn from surveys conducted early in the pandemic and less is known about the rates of anxiety and depression across U.S. racial/ethnic groups in studies that have collected data more recently, as we reach the second and third years of the ongoing pandemic. Survey data of youth in the United Kingdom found that later lockdowns were more difficult to cope with and, as the pandemic and its effects extended, so did feelings of loneliness and isolation, uncertainty, grief, and challenges accessing mental health support (YoungMinds, 2021). Studying the long-term impact of the pandemic on youth is needed as there is ample evidence of the heavy load being carried by parents, including loss of employment, relationship difficulties, challenges managing children’s schooling and academics, and exhaustion (Brown et al., 2020). The negative effects of the pandemic on parenting and parental mental health have been well documented (Feinberg et al., 2021), but more research is needed with those of low income and non-European American backgrounds.

Depression and Anxiety in Latinx Children and Adolescents Before COVID-19

Empirically derived dimensions of youth mental health problems have consistently yielded two major problem types: internalizing and externalizing (Rescorla et al., 2012). Internalizing problems, which include depression, anxiety, and somatic problems, are best defined as problems directed inward (Liu et al., 2011). Anxiety and depression are highly prevalent among children and adolescents and are associated with significant role impairment, disability, and other negative outcomes, including suicidal ideation and behaviors (Avenevoli et al., 2015).

A comprehensive understanding of the mental health problems brought upon children and adolescents by the pandemic, and on Latinx youth, specifically, requires examining the prevalence and trends for these problems prior to 2020. According to the biennial Youth Risk Behavior Survey (YRBS), more than one in three high school students, including nearly half of female students, reported persistent hopelessness and depression in 2019, prior to the pandemic. The 10-year trend from 2009–2019 showed a steady and rising percentage of these symptoms, from 26.1% in 2009 to 36.7% in 2019 (Centers for Disease Control and Prevention [CDC], 2019). Data on the past-year prevalence of major depressive episodes (MDE) in adolescents ages 12–17 from the National Survey on Drug Use and Health (NSDUH) show a similarly disquieting trend. MDEs steadily increased (8.3% to 14.6%) from 2010 to 2018, while mental health service utilization remained low (Fan et al., 2022). These findings mirror those found for anxiety symptoms. In a large sample of over 37,000 high school students, risk for generalized anxiety among youth increased significantly and steadily between 2012 (34.1%) and 2018 (44.0%) (Parodi et al., 2022). A study of adults showed that the highest increase in anxiety in the period between 2010–2018 was among the youngest cohort of 18–25-year-olds (Goodwin et al., 2020). Suicidal ideation and behaviors commonly linked to anxiety and depression similarly rose among children and adolescents in the decade prior to the pandemic (CDC, 2019).

One of the main goals of this study is to explore differences in the internalizing distress of Latinx students, relative to those who are not of Latinx backgrounds, before and during the pandemic. Youth with anxiety and depressive disorders are among the least likely to receive care, and this unmet need is particularly large among Latinx youth (Fox & Hanes, 2022; Merikangas et al., 2011). For over 30 years, large numbers of studies have documented the presence of significant racial/ethnic differences in the levels of risk for depression among U.S. adolescents. The most consistent finding is that Latinx youth report higher depression symptoms and are at a higher risk for major depressive disorder compared to their counterparts from other backgrounds. These disparities have been documented in large studies in Texas and California (Emslie et al., 1990; Joiner et al., 2001; Mikolajczyk et al., 2007; Roberts et al., 1997; Siegel et al., 1998), as well as in nationally representative surveys (Roberts & Sobhan, 1992).

In each of the last 10 YSBR surveys, which were collected biennially between 1999 and 2019, Latinx adolescents, compared to European American and African American adolescents, had the highest endorsement of persistent sad and hopeless feelings that affect their ability to participate in daily activities (CDC, 2019; Wagstaff & Polo, 2012). In a meta-analysis of the Children’s Depression Inventory that included 310 samples, Latinx youth scored higher than European American and African American youth. This ethnicity effect was larger than those found for age and gender, and all other individual characteristics evaluated (Twenge & Nolen-Hoeksema, 2002).

The data comparing Latinx youth to other racial/ethnic groups for youth anxiety symptoms are not as consistent and do not date as far back as those documenting differences in depression (Anderson & Mayes, 2010). Higher general anxiety symptoms and anxiety sensitivity have been found for Latinx youth compared to European American youth (Glover et al., 1999; Weems et al., 2002). Latinx youth also scored higher than European American and African American youth in social anxiety, separation anxiety, and generalized anxiety (McLaughlin et al., 2007). In school-based samples Latinx youth are at higher risk in anxiety symptoms and endorse higher levels of worry/oversensitivity (Suarez-Morales & Bell, 2006) as well as separation anxiety, panic disorder, and obsessive-compulsive disorder symptoms compared to European American youth (Holly et al., 2015). In the National Comorbidity Survey Replication – Adolescent Supplement, Latinx youth, relative to European American youth, had higher lifetime odds of mood but not anxiety disorders (Merikangas et al., 2010).

Understanding Depression and Anxiety Risk Among Latinx

A comprehensive review of the variables associated with the internalizing problems found among Latinxs and their relative risk compared to youth from other racial/ethnic groups is beyond the scope of this article. However, there are some well-documented factors worth highlighting that help explain the risk and resilience of Latinx youth in studies focused on anxiety and depression. For example, acculturative stressors such as language difficulties, discrimination, and cultural gaps within family members have for a long time been linked to internalizing problems among Latinx children and adolescents (Hovey & King, 1996). Additionally, Latinx youth endorsing higher heritage cultural values that include familism, family obligation, and others are consistently protective against maladjustment, including internalizing problems (Stein et al., 2015). Integrative and asset-based models (Garcia Coll et al., 1996; Gaylord-harden et al., 2012) that account for and center social, cultural, and contextual determinants of health, including racial/ethnic discrimination, socio-economic status, gender, social position, immigration, and structural barriers as well as their interactions are best equipped to explain the well-being of Latinx youth and their differential risk.

Studies on the internalizing problems of Latinx youth have identified subgroups at increased risk. Latinx females consistently show the highest rates of both anxiety and depression, compared to Latinx males and compared to females from other racial/ethnic groups (McLaughlin et al., 2007; Mikolajczyk et al., 2007; Wagstaff & Polo, 2012). Differences between Latinx youth and those of other racial/ethnic groups, however, are not solely accounted for by Latinx females endorsing higher depression and anxiety symptoms, as Latinx males have also been found to be at greater risk relative to their male counterparts of other backgrounds (Holly et al., 2015; Wagstaff & Polo, 2012).

Family immigrant generation is a sociodemographic variable that consistently accounts for differential risk of mental health problems and disorders among Latinx adults. Compared to those who are first generation, second and third generation Latinx adults have higher rates of lifetime psychiatric disorders, especially for substance use disorders (Alegría et al., 2007). Among youth, a similar pattern has emerged for substance use and suicide attempts, but not depression (Peña et al., 2008). Polo and Lopez (2009) found that immigrant Mexican American adolescents reported higher social anxiety and loneliness, but not higher depressive symptoms, than U.S.-born Mexican American adolescents.

Among adults, Mexican Americans have lower lifetime rates of disorders than those of Puerto Rican and other Latinx backgrounds (Alegría et al., 2007). Limited research has examined risk of internalizing problems across country-of-origin subgroups within youth U.S. Latinx populations. No significant differences in depressive symptoms were found between middle and high school students of Mexican American, Puerto Rican, Cuban American, other Latinx, and Mixed Latinx backgrounds in a nationally representative sample (Peña et al., 2008). Higher risk of internalizing problems has been found among youth with non-binary identities and mixed-racial/ethnicity backgrounds (Chodzen et al., 2019; Fan et al., 2022) and research is needed to examine their risk levels within Latinx samples.

Depression and Anxiety in Referred Latinx Samples

Understanding the referral process can help to address disparities because identification increases the likelihood of families accessing services regardless of ethnic/racial background (Alegría et al., 2012). Non-Latinx White youth are more likely to be referred for specialty mental health services compared to racial/ethnic minority youth for internalizing problems (Gudiño et al., 2009). Schools are the primary point of entry for mental health services for youth in the U.S., and often the only source of care they receive (Farmer et al., 2003). However, evidence shows that, among youth diagnosed with mental health disorders, Latinxs are more than 50% less likely than EA youth to receive in-school services across a variety of diagnostic conditions (Locke et al., 2017).

The literature on ethnic differences in identification for services has focused on comparisons between African American and European American students and has found that African American students (boys, in particular) are disproportionately disciplined and referred for special education services (Bal et al., 2019; Maydosz, 2014). Evidence shows that Black youth are more likely to be nominated for services by teachers than youth of other ethnic groups, including Latinx youth (Villodas et al., 2019). However, these differences are accounted for by differences in externalizing problems, and not by depression or generalized anxiety (Villodas et al., 2019). A meta-analysis of school personnel referrals for services showed no differences in referral rates by school personnel between Latinx and European American youth, although the referrals were for intervention and assessments, not specifically internalizing problems (Hosp & Reschly, 2003). In a nationally representative study, Latinx and European American youth with internalizing disorders were equally likely to have been encouraged to receive services by their teachers and other school personnel (Alegría et al., 2012).

For school-based services, Latinx youth with externalizing and co-morbid (internalizing and externalizing) presentations were more likely to receive services than Latinx youth with internalizing problems only (Gudiño et al., 2009). As mentioned, due to the inward nature of symptoms, internalizing problems are more difficult to detect, which can hinder service delivery if not properly screened. Moreover, barriers to services persist beyond the initial referral. Cultural match, knowledge of resources, and acculturation can promote service use within the Latinx community (Bledsoe, 2008).

The Chicago Public Schools District Context

This study’s sample is comprised of elementary and middle schools from the CPS district, which is the fourth largest in the U.S., enrolling over 320,000 students. Most CPS students are economically disadvantaged (72.7%), and from Latinx (46.5%), African American (35.8%), European American (11.0%), and Asian American (4.4%) backgrounds (Chicago Public Schools [CPS], 2022). CPS shut down in March 2020 and transitioned to remote learning in April 2020. This decision, initially intended as a temporary strategy, became permanent due to statewide mandates, leading students to finish the 2019–2020 school year remotely (Sherry & Brinson, 2020). Remote learning continued during the 2020–2021 school year until March 2021 when families could select between in-person or remote learning. All students returned to in-person learning during the 2021–2022 school year, except for a couple of weeks in January 2022 when schools shut down again as safety guidelines were finalized between school staff and district officials during the Omicron variant surge (Rumore, 2022).

The Office for Social and Emotional Learning (OSEL) helps CPS schools establish multi-tiered systems of support (MTSS) for individualized instruction and intervention (Tier 3) and group programs targeting at-risk students (Tier 2). Since 2017, our group has partnered with OSEL to provide training and support to school-based staff (social workers, counselors, and psychologists) to deliver Act & Adapt, a video-guided group program designed to prevent and treat depression among early adolescents. This 10-session program coping skills through vignettes, discussions, and group activities. Act & Adapt was designed and tailored to serve youth of diverse backgrounds within a school context. This intervention, and others that include the Primary and Secondary Control Enhancement model, has been shown to be efficacious (Polo et al., 2023; Weisz et al., 1997).

Study Rationale and Aims

The COVID-19 pandemic has increased anxiety and depression among youth, at a time when internalizing problems had been rising steadily for almost a decade. In the U.S., Latinx youth, compared to their peers, have for several decades demonstrated higher risk of depression and, to a large extent, anxiety. This study focuses on the prevalence and risk profiles of referred students before and during the pandemic, and on Latinx adolescents. Several gaps in research are addressed in the study. These include reporting on data collected during the first two years of the pandemic, as most available reports have collected data during the first months of 2020. Also, COVID-19 studies conducted in the U.S. have not focused on the internalizing problems of Latinx youth or compared racial/ethnic groups to determine differential patterns of risk. Finally, few studies of Latinx youth have documented levels of risk for non-binary, mixed-Latinx youth, or Latinxs of different countries of origin.

Three aims investigated in this report are: 1. What are the depression and anxiety risk profiles of students referred for school-based services before and during the pandemic?; 2. Do referred Latinx students report higher symptoms and/or risk of depression and anxiety than non-Latinx students before and during the pandemic?; and 3. Within the Latinx sample, who reports the highest internalizing risk? Socio-demographic variables considered include Latinx subgroup, gender identity, and nativity.

Method

Participants

In total, 1220 students (M_age = 12.1; SD = 1.1) were referred and assessed across four academic years. They identified as girls (727; 59.6%), boys (n = 440; 36.1%) or as something else (e.g., “non-binary”) (n = 53; 4.3%) and were in 5th (n = 143; 11.7%); 6th (n = 413; 33.9%); 7th (n = 354; 29.0%) and 8th (n = 310; 25.4%) grade. The largest group of students were of Latinx only backgrounds (n = 541; 44.3%), followed by African American only (n = 322; 26.4%), European American only (n = 58; 4.8%), Asian American only (n = 56; 4.6%) and other only (e.g., Middle Eastern; n = 3; 0.2%) backgrounds. Those of mixed race/ethnicity backgrounds included those of mixed Latinx and other (e.g., Latinx and African American) (n = 190; 15.6%) and of mixed non-Latinx (African American and European American) (n = 46; 3.8%) backgrounds. Race/ethnicity could not be determined for 4 students due to missing data.

Latinx subgroup and nativity information were collected only for the last two academic years (2020–2021 and 2021–2022). Latinx and mixed Latinx students reported being Mexican American (n = 365; 70.1%), Puerto Rican (n = 40; 7.7%), or Central/South American (n = 35; 6.7%). Students of mixed Latinx subgroups included those of mixed Mexican American and other backgrounds (n = 71; 13.6%) and those of non-Mexican American mixed backgrounds (n = 10; 1.9%). The sample included students born outside of the U.S. (first generation; n = 34; 4.1%), U.S.-born students with at least one foreign-born parent (second generation; n = 402; 48.9%), U.S.-born students with U.S.-born parents and at least one foreign-born grandparent (third generation; n = 94; 11.4%) and students who did not report being of immigrant background (n = 292; 35.5%). Two students did not report nativity data.

Recruitment began in October or November of each year and ended by January or February of the following calendar year (see timeline in Figure 1). This study compares three groups. The first combines two cohorts (n = 396; 32.5%) assessed prior to the start of the pandemic in March 2020 (2018 through 2020 academic years). The second group (n = 231; 18.9%) was assessed during the pandemic while students were fully remote (2020–2021 academic year). The third and final group (n = 593; 48.6%) was assessed during the pandemic while students were receiving in-person instruction (2021–2022 academic year). As part of the dissemination and sustainability efforts for the Act & Adapt program, new schools were added to each cohort and were supported in their delivery efforts, along with those previously enrolled that chose to continue to deliver the program. This sample includes students from 59 schools. Nine schools were added in the first academic year; 16 in the second; 13 in the third; and 21 in the fourth. The demographics of the participating schools (77.6% economically disadvantaged; 33.7% African American; 51.1% Latinx; 8.1% European American; and 5.1% Asian American) mirror those of the district.

Figure 1. Timeline for referrals and assessments and learning modalities in Chicago Public Schools before and during the COVID-19 pandemic.

This timeline delineates transitions between in-person and remote learning for students. IPL = In-person learning; RL = Remote learning; HL = Hybrid - remote and in-person learning; and SD/RL = shut-down followed by remote learning. Assessments and program delivery occurred around the same time each year regardless of classroom modality.

Measures

Children’s Depression Inventory (CDI; Kovacs 1992)

The CDI is one of the most widely used clinical measures to assess depression symptoms in children and adolescents and has established reliability and validity with Latinx populations (Knight et al., 1994; Rivera et al., 2005). Students evaluate three statements for each item, such as “I am sad once in a while” “I am sad many times” and “I am sad all of the time.” CDI items are scored from 0 to 2 with higher scores representing higher depression symptom endorsement. In this study, 26 of the 27 items were administered. Item 9, which assesses suicidal ideation, was not included after consultation with district officials. High internal consistency was found for this measure in this sample (α = .91). Using the CDI manual and established guidelines, students were classified as low to moderate risk (<19) or high risk (19 or higher).

The Revised Children’s Anxiety and Depression Scale (RCADS; Chorpita et al., 2000)

The RCADS is a well-established measure with strong psychometrics across cultural groups, including Latin American samples (Cervin et al., 2022; Piqueras et al., 2017). Three subscales from the RCADS were administered. RCADS items are rated on a four-point scale from Never (0) to Always (3). The Major Depression subscale consists of 10 items (α = .89 in this sample), including “I feel sad or empty.” The Social Phobia subscale consists of 9 items (α = .89 in this sample), including “I worry I might look foolish.” The Generalized Anxiety subscale consists of six items (α = .88 in this sample), including “I worry that bad things will happen to me.” Raw scores were converted into standard scores according to sex and gender norms and were classified as falling within the normal to borderline (T ≤ 69) or clinical (≥70) range.

The student survey also included a set of background questions to determine the student’s gender identity, age, race/ethnicity, and family generation/nativity. Students reported on their own and each of their parent’s backgrounds, allowing them to choose one or more options for each (e.g., Asian American and African American). Students who identified as Latinx were asked to report on their subgroup by choosing one or more options (e.g., Mexican American and Puerto Rican). Students also reported whether they were born in the U.S. or another country. Parallel nativity questions were asked about their parents and grandparents to determine nativity and family generation backgrounds.

Procedure

Students completed the assessments with the assistance of their school staff, who were school counselors, school social workers, and school psychologists (henceforth referred to as “providers”). The research team provided instructions and guidance to standardize the referral and assessment procedures across schools. Providers first participated in a two-day training focused on the content and delivery of the coping skills program, but also the process and strategies to identify, recruit, and assess students. Handouts were shared with specific steps, scripts, and recommendations to follow, and a referral form was shared that included common symptoms of depression. Providers were encouraged to: 1) Send the form to teachers and other administrators to assist in the identification of potential students; 2) Meet with grade-level teachers to obtain referrals; and 3) Review their caseloads and meet with their behavioral health team, if one was available to them, to identify appropriate referrals. The research team communicated regularly with the providers and provided recruitment updates on all schools via monthly e-mail messages and regularly scheduled professional learning community meetings. A shared recruitment tracker was set up for each school, and the research team posted results on the tracker for each student assessed to help providers determine eligibility and fit. Students were excluded from the program if they had previously participated in Act & Adapt or if they were scheduled to transfer to another school. No other exclusion criteria were imposed so that providers did not feel restricted on who could benefit from being assessed for eligibility.

Across both pre-pandemic and pandemic academic years, providers shared a Qualtrics link with students and students completed the surveys individually on their own or in a group with the provider available to assist them in person or via Zoom, as needed. Students received a $5 electronic gift card for completing the survey. Students were considered eligible if they met criteria for moderate to severe symptoms on the CDI or met borderline to clinical classification on the major depression scale of the RCADS. The study and procedures were reviewed and approved by DePaul’s Institutional Review Board.

Data Analytic Plan

Analyses are first conducted for the entire sample and presented across all four academic years and then separately for the three pre-pandemic and pandemic cohorts (Aim 1). Then, Latinx and non-Latinx students are compared as well as mixed Latinx and mixed non-Latinx students (Aim 2). Finally, within-group differences are examined among Latinx students, focusing on subgroup/nationality, gender identity, and nativity/family generation (Aim 3). Continuous scores on each of the four measures are compared via standardized means, and differences are reported using Cohen’s d to examine the effect size of any differences found (0–.19 very small to small; 20–.49 small to medium; and ≥.50 large). Clinical classification and comorbidity rates are similarly compared using χ² tests and Cramer’s V to measure the strength of the associations and estimate of the effects using established guidelines based on the degrees of freedom (Cohen, 1988) (e.g., if df = 1, then .10 = small; .30 = medium; and .50 = large).

Results

The first aim of this study is to report on the depression and anxiety scores and risk profiles of all referred students in the sample. Table 1 shows Mean symptoms scores for each of the pre-pandemic and pandemic cohorts. The Mean CDI score across all four years was 17.1 and 42.1% of students were classified into the high-risk range (possible Major Depressive Episode). The Mean RCADS depression score across the four years was 12.1 and 31.8% of students were in the clinical range (98^th percentile). Across cohorts, the Mean social anxiety (SA) score was 14.1 and 16.3% of students were classified as being in the clinical range. Finally, the Mean generalized anxiety (GA) score across cohorts was 8.3 and 16.4% of students were in the clinical range. Standardized Mean differences between the cohorts were in the minimal to small range, with the largest effect sizes found for RCADS depression and social anxiety. In both cases, students in the second year of the pandemic reported higher scores than those in the pre-pandemic cohorts. In the classification rates comparisons, students were most likely to be classified at clinical levels for depression during the second year of the pandemic, and in the clinical range for anxiety in the first year of the pandemic, although these differences were not statistically significant and represent minimal to small effects.

Table 1. Mean internalizing symptom scores and percent classified as clinical/high risk among referred students before and during the COVID-19 pandemic (N = 1220).

	a. Pre-COVID (n = 396)	b. COVID Yr. 1 (n = 231)	c. COVID Yr. 2 (n = 593)
	Mean (Standard Deviation) Scores			a vs b Cohen’s d (95% C.I.)	a vs c Cohen’s d (95% C.I.)
CDI Depression	16.7 (10.1)	16.7 (10.0)	17.5 (9.2)	.002 (−.16 to .16)	.08 (−.05 to .21)
RCADS Depression	11.4 (7.0)	11.6 (7.2)	12.7 (6.8)	.03 (−.14 to .19)	.19 (.06 to .32)
RCADS SA	13.5 (6.8)	13.9 (7.2)	14.6 (6.9)	.06 (−.11 to .22)	.16 (.03 to .29)
RCADS GA	8.1 (4.9)	8.1 (5.1)	8.5 (4.6)	−.002 (−.16 to .16)	.09 (−.04 to .21)
	Percent in the Clinical/High Risk Range			χ^2 (2, 1220)	Cramer’s V
CDI Depression	40.9	38.5	44.4	2.67	.05
RCADS Depression	28.3	29.9	34.9	5.30	.07
RCADS SA	13.4	19.5	17.0	4.41	.06
RCADS GA	16.9	16.9	15.8	0.29	.02

Pre-COVID group includes students referred in both 2018–2019 and 2019–2020; SA = Social Anxiety; GA = Generalized Anxiety.

Comorbidity patterns were also examined for the entire sample and across cohorts. The percentage of students who reported clinical levels of depression and anxiety (SA and/or GA) was 19.5%. Significant differences representing small to medium effects were found in the clinical range and comorbidity classification of students across the pre-COVID-19 and COVID-19 cohorts (see Table 2). The highest rate of morbidity was also found in the most recent year of the pandemic, relative to rates from pre-pandemic and year 1 of the pandemic. Over half of the students referred in 2021–2022 were found to be in the clinical range in either depression, anxiety, or both categories.

Table 2. Comorbidity patterns among referred students before and during the COVID-19 pandemic.

	Pre-COVID		COVID Yr. 1		COVID Yr. 2
No clinical/high risk	55.1%		56.3%		47.5%
Depression only	24.7%		21.2%		29.4%
Depression and SA plus GA	9.1%		12.6%		8.3%
Depression and SA or GA	9.8%		7.4%		11.4%
SA and/or GA only	1.3%		2.6%		3.4%
χ^2(8, 1216) = 18.66; p = .02; Cramer’s V = .09
	a. Pre-COVID		b. COVID Yr. 1		c. COVID Yr. 2
	Latinx	Non-Latinx	Latinx	Non-Latinx	Latinx	Non-Latinx
No clinical/high risk	49.5%	60.4%	53.8%	60.8%	40.7%	59.7%
Depression only	27.0%	22.3%	20.5%	23.0%	32.8%	23.2%
Depression and SA plus GA	12.2%	6.1%	15.4%	6.8%	9.8%	5.7%
Depression and SA or GA	10.2%	9.6%	7.1%	8.1%	13.5%	7.6%
SA and/or GA only	1.0%	1.5%	3.2%	1.4%	3.2%	3.8%

SA = Social Anxiety; GA = Generalized Anxiety.

a. χ²(4, 393) = 7.30; p = .12; Cramer’s V = .14; b. χ²(4, 230) = 4.28; p = .37; Cramer’s V = .14; and c. χ²(4, 589) = 21.53; p < .001; Cramer’s V = .19.

A second aim of this study was to determine whether Latinx students, before and during the pandemic, were at higher risk of depression, SA, and GA than their peers from other racial/ethnic groups. These analyses were run across cohorts and within each of the three cohorts. Students were categorized into four groups: a) Latinx (n = 541; 44.3%); b) non-Latinx (n = 439; 36.0%); c) Latinx mixed with non-Latinx (n = 190; 15.6%); and d) Mixed non-Latinx (n = 46; 3.8%).

Mean Symptom Differences – Latinx vs. Non-Latinx

Table 3 compares Latinx and non-Latinx students to each other and compares mixed Latinx with mixed non-Latinx students across the depression and anxiety measures. Overall, Latinx students endorsed higher depression, higher SA, and higher GA symptoms than their non-Latinx peers, with effect sizes in the small to medium range. This pattern was seen during both the pre-COVID and COVID years. Pre-COVID, differences were larger between Latinx and non-Latinx students for depression (ES > .20) compared to anxiety (ES < .20). During COVID, moderate magnitude differences emerged for both depression (COVID year 2), as well as for SA (COVID years 1 and 2) and GA (COVID year 1).

Table 3. Mean internalizing symptom scores among Latinx and non-Latinx students.

	Non-Latinx (n = 439)	Latinx (n = 541)	Cohen’s d (95% CI)	Mixed Non-Latinx (n = 46)	Mixed Latinx (n = 190)	Cohen’s d (95% CI)
CDI Depression
Overall	15.3 (9.1)	18.1 (9.6)	.30 (.18 to .43)	16.2 (10.6)	18.7 (10.2)	.25 (−.08 to .57)
Pre-COVID	15.2 (9.5)	17.3 (10.3)	.21 (−.01 to .43)	16.3 (11.3)	20.6 (11.0)	.39 (−.17 to .95)
COVID Yr. 1	16.0 (9.2)	17.6 (10.2)	.16 (−.15 to .46)	15.6 (11.2)	16.0 (10.4)	.04 (−.69 to .77)
COVID Yr. 2	15.1 (8.7)	18.7 (9.0)	.41 (.23 to .60)	16.3 (10.3)	18.7 (9.5)	.25 (−.22 to .72)
RCADS Depression
Overall	10.9 (6.5)	12.6 (6.9)	.25 (.12 to .37)	11.4 (7.3)	13.5 (7.6)	.28 (−.04 to .60)
Pre-COVID	10.2 (6.4)	12.0 (7.3)	.27 (.05 to .49)	10.9 (6.7)	14.3 (7.7)	.45 (−.12 to 1.01)
COVID Yr. 1	11.5 (6.3)	12.0 (7.4)	.07 (−.23 to .37)	10.1 (8.3)	11.3 (7.7)	.15 (−.58 to .88)
COVID Yr. 2	11.5 (6.6)	13.2 (6.6)	.26 (.08 to .45)	12.2 (7.5)	13.9 (7.4)	.22 (−.25 to .69)
RCADS Social Anxiety
Overall	13.0 (6.8)	14.9 (6.8)	.29 (.16 to .41)	11.9 (7.6)	15.3 (7.4)	.47 (.14 to .79)
Pre-COVID	12.8 (6.9)	13.5 (6.5)	.10 (−.12 to .32)	10.2 (7.3)	17.1 (6.2)	1.06 (.47 to 1.65)
COVID Yr. 1	12.6 (7.0)	14.9 (7.0)	.33 (.02 to .63)	12.9 (8.1)	13.6 (7.9)	.09 (−.64 to .81)
COVID Yr. 2	13.2 (6.6)	15.6 (6.7)	.36 (.18 to .55)	12.7 (7.8)	15.1 (7.6)	.31 (−.16 to .78)
RCADS Generalized Anxiety
Overall	7.6 (4.8)	8.6 (4.7)	.21 (.09 to .34)	7.5 (5.2)	9.0 (5.1)	.30 (−.02 to .63)
Pre-COVID	7.5 (4.9)	8.2 (4.7)	.14 (−.08 to .36)	7.4 (5.4)	9.9 (5.3)	.48 (−.08 to 1.05)
COVID Yr. 1	7.0 (4.8)	8.7 (5.1)	.35 (.05 to .66)	7.8 (5.4)	8.2 (5.1)	.08 (−.65 to .81)
COVID Yr. 2	7.9 (4.7)	8.8 (4.4)	.19 (.01 to .38)	7.4 (5.2)	8.8 (4.8)	.29 (−.18 to .76)

Ns for non-Latinx pre-COVID, COVID Yr. 1, and COVID Yr. 2 = 181, 65, and 193, respectively; for non-Latinx = 144, 118, and 279, respectively; for Mixed non-Latinx = 16, 9, and 21, respectively; and for Mixed Latinx = 52, 38, and 100, respectively.

Similarly, mixed Latinx students reported higher scores than their mixed non-Latinx peers (see Table 3). Across cohorts, these differences corresponded to medium to large effects for both depression measures and were largest for SA. The higher risk found for depression, SA, and GA seen in mixed Latinx youth do not seem to be exacerbated by the pandemic, as there were medium to large differences in these measures found in the pre-pandemic cohort.

Clinical and Comorbidity Differences – Latinx vs. Non-Latinx

Figure 2 examines the risk status of students across cohorts, by presenting the percentage of students who were classified as falling within the clinical range of symptoms and comparing Latinx and non-Latinx students. For these analyses, the Latinx (only) and mixed-Latinx groups were combined into one group, and the non-Latinx (only) and mixed non-Latinx groups were combined into another group. Also, the two depression measures were combined so that students were classified as being in the clinical range if they were in the clinical or high-risk range on either the CDI or RCADS. Overall, significantly higher number of students of Latinx (51.5%) than of non-Latinx (37.5%) backgrounds were classified as being in the clinical range in depression overall across cohort years (χ²(1, 1213) = 23.05; p < .001; Cramer’s V = .14), and in both the pre-pandemic year (χ²(1, 393) = 5.21; p < .05; Cramer’s V = .12) and in Year 2 of the pandemic (χ²(1, 590) = 20.23; p < .001; Cramer’s V = .19), specifically.

Figure 2. Percentage of referred students in the clinical/high risk range for depressive, social anxiety, and generalized anxiety symptoms across cohorts.

** = p < .01; and * = p < .05.

For SA, a significantly higher number of students of Latinx (20.1%) than of non-Latinx (10.8%) backgrounds fell in the clinical range overall across cohorts (χ²(1, 1210) = 18.20; p < .001; Cramer’s V = .12), and in Year 2 of the pandemic (χ²(1, 587) = 13.31; p < .001; Cramer’s V = .15), specifically. For GA, 18.5% of Latinx and 13.3% of non-Latinx students fell in the clinical range across cohorts (χ²(1, 1213) = 5.83; p = < 0.05; Cramer’s V = .07), and significant differences were found in Year 1 of the pandemic (χ²(1, 230) = 4.36; p < .05; Cramer’s V = .14) only. For that year, more than twice as many Latinx students were in the clinical range for GA, compared to non-Latinx students (see Figure 2).

Latinx students were more likely to meet comorbid criteria than non-Latinx students across cohort years (χ²(4, 1212) = 27.11; p = .001; Cramer’s V = .15). No statistically significantly differences in comorbidity were found between Latinx and non-Latinx students during the pre-pandemic years or in the first year of the pandemic. In Year 2 of the pandemic, Latinx students had significantly higher rates of comorbidity with depression plus SA and/or GA than non-Latinx students (23.3% vs. 13.3%).

Latinx Within Group Analyses

The third aim of this study examined internalizing symptoms and risk categories within the Latinx subsample. Latinx students were combined into three subgroup categories: Mexican American, other Latinx, and mixed Latinx subgroups (Table 4). Differences in mean symptoms and clinical classification rates were in the minimal to small range. In all instances, Mexican American students scored higher than the other two subgroups of students. None of the risk classification comparisons for Latinx subgroups were significant and differences in clinical rates were in the minimal to small range.

Table 4. Mean internalizing symptom scores and percent classified as clinical/high risk among Latinx subgroups during two years of the COVID-19 pandemic.

	a. Mexican American (n = 365)	b. Other Latinx (n = 75)	c. Mixed Latinx (n = 93)
	Mean (Standard Deviation) Scores			Cohen’s d (b vs a)	Cohen’s d (c vs a)
CDI Depression	18.7 (9.4)	17.0 (9.1)	17.4 (9.9)	.18 (−.07 to .43)	.14 (−.08 to .37)
RCADS Depression	13.0 (6.9)	12.4 (7.4)	12.7 (6.7)	.10 (−.15 to .35)	.05 (−.28 to .18)
RCADS SA	15.4 (7.1)	15.1 (6.5)	14.5 (7.3)	.04 (−.21 to .29)	.12 (−.34 to .11)
RCADS GA	8.9 (4.8)	8.1 (4.3)	8.5 (4.8)	.18 (−.07 to .43)	.08 (−.31 to .15)
	Clinical/High Risk Range			χ^2 (2, 533)	Cramer’s V
CDI Depression	49.6%	44.0%	44.1%	1.42	.05
RCADS Depression	36.5%	37.3%	35.5%	0.06	.01
RCADS SA	22.3%	18.9%	20.4%	0.50	.03
RCADS GA	19.2%	14.7%	15.1%	1.49	.05

SA = Social Anxiety; GA = Generalized Anxiety.

Table 5 presents the gender identity and nativity analyses within the Latinx sample. For gender identity, differences were in the medium to large effects range for all depression and anxiety measures. Latinx girls and Latinx non-binary students endorsed higher symptoms of depression, SA, and GA than Latinx boys. Compared to boys, other/non-binary youth were over 2.5 times more likely to be in the clinical range for depression, 2.7 times more likely to be in the clinical range for SA, and 1.9 times more likely to be in the clinical range for GA. In contrast, small differences were found for nativity mean symptom scores and risk categories. First and second generation Latinx students reported higher depression and anxiety scores than Latinx students of third or more generations, but clinical classification rates were nearly identical for anxiety across nativity groups.

Table 5. Mean internalizing symptom scores and percent classified as clinical/high risk across gender identity and nativity of Latinx students during two years of the COVID-19 pandemic (n = 535).

	Gender Identity					Nativity/Generation
	a. Boy (n = 181)	b. Girl (n = 316)	c. Other (n = 38)	Cohen’s d (a vs. b)	Cohen’s d (a vs. c)	1^st or 2^nd (n = 389)	3^rd+ (n = 146)	Cohen’s d
CDI Depression	14.8 (9.0)	19.4 (8.8)	25.7 (10.5)	.51 (.33 to .70)	1.17 (.81 to 1.54)	18.5 (9.6)	17.6 (9.0)	.10 (−.29 to .09)
RCADS Depression	10.4 (6.5)	13.8 (6.6)	17.4 (7.8)	.52 (.33 to .70)	1.04 (.68 to 1.40)	13.1 (7.1)	12.4 (6.4)	.11 (−.30 to .08)
RCADS SA	11.9 (6.5)	16.6 (6.7)	19.9 (6.0)	.71 (.52 to .89)	1.25 (.88 to 1.62)	15.4 (7.0)	14.6 (7.1)	0.11 (−.30 to .08)
RCADS GA	7.3 (4.6)	9.3 (4.6)	10.7 (4.9)	.45 (.27 to .64)	.75 (.39 to 1.10)	8.9 (4.6)	8.2 (4.9)	0.15 (−.34 to .04)
				χ^2 (2, 535) (Cramer’s V)				Χ^2 (1, 535) (Cramer’s V)
CDI Depression	30.4%	54.7%	76.3%	40.5*** (.28)		49.6%	43.8%	1.42 (.05)
RCADS Depression	23.9%	40.8%	63.2%	26.5*** (.22)		38.6%	31.7%	2.12 (.06)
RCADS SA	15.6%	22.5%	42.1%	13.3** (.16)		21.6%	21.5%	0.001 (.001)
RCADS GA	15.0%	18.0%	28.9%	4.6 (.09)		17.7%	17.9%	0.003 (.002)

** = p < .01 and *** = p < .001; SA = Social Anxiety; GA = Generalized Anxiety.

Discussion

The COVID-19 pandemic is on-going, and waves of infection continue, but with fewer hospitalizations and deaths due to less harmful variants and vaccine protections (Johnson et al., 2022). Uncertainty remains as society takes inventory of the effects of drastic lifestyle changes, and of the pronounced mental health difficulties experienced by children and adults. In the U.S., Latinx youth and families have been disproportionately affected. A primary goal of this study was to document the internalizing problems of Latinx youth before and during the pandemic. Prior research studies with school-based samples have shown that Latinx youth endorse higher depression and anxiety symptoms than their peers (McLaughlin et al., 2007). This study extends those findings by finding a similar pattern among students referred by teachers and other school staff. Relative to non-Latinx students, more than twice as many Latinx students fell in the clinical range for generalized anxiety in the first year of the pandemic and for social anxiety in the second year of the pandemic. Continued efforts are needed to address the needs of Latinx youth who, along with other underrepresented and low-income groups, were more affected by school closures (Hawrilenko et al., 2021) and whose parents endorsed heightened and disproportionate levels of stress during the pandemic (Brown et al., 2020).

This study included a sizable number of students of mixed ethnic/racial backgrounds, who have been understudied and previously found to be at high risk (Parodi et al., 2022). Mixed Latinx students in this sample showed comparable levels of internalizing problems than Latinx students, while the scores of mixed non-Latinx students were similar to the non-Latinx sample. Mixed-Latinx students reported higher internalizing symptoms than their mixed non-Latinx counterparts and higher risk was associated with being of Latinx background, rather than being of mixed backgrounds. A limitation of the study is that it was not possible to identify Latinx students of African backgrounds (e.g., African Caribbean) and separately examine their profiles from those of other racial/ethnic backgrounds (e.g., Indigenous).

Consistent with the few studies that have compared comorbidity patterns for youth across racial/ethnic groups (McLaughlin et al., 2007), Latinx students were 1.5 to 2 times more likely to present with both depression and anxiety than non-Latinx students (during every academic year cohort assessed). Practical and efficacious programs are needed to address the needs of adolescents in school settings, and this is a critical time to implement them widely. Socio-emotional interventions in schools for urban youth of African American and Latinx backgrounds have not yielded strong effects (Farahmand et al., 2011), and RCTs for youth depression and anxiety have not documented treatment effects for diverse populations (Polo et al., 2019). Training and dissemination should be prioritized for interventions evaluated with Latinx youth for internalizing problems (Fung et al., 2019; Pina et al., 2020).

Intersectionality Theory (Crenshaw, 1989) suggests that youth with multiple marginalized identities are systemically and disproportionately oppressed, making them vulnerable to internalizing problems (Luthar et al., 2021; Parodi et al., 2022). The highest risk for internalizing problems within the Latinx sample was among girls and youth with non-binary and non-conforming gender identities. Large effects were found, despite the relatively small sample size. The findings highlight the need for staff to make their school environment inclusive and welcoming of youth across the gender spectrum so that these students access the services they need.

Meta-analytic studies have concluded that anxiety and depression have increased during the pandemic in children and adolescents (Brasso et al., 2022; Racine et al., 2021). The current study focused on students of predominantly non-European American and low-income backgrounds before COVID-19 and during the first two years of the pandemic. One half met criteria for clinical or high-risk classification in depression, social anxiety, and/or generalized anxiety. Some evidence was found in suggesting that these early adolescents experienced higher severity of internalizing problems during the pandemic, but particularly among Latinx youth.

It is not surprising that, as the pandemic drags on, internalizing problems are increasing for Latinx youth and for youth, in general. Families have been in isolation and withdrawn from others for prolonged periods. Most students received instruction strictly via video conferencing for over one year and without opportunities for natural and less restrictive socialization. As children and adolescents re-adjust to social interactions with peers and other adults, those at risk may find this process particularly difficult, as they are vulnerable to being self-critical and overly focused on how others judge them during social interactions (Khan et al., 2021). Additionally, mental health services were severely disrupted and continue to be unavailable for many who need them, particularly Latinx youth who are more likely to be uninsured and of low-income backgrounds (Kaiser Family Foundation, 2022). There are reasons to suggest that internalizing problems will continue to rise or stay at these unprecedented levels. The latest data from the state of Illinois reveal lower teacher retention, high and chronic student absenteeism, and significant achievement drops in math, English, and other subjects (Illinois State Board of Education, 2022) which, among Latinx students, are closely connected to depression (Zychinski & Polo, 2012). As noted earlier, rates of both anxiety and depression among children and adolescents were already on the rise during the decade before the pandemic (Fan et al., 2022; Goodwin et al., 2020), suggesting that addressing these problems is of utmost importance.

It is important to note some limitations of the current study, which used cross sectional data across four academic years to compare students referred before and during the pandemic. A longitudinal design tracking the same students over time could more directly evaluate incidence of depression and anxiety along with symptom trajectories. Also, only social anxiety and generalized anxiety were assessed, and other anxiety disorder symptoms and other comorbid conditions were not, some of which may be closely connected to the COVID-19 illness (e.g., obsessive compulsive symptoms due to fears of being contaminated by germs).

Moreover, the pandemic kept students at home and away from providers’ purview. Previous knowledge about students informs referral decision-making, therefore, a disconnect could have prevented those with symptom onset during the shelter in place order from being identified. In addition, this study did not examine school or provider-level characteristics. Racial/ethnic match between therapists and clients has been identified as a facilitator of mental health service delivery among adolescents (Lu et al., 2021) and concerted efforts are needed to recruit and train for a diverse mental health workforce that can staff schools. Agreement on problem etiology predicted youth engagement, including perceived usefulness in a predominantly Latinx sample (Yeh et al., 2019). Therefore, a future line of research could examine the interplay between school, provider, and student-level factors in the context of school-based referrals. Finally, while there are several advantages to school-based services (e.g., increased accessibility, reduced cost, etc.), school-level factors that impede these benefits exist, such as large student to provider ratios, lack of knowledge about mental health problems by teachers and caregivers, and funding (Goodcase et al., 2022).

Importantly, there are multiple stressors that Latinx children and families of underrepresented backgrounds have endured historically and in the past few years, in addition to the pandemic. These include hostile and discriminatory immigration policies (Torres et al., 2018) and other forms of ethno-racial trauma (Chavez-Dueñas et al., 2019). In the U.S., racially motivated mass shootings, anti-Asian American discrimination, and the murders of George Floyd and others by police are simultaneously affecting youth and families of color (Cheah et al., 2020; Eichstaedt et al., 2021). Measuring the direct and indirect impact of these events and practices is challenging, and efforts are needed to isolate and evaluate the combined effects of these stressors from those of the pandemic.

Acknowledgments

We thank the providers and schools who partnered with us and the students who participated.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was funded by a grant from the Annie E. Casey Foundation and contracts with the Chicago Public School District.

Notes

This article is part of the special issue “Understanding the Impact of the COVID-19 Pandemic on the Mental Health of Latinx Children, Youth, and Families: Clinical Challenges and Opportunities” edited by José M. Causadias and Enrique W. Neblett, Jr.