Abstract
Objectives. To determine the burden of mental health disorders among children enrolled in Michigan’s Flint Registry in the context of a local public health crisis and a nationally declared pediatric mental health crisis.
Methods. This survey-based study included 1203 children aged 3 to 17 years whose caregivers enrolled them in the Flint Registry between December 2018 and March 2020 and who completed a follow-up survey between October 2020 and March 2022. The baseline and follow-up surveys included caregiver reports of childhood anxiety and depression and overall mental health wellness.
Results. At enrollment, Flint Registry caregivers reported significantly higher rates of anxiety and depression among their children than caregivers reported nationally (12.9% vs 9.4% and 8.2% vs 4.4%; P < .001). Flint Registry caregivers also reported declines in their children’s overall mental health wellness at follow-up, t(1472) = −4.17; P < .001.
Conclusions. Our findings reveal a disparate burden of pediatric mental health disorders and exemplify the health inequities vulnerable populations face.
Public Health Implications. More proactive and preventive steps should be taken to lessen this burden, especially in chronically disadvantaged communities that experience public health crises. (Am J Public Health. 2023;113(12):1318–1321. https://doi.org/10.2105/AJPH.2023.307406)
In 2021, the US Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics, and the Office of the Surgeon General acknowledged a national pediatric mental health emergency. Between 2010 and 2020, rates of childhood anxiety and depression increased steadily.1 In 2019, 1 in 3 high school students reported persistent feelings of sadness or hopelessness; by 2021, that figure reached 42%.2,3 Longitudinal studies have shown that childhood anxiety or depression can stem from genetic factors and experiences of trauma, maltreatment, or other early adversities.4
From April 2014 through October 2015, the Flint, Michigan, community was exposed to unsafe drinking water with the risk of elevated blood lead levels. Lead exposure has mental and behavioral health consequences, as does exposure to the trauma of an environmental disaster.5–7 Furthermore, pediatric mental health worsened during the COVID-19 pandemic as a result of social isolation, family economic hardship, family loss or illness, and reduced health care access.8
Established before the COVID-19 pandemic, the CDC-supported Flint Registry has engaged in voluntary survey-based population-level surveillance and support for individuals exposed to the Flint water crisis. Enrollment for the Flint Registry began in December 2018, and individuals were recruited through an extensive community-based outreach and marketing campaign.
Recognizing the need to better understand the mental health implications of lead exposure and trauma in the context of a global pandemic, we sought to answer the following question: Considering the national trends in pediatric mental health, what is the mental health status of Flint Registry children? Also, we sought to determine how their mental health status has changed over time.
This study included 1203 children aged 3 to 17 years whose caregivers completed a baseline enrollment Flint Registry survey between December 2018 and March 2020 and a follow-up survey between October 2020 and March 2022. The mean (±SD) interval between the completion of the baseline and follow-up surveys was 16 months (±5 months). The children were Flint residents during the water crisis (April 25, 2014, to October 15, 2015), and 88% of caregivers reported that their child was exposed to unfiltered City of Flint tap water during the crisis. Michigan Department of Health and Human Services records were used to verify the identities of the child participants.
Extracted survey data included questions from or adapted from the National Survey of Children’s Health: Has a doctor, other health care provider, or educator (such as a teacher or school nurse) ever told you that your child has anxiety problems? Has a doctor, other health care provider, or educator (such as a teacher or school nurse) ever told you that your child has depression? During the past 12 months, has your child received any treatment or counseling from a mental health professional? We compared rates of childhood anxiety and depression among Flint children with CDC data gathered via the same National Survey of Children’s Health questions.9
In addition, data on overall child mental health were included: In general, would you say your child’s mental health is excellent, very good, good, fair, or poor? Information on age, biological sex, free and reduced-cost meal services, and race was also collected.
The survey data were collected via REDCap electronic data capture tools hosted at Michigan State University.10 SPSS 27 (SPSS Inc, Chicago, IL) was used to analyze the data with 1-sample χ2, paired sample proportions, and paired t tests.
Data were missing for less than 3% of the demographic variables (Table 1). Missing data for the outcome variables anxiety, depression, and parents’ reports of overall mental health wellness and treatment ranged from 5% to 8%, and thus our analysis included SPSS multiple imputation for these variables; pooled values are reported.
TABLE 1— Flint Registry Children at Enrollment (December 2018–March 2020) Versus National Sample (2019) and at Follow-Up Survey (October 2020–March 2022): Flint, MI
| Study Participant Demographics | Mean ±SD, No. (%), or Percentage Point Difference | Significance |
| Age, y | 9 ± 3.7 | |
| Biological sex | ||
| Female | 561 (46.6) | |
| Male | 638 (53.0) | |
| Missing | 4 (0.3) | |
| Free or reduced-cost meals | ||
| No | 213 (17.7) | |
| Yes | 959 (79.7) | |
| Missing | 31 (2.6) | |
| Race | ||
| Black only | 736 (61.2) | |
| White only | 274 (22.8) | |
| Other minority only | 12 (1.0) | |
| More than 1 | 151 (12.6) | |
| Missing | 30 (2.5) | |
| Flint vs national sample | ||
| Anxiety | 3.5 | χ2(1, n = 1203) = 17.04; P < .001 |
| Depression | 3.8 | χ2(1, n = 1203) = 41.76; P < .001 |
| Change at follow-up | ||
| % with anxietya | −0.8 | 95% CI = −0.01, 0.03; P = .446 |
| % with depressiona | −0.2 | 95% CI = −0.01, 0.02; P = .762 |
| % receiving treatmenta | −0.4 | 95% CI = −0.06, 0.07; P = .922 |
| % with poor or fair mental health | 2.4 | t(1472) = −4.17; P < .001 |
Note. CI = confidence interval. Percentages may not sum to 100 owing to rounding. The sample size was 1203.
Source. National sample data are from Bitsko et al.9
a Tested with paired sample proportion tests.
The mean (±SD) age of the 1203 children at enrollment was 9.0 (±3.7) years. About half of the children (46.6%) were female, and 79.7% were eligible for free or reduced-cost school meals. Most caregivers reported that their child identified as Black or African American only (61.2%); 22.8% reported White only, 1% reported Native American or Alaska Native only, and 12.6% reported more than 1 race.
At enrollment, Flint Registry caregivers reported significantly higher rates of anxiety and depression among their children than in the general population (as reported in 2019 by the CDC9), χ2(1, n = 1203) = 17.04; P < .001 and χ2(1, n = 1203) = 41.76; P < .001, respectively. At baseline, 12.9% of the study participants reported anxiety and 8.2% reported depression (as compared with the national rates of 9.4% and 4.4%, respectively9).
The percentages of children with anxiety and depression did not change significantly at follow-up. However, caregivers reported a decline in the rating of their child’s overall mental health, t(1472) = −4.17; P < .001. A total of 16.9% of caregivers reported their child’s mental health as fair or poor at follow-up, as compared with 14.5% at baseline.
At follow-up, most (54.3%) caregivers reported that children with anxiety or depression had received treatment or counseling from a mental health professional in the preceding 12 months; 13.5% reported that their child had not received treatment or counseling from a mental health professional in the past 12 months but believed that the child needed to see a mental health professional, and 32.2% reported that their child did not need to see a mental health professional. These figures are not significantly different from reported mental health care access rates at baseline (54.7%, 12.8%, and 32.5%, respectively).
In this large cohort of children enrolled in the Flint Registry, the findings reveal an outsized burden of pediatric mental health disorders. National trends have prompted declarations of emergency, and our local data reflect even greater alarm and exemplify the health inequities that certain populations face.
Our data may reflect the pathogenesis of exposure to lead and trauma as well as historic and systemic adversity. This study mirrors research on behavioral and mental health outcomes among children in communities affected by manmade environmental disasters.5–7
The results of our study do not reveal increases in childhood anxiety and depression after the onset of the pandemic, but they do show a worsening of parent-reported overall mental health wellness. This may reflect the impact of the pandemic on the services needed to diagnose new cases of anxiety and depression.
Crisis mitigation efforts in Flint included universal early intervention, mindfulness programming, high-quality child care, Medicaid expansion, parenting support, literacy programming, trauma-informed care, and nutrition services. The effects of these efforts on our findings are unknown. More research is needed.
The limitations of this study rest largely on the registry as a voluntary surveillance tool. In addition, we used a cross-sectional design, and therefore causal inferences cannot be made. The strengths of the study are that the sample size was large and that participants’ demographic characteristics mirrored those of the Flint population.
This study of a marginalized population of children is consistent with and supports national efforts to amplify pediatric mental health concerns and encourage early identification. New US Preventive Services Task Force recommendations for anxiety screening of all children beginning at 8 years of age11 are promising; however, more proactive and preventative steps should be taken to lessen this burden, especially in communities such as Flint that have experienced long-standing systemic inequities atop manmade environmental disasters.6 Our data also support the expansion of early mental health screening and treatment of mental health disorders, particularly in partnership with local schools, which has been shown to increase receipt of care.12
ACKNOWLEDGMENTS
This secondary analysis of data was not supported by external funding. Data collected in the Flint Registry project were used in our study. The Flint Registry was supported by grant funding from the Centers for Disease Control and Prevention (CDC; award NUE2EH001370) for an award totaling $20,360,339, with 0% financed with nongovernmental sources; the Genesee County (Michigan) Health Department through the Healthy Start project (grant U62MC31100) from the Health Resources and Services Administration (HRSA) for an award totaling $3,255,399, with 0% financed with nongovernmental sources; and the State of Michigan Department of Education.
This work was presented at the American Public Health Association 2022 Annual Meeting and Expo.
We thank Katlin Harwood-Schelb and Katherine Negele for their assistance with the preparation of the article.
Note. The contents are those of the authors and do not necessarily represent the official views of, or an endorsement by, the CDC, the Genesee County Health Department, HRSA, the US government, or the State of Michigan Department of Education.
CONFLICTS OF INTEREST
Mona Hanna-Attisha is an author (What The Eyes Don’t See) and speaker and has provided testimony during congressional hearings as a child health expert. The other authors declare no conflicts of interest.
HUMAN PARTICIPANT PROTECTION
The Michigan State University institutional review board approved this secondary analysis of Flint Registry data.
