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we can fix overnight or with a single prescription. Ensuring healthy children and families will take an all-ofsociety effort, including policy, institutional, and individual changes in how we view and prioritize mental health. This Advisory provides actionable recommendations for young people and their families, schools and health care systems, technology and media companies, employers, community organizations, and governments alike. Our obligation to act is not just medical—it’s moral. I believe that, coming out of the COVID-19 pandemic, we have an unprecedented opportunity as a country to rebuild in a way that refocuses our identity and common values, puts people first, and strengthens our connections to each other. If we seize this moment, step up for our children and their families in their moment of need, and lead with inclusion, kindness, and respect, we can lay the foundation for a healthier, more resilient, and more fulfilled nation. Vivek H. Murthy, M.D., M.B.A. Vice Admiral, U.S. Public Health Service Surgeon General of the United States Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory 5 A Surgeon General’s Advisory is a public statement that calls the American people’s attention to an urgent public health issue and provides recommendations for how it should be addressed. Advisories are reserved for significant public health challenges that need the nation’s immediate awareness and action. This Advisory offers recommendations for supporting the mental health of children, adolescents, and young adults. While many of these recommendations apply to individuals, the reality is that people have widely varying degrees of control over their circumstances. As a result, not all recommendations will be feasible for everyone. That’s why systemic change is essential. The Advisory includes essential recommendations for the institutions that surround young people and shape their day-to-day lives—schools, community organizations, health care systems, technology companies, media, funders and foundations, employers, and government. They all have an important role to play in supporting the mental health of children and youth. For additional background and to read other Surgeon General’s Advisories, visit SurgeonGeneral.gov. ABOUT THE ADVISORY Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory 6 Youth Mental Health Prior to the COVID-19 Pandemic Mental health affects every aspect of our lives: how we feel about ourselves and the world; solve problems, cope with stress, and overcome challenges; build relationships and connect with others; and perform in school, at work, and throughout life. Mental health encompasses our emotional, psychological, and social wellbeing, and is an essential component of overall health.1 As described in the 1999 Surgeon General’s Report on Mental Health, it is the “springboard of thinking and communication skills, learning, emotional growth, resilience and self-esteem.”2 Mental health challenges can be difficult to define, diagnose, and address, partly because it isn’t always clear when an issue is serious enough to warrant intervention.2 All of us, at all ages, occasionally experience fear, worry, sadness, or distress. In most cases, these symptoms are short-lived and don’t affect our ability to function. But, at other times, symptoms can cause serious difficulties with daily functioning and affect our relationships with others, as in the case of conditions such as anxiety disorders, major depressive disorder, schizophrenia, bipolar disorder, and eating disorders, among others.3 Mental health conditions can be shaped by biological factors, including genes and brain chemistry, and environmental factors, including life experiences. Some mental health disorders seem to cluster in families, but they are often shaped by multiple genes, and whether an individual develops symptoms can be further modified by their experiences and surrounding environment.4, 5 Environmental factors can range from exposure to alcohol or drugs during pregnancy, to birth complications, to discrimination and racism, to adverse childhood experiences (ACEs) such as abuse, neglect, exposure to community violence, and living in under-resourced or racially segregated neighborhoods.6, 7, 8, 9, 10, 11, 12 ACEs can undermine a child’s sense of safety, stability, bonding, and wellbeing.13 Moreover, ACEs may lead to the development of toxic stress. Toxic stress can cause long lasting changes, including disrupting brain development and increasing the risk for mental health conditions and other health problems such as obesity, heart disease, and diabetes, both during and beyond childhood as well as for future generations.12, 14 Biological and environmental factors can also be interrelated, making it difficult to isolate unique “causes” of mental health challenges. For example, if a child is genetically predisposed to depression, they might be more affected by experiences such as bullying than other children.15, 16 Figure 1 (next page) includes a longer list of factors that shape the mental health of young people. BACKGROUND Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory 7 FIGURE 1 Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory 8 Even before the COVID-19 pandemic, mental health challenges were the leading cause of disability and poor
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