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Increasingly, research confirms the negative effects of COVID-19 safety measures on the mental health of children and adolescents.1-5 Saunders and colleagues6 call for an urgent response to the increasing sustained demand for mental health services inclusive of substance use and developmental disorders. The authors’ population-based cross-sectional study used linked administrative and health data to examine changes in utilization of physician-provided mental health services for 2.5 million children and adolescents aged 3 to 17 years in Ontario, Canada. From March 2020 through February 2021, the authors found a rapid and sustained 10% increase in outpatient mental health service utilization by children and adolescents compared with prior rates. Similar trends were not observed for acute mental health service utilization for the same period, except for girls. The current study found striking sex differences with substantially higher rates of utilization observed for acute inpatient psychiatric hospitalization and outpatient mental health services for school-aged and adolescent girls. The authors hypothesized that there would be a large, rapid shift toward virtual care that would be sustained throughout the COVID-19 pandemic and that utilization would vary by diagnostic groups and age. Thus, they examined variations in utilization of virtual care by diagnostic groups and adoption of telehealth as a modality for treatment. Rapid major shifts in utilization of virtual visits occurred very early during the COVID-19 pandemic and were sustained at approximately 70% of treatment.6 Increased rates of substance use disorders and psychotic disorders occurred early and were sustained at levels higher than expected, although they represent a small proportion of visits. The largest increases were noted for mood and anxiety disorders (74.7%), psychosis (73.2%), substance use (83.6%), social problems (64.6%), and neurodevelopmental disorders (69.8%). Saunders and colleagues6 join the growing number of investigators confirming the substantial mental health outcomes associated with the COVID-19 pandemic in youth and a need to respond to the increasing demand for services. The authors highlight the need for a systematic response to address increasing mental health needs, including variations in demand by age and sex differences noted across studies.6-8 The results of this population-based study suggest that youth in Ontario are experiencing increasing psychological distress that underlies the 10% greater utilization of physician-provided outpatient mental health services. Although this study highlighted increasing mental health service needs for children and adolescents during the COVID-19 pandemic, the authors noted several limitations. The administrative and health data for mental health services provided by physicians were not linked with the data for services provided by psychologists, social workers, and other therapists, who provide a significant proportion of mental health care in Canada, nor did the data set allow for measurement of unmet need.6 Classification of diagnostic groups by physician billing codes, rather than clinical diagnostic criteria, complicated assessing prevalence of diagnosis, illness severity, or family contexts that might influence care seeking. Furthermore, billing codes did not differentiate virtual visits by telephone or video, nor could they account for the outcomes of variations in reimbursement that affect utilization, thus limiting generalizability. Moreover, digital equity and disparities among Asian, Black, Indigenous (Inuit and Métis), and Latin American people; rural and urban communities; and access and utilization were not addressed. The findings of a sustained 10% increase in mental health service utilization are far-reaching with both shortand long-term consequences. Since the start of the COVID-19 pandemic, survey data for children and adolescents reported higher rates of anxiety and depressive symptoms and parental concerns about their children’s mental health.1,4,5 A 2021 meta-analysis7 found a 2-fold increase in the global prevalence of depression and anxiety for children and adolescents, with higher rates for adolescents and girls. Other studies have found increasing rates of anxiety, depression, and suicidal behaviors among school-aged children and adolescents (especially for girls8); increasing emergency visits9 and hospitalizations8,10; and long waits for acute psychiatric care.8,10 The adverse effects of lockdowns, social isolation, educational adaptations, and loss of moderating community supports are significant contributors. The COVID-19 pandemic has further highlighted disparities in mental health burden for girls; lesbian, gay, bisexual, transgender, queer or questioning, asexual or allied, and intersex youth; and racially and ethnically minoritized youth.11-13 Despite these limitations, the authors’ call for a systematic approach to increasing access to mental health services is well founded.6 Accessing mental health treatment for children and adolescents was challenging before the COVID-19 pandemic. In response to the alarming mental health crisis within the US, leading pediatric and mental health professional organizations have declared “a national state of emergency in child and adolescent mental health,”14(p1) urging a national response to address these needs. Related article Opinion