“…However, prior studies have shown between 2016-2020, there were significant increases in children's diagnosed depression and anxiety, although after onset of the COVID-19 pandemic specifically, there were significant year-over-year increases in children's diagnosed behavioral or conduct issues, supporting our conclusions that the increase in MH-visits is attributable to factors related to the pandemic. 19 Our study was also limited to schools geographically where in-person learning was available, and did not include children seeking MH-services from providers other than school-nurses, such as school counselors, other school-based MH-providers, or MH-providers outside of school, which may limit the generalizability of our findings. Given the nature of school-nurse services, it is likely the same students may be visiting the school-nurse for MH-related symptoms on more than one occasion; given we did not have access to individual level data to examine this, our analyses used school-nurse visits as observations.…”