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IMPORTANCE: Public health measures to reduce the spread of COVID-19 have heightened distress among children and adolescents and contributed to a shift in delivery of mental health care services. OBJECTIVES: To measure and compare physician-based outpatient mental health care utilization before and during the COVID-19 pandemic and quantify the extent of uptake of virtual care delivery. DESIGN, SETTING, AND PARTICIPANTS: Population-based repeated cross-sectional study using linked health and administrative databases in Ontario, Canada. All individuals aged 3 to 17 years residing in Ontario from January 1, 2017, to February 28, 2021. EXPOSURES: Pre–COVID-19 period from January 1, 2017, to February 29, 2020, and post–COVID-19 onset from March 1, 2020, to February 28, 2021. MAIN OUTCOMES AND MEASURES: Physician-based outpatient weekly visit rates per 1000 population for mental health diagnoses overall and stratified by age group, sex, and mental health diagnostic grouping and proportion of virtual visits. Poisson generalized estimating equations were used to model 3-year pre–COVID-19 trends and forecast expected trends post–COVID-19 onset and estimate the change in visit rates before and after the onset of COVID-19. The weekly proportions of virtual visits were calculated. RESULTS: In a population of almost 2.5 million children and adolescents (48.7% female; mean [SD] age, 10.1 [4.3] years), the weekly rate of mental health outpatient visits was 6.9 per 1000 population. Following the pandemic onset, visit rates declined rapidly to below expected (adjusted relative rate [aRR], 0.81; 95% CI, 0.79-0.82) in April 2020 followed by a growth to above expected (aRR, 1.07; 95% CI, 1.04-1.09) by July 2020 and sustained at 10% to 15% above expected as of February 2021. Adolescent female individuals had the greatest increase in visit rates relative to expected by the end of the study (aRR, 1.26; 95% CI, 1.25-1.28). Virtual care accounted for 5.0 visits per 1000 population (72.5%) of mental health visits over the study period, with a peak of 5.3 visits per 1000 population (90.1%) (April 2020) and leveling off to approximately 70% in the latter months. CONCLUSIONS AND RELEVANCE: Physician-based outpatient mental health care in Ontario increased during the pandemic, accompanied by a large, rapid shift to virtual care. There was a disproportionate increase in use of mental health care services among adolescent female individuals. System-level planning to address the increasing capacity needs and to monitor quality of care with such large shifts is warranted.