The coronavirus 2019 (COVID-19) pandemic has resulted in drastic shifts in daily life and routine activities [1,2], in addition to significant health, economic, financial, and social consequences [3]. Beginning in March 2020, several countries around the world implemented lockdowns and physical/social distancing measures [4]. Hundreds of thousands of lives have been lost because of COVID-19 around the world. This massive loss of lives, along with the abrupt changes in day-to-day life because of the COVID-19 pandemic, may have an adverse effect on child and adolescent mental health [3–8]. There is a dearth of scientific evidence on the effects of the COVID-19 pandemic on child and adolescent mental health.
Although on one hand, the COVID-19 pandemic has presented an opportunity for more family time, time for resuming hobbies/interests, and an opportunity for an ‘individualized pace of learning’ (for children and adolescents who find traditional school environment challenging) [9], on the other hand, many children or adolescents may be at increased risk due for domestic violence and maltreatment, secondary to pandemic related isolation measures [1,3,6]. Children and adolescents with a history of mental health conditions, history of trauma, and parental mental illness or high parental/caregiver distress [2] may be at additional risk during this pandemic [1]. Disadvantaged children and adolescents are likely to be affected to a greater degree by the mental health consequences of COVID-19 [1].
Little contact with peers, fear of ill health/death of family members [10], decreased structure, lesser direct contact with teachers at school because of school closures, may be some of the factors that can increase anxiety, behavioral difficulties, and adversely affect child and adolescent mental health during this time [1]. Increased internet use by adolescents, secondary to the isolation and physical distancing measures, confers the advantages of social connectivity, but, comes with its own risks [3].
The effects of the COVID-19 pandemic may include exacerbation and/or worsening of mental health challenges among children and adolescents with preexisting psychiatric conditions, and potential new onset of mental health challenges, particularly, anxiety and stress-related disorders among at-risk children and adolescents [1,3]. For some children or adolescents with prepandemic psychiatric conditions, the lockdown may have led to a shift or even disruption in care [3,7]. Children and adolescents with chronic psychiatric and/or neurodevelopmental conditions, such as autism-spectrum disorders, psychotic disorders, intellectual disability, especially those who had been receiving a significant proportion of their mental healthcare and services in-person during prepandemic times, may be affected [1,3]. The mental health of children and adolescents hospitalized to inpatient facilities where parents’ visitations are restricted [6] because of physical distancing measures, may be affected [1]. Although rapidly growing telepsychiatry use has helped maintain continuity and provision of psychiatric care in many parts of the world during this pandemic, the scarcity of in-person care may pose a challenge for many children/adolescents/families [11], particularly for those not having access to technology or living in unsafe environments [1,7].
Available evidence estimates significantly elevated rates of anxiety and stress among a significant proportion of adults during this pandemic [12], particularly parents [2]. The effects of increased anxiety and stress among parents/caregivers may seep into the lives of children and adolescents [2]. Additionally, parental job loss and financial difficulties are other factors which may result in decreased access to mental healthcare for many children and adolescents, in addition to contributing to parental stress, and in turn, affecting child and adolescent mental health and wellbeing [1,8].
Given childhood and adolescence are crucial periods of brain maturation, the psychological effects of disaster-related trauma experienced in childhood and adolescence can be long-lasting [13]. A 2013 study which examined the ‘psychosocial responses of children and their parents to pandemic disasters’ (398 parents), found that ‘30% of isolated or quarantined children’ met criteria for posttraumatic stress disorder (PTSD), based on ‘parental reports’ [14]. In another study, Udwin et al.[15] examined risk factors for PTSD among 217 young adults who experienced a shipping disaster during adolescence. The study followed participants five to eight years following the shipping disaster, and found that the emergence of PTSD was significantly linked with ‘being female, with predisaster factors of learning and psychological difficulties in the child and violence in the home, with severity of exposure to the disaster, survivors’ subjective appraisal of the experience,’ and with postdisaster coping, life events, and social supports thereafter [15].
A survey of 1143 parents of children and adolescents age 3–18 years in Italy and Spain during the COVID-19 pandemic, found that ‘85.7% of the parents perceived changes in their children's emotional state and behaviors during the quarantine,’ the most common features being ‘difficulty concentrating (76.6%), boredom (52%), irritability (39%), restlessness (38.8%), nervousness (38%), feelings of loneliness (31.3%), uneasiness (30.4%), and worries (30.1%)’ [4]. The study also reported that children and adolescents engaged in more frequent screen usage, lesser physical activity, and more number of hours of sleep, during the quarantine period during this pandemic [4].
Soest et al.[8] conducted online surveys among adolescents in Oslo (n = 8116) when COVID-19 restriction measures were in place, and compared the results with two, ‘equivalent’ surveys done in Oslo in 2018 and early 2020 (before COVID-19 restrictions came into effect). The study revealed a significant decline in life satisfaction among both boys and girls during the COVID-19 restriction period (P < 0.001) [8]. Reduced life satisfaction was found to be linked with ‘concerns about illness and infection’ [8]. Given life satisfaction is linked with mental health, particularly with anxiety and depression, these findings are significant [8].
A cross-sectional, online, survey of 4805 female adolescents (age 11–18) in China, using the Center for Epidemiologic Studies Depression Scale, found that 39.5% of study participants experienced depression with a CED-S score greater than 15 [16]. Age 15–18 years, distant learning, being ‘concerned about COVID-19,’ sleep less than 6 h/day, physical exercise less than 30 min/day, were found to be factors linked with depression, in this study [16].
A cross-sectional study evaluating the link between social support and mental health among adolescents (n = 7202) via online surveys in March 2020 during the COVID-19 outbreak in China, found ‘COVID-19 exposure’ to be linked with greater prevalence of depression and anxiety [10]. The study also noted that low level of social support was linked with greater prevalence of depressive and anxiety symptoms, suggesting social support as a protective factor for adolescent mental health during the COVID-19 pandemic [10].
Duan et al.[5] conducted an online questionnaire-based study of 359 children and 3254 adolescents. The Spence Child Anxiety Scale, Child Depression Inventory, and Coping Style Scale were used [5]. Around 22.28% of participants were found to experience depressive symptoms [5]. Some of the factors found to be linked with elevated depressive symptoms in this study were ‘smartphone addiction’ and ‘internet addiction’ [5]. Some of the factors linked with heightened anxiety in this study, included being female, living in urban areas, and ‘emotion-focused coping style’ [5]. The study found a ‘significant psychosocial impact’ of COVID-19 on children and adolescents [5].
A cross-sectional, online survey of Chinese adolescents age 12–18 (n = 8079) during the COVID-19 pandemic, utilized the Patient Health Questionnaire and the Generalized Anxiety Disorder questionnaire to evaluate depressive and anxiety symptoms among the participants [17]. The study findings revealed that the prevalence of depressive symptoms was 43.7%, of anxiety symptoms was 37.4%, and that of comorbid depressive and anxiety symptoms was 31.3%, among the study participants [17]. In this study, being female and being in senior high school were some of the risk factors linked with depressive and anxiety symptoms [17].
The European ADHD Guidelines Group, in April 2020, highlighted the challenges experienced by children and adolescents with ADHD during the COVID-19 pandemic, particularly in the form of heightened behavioral problems, and recommended the use of telepsychiatry for continuing ‘all relevant service provision’ for this patient population during the current pandemic, in light of the pandemic related physical distancing requirements [18].
Not all children and adolescents will go on to develop adverse mental health outcomes [2,9]. Strengthening and supporting resilience promoting factors can be a vital step in reducing the adverse mental health impact of the pandemic among children and adolescents. Given the widescale, significant impact of the COVID-19 pandemic, designing and implementing suitable preventive as well as response measures is vital. Targeted interventions [8] and ‘response strategies’ are needed to address the mental health needs of children and adolescents during this time [14].
Educating parents with information on how to support and appropriately reassure children and adolescents during this pandemic, can be one of the beneficial preventive measures [1]. Effective parental coping and self-care can facilitate more responsive parenting; also, maintaining some predictability in the child/adolescent's routine can be beneficial [2]. Therefore, measures and resources to support parents’ ability to do so during the pandemic, should be considered and implemented [2].
Measures to enhance social support for youth during the pandemic, particularly, for at risk youth, may be beneficial [10].
At-risk children, for example, children or adolescents with disabilities, or those who have lost their parents/primary caregivers, need to be monitored and paid particular attention to [19].
Measures to ensure continuity of child protection services during the pandemic are needed [6,19].
Telepsychiatry can be valuable during the COVID-19 pandemic, especially to maintain continuity of care for a large number of children and adolescents with psychiatric conditions [6,11,18]. In fact, telepsychiatry has rapidly replaced traditional, outpatient visits in many parts of the world during this pandemic [6]. Further research to evaluate telepsychiatry usage for children and adolescents, and techniques to improve the efficacy and accessibility of telepsychiatry, is needed [1].
Training of healthcare workers, teachers, and social workers, about the effects of COVID-19 pandemic on children and adolescents’ mental health, is needed, to ensure that children receive appropriate support [19].
Further research is needed, especially studies from more varied geographical areas, given there may be cultural factors influencing the specific effects of the pandemic on youth in various regions [17]. Also, longitudinal studies are warranted to better understand the effects (along with risk and resilience factors [9]) of the COVID-19 pandemic on the mental health of children and adolescents, to devise more specific and targeted interventions and minimize adverse long-term consequences of the pandemic on child and adolescent mental health [1].
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