INTRODUCTION
In December 2019, the first patient with pneumonia of an unknown cause was reported in China and then it was subsequently linked to a seafood market in Wuhan, China.[ 1 ] COVID-19 has spread worldwide and has changed dramatically normal life-disrupting social and economic functioning comparable to the Spanish flu pandemic of 1918.[ 2 ] As of now, worldwide 54,301,156 confirmed cases have been reported along with 1,316,994 deaths worldwide. COVID-19 has spread rapidly leading to a high number of fatalities.[ 3 ]
As per recent studies, the pediatric age group constitutes 1%-2% of the diagnosed cases with a median age in the range of 3.3–11 years and a male/female ratio to be 1.15–1.55. The incidence of COVID-19 was lower among the children and adolescent age group in comparison with the adult population with death being a rare phenomenon. The possible reason could be a difference in the immune system function of children and adolescents or could be due to differences in the expression/function of the cellular receptor for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)-Angiotensin-converting enzyme 2 (ACE2).[ 4 ] In a time of an emergency like a pandemic , the psychological health of children and adolescents is at risk mainly due to their limited coping skills and understanding of the situations. Response of a child or an adolescent to adversity varies and it depends upon multiple factors such as previous exposure to similar kinds of situations, current physical and psychological health, socioeconomic circumstances, and the cultural background of the family. Different studies have elicited that crises have a derogatory impact on the psychological impact on the wellbeing of the child and concomitantly there has been a rise in the incidence of psychiatric disorders worldwide.[ 5 ] The influence of COVID-19 in the lives of children has been substantial and it should not be belittled as this pandemic has led to social isolation and restrictions, which are particularly disrupting for children and be both baffling and petrifying. Although apart from anxiety a rise in stress, depressive symptoms, insomnia, denial, anger, and fear has been observed globally.[ 6 ] This systematic review and meta-analysis aim to find the pooled prevalence of both depression and anxiety in children and adolescent age groups during the COVID-19 pandemic .
METHOD
This systematic review aims to find out the prevalence of depression and anxiety in the child and adolescent age group during the COVID-19 pandemic . We searched data from PubMed, Google Scholar, Science Direct, Medline, and Cochrane. The search was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.[ 7 ]
We followed PICOS criteria for our search which stands for Participants (P): Child and adolescent population during this pandemic ; Intervention (I): no intervention was done; Comparison (C): no comparison or control group; Outcome (O): prevalence of depression and anxiety in the study population; and Study design (S): published cross-sectional studies. As per Methley et al. , PICOS process for systematic review and meta-analysis is beneficial when there are limited resources unlike PICO and SPIDER.[ 8 ]
We searched with MESH terms “COVID-19 AND anxiety, DEPRESSION, AND STRESS AND CHILDREN OR ADOLESCENT”; “COVID-19 AND ANXIETY OR STRESS AND CHILDREN AND ADOLESCENT”; COVID-19 AND ANXIETY OR STRESS AND CHILDREN OR ADOLESCENT; COVID-19 AND DEPRESSION OR STRESS AND CHILDREN AND ADOLESCENT; COVID-19 AND DEPRESSION OR ANXIETY AND CHILDREN AND ADOLESCENT; COVID-19 AND PSYCHOLOGICAL EFFECTS AND CHILDREN OR ADOLESCENT; “COVID-19 AND PSYCHOLOGICAL EFFECTS AND CHILDREN AND ADOLESCENT”.
Additional filters were also applied for age, and period, we included journal articles and clinical studies involving human subjects, we excluded these categories by applying filters that are review articles, case series, case reports, and case-control studies.
Quality assessment
We adopted Newcastle-Ottawa Quality Assessment Scale for cohort studies to perform a quality assessment of cross-sectional studies for the systematic review. In our version of the scale, we have specifically assigned 1 star for self-reported outcomes because many of the studies used self-reporting questionnaires. The 4 items in the selection criteria had a maximum score of 5 stars; comparability had a maximum of 2 stars with 3 stars for the outcome. Quality assessment was done by one author (S.C.).[ 9 ]
Data extraction
The study data were extracted from January 2020 to April 2021. Data extraction was done by 2 authors (G.M. and V.V.) and was put in predefined categories in table format in MS word and excel sheets. Any discrepancy or controversy was sorted out mutually by 3 authors (G.M., V.V., and S.C.). Inclusion and exclusion criteria for vetting search results along with their rationale are given in Box 1 . Box 2 shows the sources of literature search and retrieval.
Box 1: Inclusion and exclusion criteria for vetting of search results along with rationale
Box 2: Sources of literature search and retrieval
Data analysis
All included studies have been conducted independently. We took mild, moderate, and severe symptoms in the analysis. The data analysis was done in Cochrane’s Revman software which is available free for academic purposes. Pooled prevalence along with 95% was calculated using the inverse variance method. This method weighs pooled prevalence estimates by their sample size. The random effect model was used to find variations across studies. The between-study heterogeneity was assessed through I2 statistics. A Forest plot was created to reflect pooled prevalences and funnel plots were used for observing publication bias. As the heterogeneity was high in this meta-analysis, therefore, we performed a moderator analysis. Bornstein et al . recommended that moderators should be examined when the number of studies is more than 10.[ 10 ]
RESULTS
Using the strategy described more than 4,245 citations were sourced. After screening, 4,191 abstracts were excluded and 54 were selected. Of these, 2 full texts were not available and 3 were duplicate records. Further 25 records did not meet the inclusion and exclusion criteria and in 3 studies the prevalence of depression and anxiety were not mentioned. Finally, 22 studies were considered suitable for inclusion in the review [Figure 1 , Tables 1 and 2 ]. The summary of the results along with the statistical techniques used in the various studies has been provided in Tables 1 and 2 . We found the total number of participants to be 71,016. Both anxiety and depression were mentioned in 14 studies of a total of 22 studies. The study design consisted of cross-sectional studies and some studies conducted through online surveys. The age range varied considerably from 1 year to 19 years; 5 studies had participants aged more than 19 years but we included them as the mean age of the total sample was less than 18 years.
Figure 1: Search process
Table 1: Prevalence of Depression and Anxiety in children and adolescents during COVID-19 pandemic
Table 2: Highlights of the included studies and statistical techniques used in the study
Prevalence of depressive symptoms in children and adolescents during COVID-19
The random-effects meta-analysis from 17 studies of a total of 22 studies revealed a prevalence rate of 27% (95% confidence interval [CI]: 21%-36%) [Figure 2a ]. The funnel plot was symmetric, indicating a low risk of publication bias, shown in Figure 2b . The between-study heterogeneity statistic was significant (I2 = 100%; Tau² = 0.34; Chi² = 41592.79, df = 16) (P <.00001) [Figure 2a ]. Significant moderators were present [Table 3 ]. The overall effect of the moderators including month, region of publication, and mean age of study participants was insignificant (adjusted R square = 0.602; P =0.089). The geographical region as a moderator was insignificant adjusted R2 = -0.015 (b [standardized coefficient] = 0.230; P =0.391) (number of studies belonging to South Asia (N) = 14; prevalence of depression = 27% (CI: 19%-38%); Europe (N) = 1, the prevalence of depression = 24% (CI: 23%-25%); Middle East (N) = 1 prevalence of depression = 57% (CI: 55%-59%); North America (N) = 1 prevalence of depression = 20% (CI: 19%-21%). The effect of the mean age was also explored, only 8 studies mentioned mean age. The age was a significant moderator and as the age increased the prevalence also increased (adjusted R2 = 0.622 b (standardized coefficients) = 0.822 (P value =.012). The month of data collection was also insignificant (adjusted R2 = -0.06; b [standardized coefficient] = 0.125; P =.658).
Figure 2: (a) Pooled Prevalence of Depression. (b) Funnel Plot for the pooled prevalence of Depression
Table 3: Moderator Analysis for Depression
Prevalence of anxiety symptoms in children and adolescents during COVID-19
The random-effects meta-analysis from 20 studies of a total of 22 studies revealed a prevalence rate of 25% (95% CI: 16%-41%) [Figure 3a ]. The funnel plot was symmetric, indicating a low risk of publication bias, shown in Figure 3b . The between-study heterogeneity statistic was significant (I2 = 100%; Tau² = 1.22; Chi² = 581499.11, df = 19) (P <.00001) [Figure 3a ]. Significant moderators were present. The overall effect of all 4 moderators was insignificant. The month of publication was not a significant predictor (Adjusted R2 = 0.046; standardized coefficient (b) = 0.123; P value =0.627). Other moderators like the proportion of the female participants and region of the publication also had no significant effect (adjusted R2 = 0.066; b = -0.412 [P value =0.237] and adjusted R2 = 0.008; b = 0.219 [P value =.367], respectively). The only significant predictor was the mean age of the participants. The pooled anxiety increased with the mean age of the study participants (Adjusted R2 = 0.598; b = 0.799) (P value =.003) [Table 4 ].
Figure 3: (a) Pooled Prevalence of Anxiety. (b) Funnel Plot for the pooled prevalence of Anxiety
Table 4: Moderator analysis of anxiety
DISCUSSION
The present study provides an estimate of global depression and anxiety among youth during the COVID-19 pandemic . Across 22 studies with a total sample size of 71,016, we found a prevalence of 27% for depression and 25% for anxiety. Compared to prepandemic global estimates, the prevalence of depression and anxiety has drastically increased.[ 33–38 ]
The rise in the prevalence of depression and anxiety is multifactorial. Children and adolescents during quarantine or lockdown are experiencing isolation from their friends, teachers, community activities, and extended family. Duration of the quarantine period, stress, monotonous life, lack of infection, and stigma increases the negative impact on psychological health. They are more likely to have a negative psychological impact than the adult population. In young children, the anxiety was mainly attributable to the fear of getting ill either for themselves or their family members while the older children manifested anxiety by repeatedly inquiring about COVID-19. In another study on school and college-going students, it was found that home confinement was associated with increased anxiety and stress mainly due to uncertainty regarding their socialization and physical activities with their peers.[ 39 , 40 ]
As per a rapid systematic review by Loades et al. , children and adolescents are more likely to experience depression and anxiety during isolation and if isolation persists then these symptoms may also advance in severity. Loneliness has been described as a painful emotional experience of a discrepancy between actual and desired social contact and has been linked with increased anxiety in children adolescent age group. About one-third of adolescents reported loneliness due to social isolation and quarantine.[ 41 , 42 ]
The impact of school closure on mental health can not be missed. Schools in India have been closed since March, although the central government has permitted the reopening of schools in mid-October. However, the decision regarding the manner and timing in which schools are to be open has been left to the discretion of the state government. Sudden school closures have led learning to be shifted from the classroom to online platforms. This sudden transition has created a state of confusion among teachers about their roles. In a country like India, there are several roadblocks including internet connectivity, as reported by an NSO survey that about 3/4th of students in India did not have internet access. There are other logistics problems as well like it is very difficult to teach maths online and not all teachers are tech-savvy. The student’s focus is also an issue that is being reported by the teachers. A study found that older adolescents and youth are anxious and stressed out regarding the cancellation of their examinations and academic events as it has left them uncertain regarding their future.[ 43 , 44 ]
Children in nuclear families with both parents working especially in the healthcare sector are facing much more difficulties because their children remain unattended at home and this can lead to risky behaviour including substance abuse. Confusion and uncertainty regarding examination dates and the reopening of school can lead to stress and anxiety in students. The resulting interruption increases already existing discrepancies within the education system but also in other aspects of their lives.[ 45 , 46 ]
In a survey by Young Minds in children and adolescents, 58% of participants had a positive effect after meeting their classmates in school, while 30% reported a negative effect and 12% had no effect. Following a routine of going to school gives a structure in life and it had a positive effect on 47% of participants, while 30% reported a negative effect and 19% were neutral about the situation. Similarly, students reported a positive effect after seeing their teachers and doing extracurricular activities. The possible reason could be that students may feel productive after going to school.
Now let us consider the other side of the coin as revealed by this survey; after the opening of schools, some participants reported that travelling to school (36%) and social distancing (51%) measures had a negative effect on them. These students reported that going to school after a long hiatus was an overwhelming experience and their stress and anxiety were mostly related to home assignments given by the school. Also, some students expressed that their school should give less home assignments as they will require some time for adjustment.[ 47 , 48 ]
As shown in Tables 2 -4 , we found that the female gender and grade level of the study subjects were the two prime risk factors that were consistently reported across all the studies, although female gender was statistically insignificant. Other factors such use of excessive use of the internet, concern about graduation, and concern about COVID-19 infection were also reported. Exercise and adequate sleep were protective against depression and anxiety.
One particular study by Kılınçel et al . focussed on “State anxiety” which is defined as a momentary reaction to adverse events with arousal in the sympathetic nervous system, while “trait anxiety” is more of a stable personality trait. It is associated with psychopathology and constant arousal of the sympathetic nervous system. Spielberg’s considered both trait and state anxiety as one-dimensional while other authors considered it a multidimensional construct. They found state anxiety was found to increase by 2.41 times in the group that was using mostly television as a source of information about COVID. State anxiety increased by 4.39-fold in subjects having a prior psychiatric referral and by 3.81-fold having a COVID positive patient in the family or surroundings.[ 24 , 49 ]
In one study, it was found that young children between the age of 3 and 6 years are more likely to be anxious than older children between the age of 6 and 18 years. Although in our systematic review, we found age to be directly proportional with psychiatric comorbidity. In young children, the anxiety was mainly attributable to the fear of getting ill either for themselves or their family members, while the older children manifested anxiety by repeatedly inquiring about COVID-19. In another study on school-going and college-going students, it was found that home confinement was associated with increased anxiety and stress mainly due to uncertainty regarding their socialization and physical activities with their peers.[ 40 ]
It has been observed that economic recession is associated with a rise in familial conflicts. Similarly, COVID-19 has affected the economy worldwide, many countries have recorded a decline in their GDP suggestive of a shrinking economy. Financial instability can lead to stress and consequent marital conflicts which can further escalate into domestic violence. Most of the parents are now working from home in a confined space and they can easily displace their anger and frustration related to their work onto their family members including children in addition, the possibility of escape from a conflicting situation is also limited in the current situation which further increases their exposure to an abusive family member. Many studies have significantly revealed that an increase in domestic violence is related to a rise in mental health adversity in children and can cause long-term consequences.[ 50 , 51 ]
The sudden arrival of new pathogenic agents has left many people psychologically vulnerable across the globe without a corresponding increase in their coping or resilience.
Various strategies have been advised to cope up by increasing resilience which includes simple tasks like helping other families, giving financial aid to persons in need, and giving encouragement to people who feel down and out. Notably, a minuscule thing like a general message of hope given by healthcare personnel and scientists has been found to be helpful in increasing individual resilience.
Higher social support is associated with less chances of developing psychological distress and it is especially required in the communities in pandemic areas.[ 52–55 ]
Limitations
The limitations of this meta-analysis are that most of the included studies were from Asia and particularly China. Also, most of them got published early, when the pandemic had just started. Very few studies were aconducted on psychiatric morbidity in children with special needs since during lockdown these children were unable to access therapies. Most of the studies used online platform to disseminate the self rating forms that were completed by either parents or children themselves. Finally, more longitudinal studies with baseline assessment of depression and anxiety would be appropriate to further instrospect this issue.
CONCLUSIONS
The take away message from this systematic review and meta-analysis is that there is a pandemic of depression and anxiety. There is an urgent need to improve the psychological wellbeing of children and adolescent on an individual level. The intervention should also include individual considerations since our meta-analysis revealed significant heterogeneity in the included studies.
Highlights
Pandemic has posed an unrivalled hazard to the mental health of children and adolescents.Relatively high incidence and prevalence of depression and anxiety in the child and adolescent population. The pooled prevalence of depression and anxiety in children and adolescents during COVID-19 has been calculated.
Characteristics of the included studies have been summarised in the table.
Significant moderators have been explored.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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