Abstract
Background and Objective: The COVID-19 outbreak had several effects on global mental health, especially among children and adolescents. Besides the great availability of studies that investigated psychological effects related to quarantine, the magnitude and the nature of many symptoms are still generically described.
Materials and Methods: Authors wrote a general review by examining the more recent literature about psychological effects of COVID-19 from Google Scholar website.
Results: The main results report several symptoms of distress among general population and youth, such as depression, anxiety, fear, uncertainty, emotional disturbance, mood alterations, irritability, insomnia, post-traumatic stress symptoms, anger, confusion, grief, numbness, and emotional exhaustion. While children often experience clinginess, irritability, inattention, agitation, separation related anxiety, poor appetite, disturbed sleep and nightmares.
Conclusion: The COVID-19 related psychological effects are generically known in the current literature. Besides, it could be possible that in future clinicians will need specific guidelines for this cluster of symptoms, leading to a possible new COVID-19 related clinical label (“limbo anxiety”) inside the next version of DSM.
Keywords: Limbo Anxiety; COVID-19; Psychological well-being; Adolescents; Children
Mini Review
The new Coronavirus, also known as SARS-CoV-2 or COVID-19
had a massive impact around the world, with high rates of mortality
and morbidity that caused a loss of income and contained billions
of people to social isolation [1]. The COVID-19 has rapidly taken
on pandemic proportions by affecting over 100.000 people in 100
countries, thus reaching the necessary epidemiological criteria
to be declared a Pandemic according to Nature [2]. Despite all
the scientific articles that have published recently, the long- and
short-term consequences about population mental health are still
unknown: the study of the acute phase mental health impacts of
COVID-19 could be crucial to inform the Government and Mental
Health Services about population’s general well-being [1]. This
global pandemic forced many countries to implement regional and
national containement measures or lockdowns [3].
For example, on January 31, 2020 the Italian Government
implemented the first measures to limit viral transmission and on
March 10, 2020, the Italian Ministry of Health announced a general
lockdown, to ensure that the number of patients hospitalized to the
emergency room would not be greater than the Hospitals capacity
[2,4]. Since then, the lockdown context has drastically altered
people’s lives, as well as the global, public and private economy:
massive reductions had been registered in the fields of tourism,
aviation, agriculture and finance industry. The economic recession,
along with mass lockdowns and uncertainties or fears due to the
COVID-19 outbreak could increase rates of suicide and mental
disorders related to suicide in countries like USA, Canada, Pakistan,
India, France, Germany and Italy. Many scientific researches also
reported an increase of psychological distress in the general
population [5].
Although this information could be generally imagined as
principally referred to adult population, it must be highlighted
that approximately 28% of the world’s population is constituted by children, and 16% by those aged between 10 to 19 years. Thus,
COVID-19 psychosocial and mental health implications can also
affect children and youth: the quality and the magnitude of impact
on younger people depends on several vulnerability factors such
as developmental age, educational status, mental health condition,
economic status, condition of quarantine and fear of infection,
female gender and being a student [3,5]. Other studies focused
on searching protection factors that could potentially contrast
psychological illnesses during pandemic: these researchers found
that the spread of updated and accurate COVID-19 related health
information from authorities, the implementation of precautionary
measures (such as handwashing and mask-wearing), positive
coping styles, secure and avoidant attachment styles, social support
and time to rest were all associated with lower levels of anxiety and
stress [5].
Most of the risk and protective factors that had been presented
previously were confirmed by a recent study realized by Pigaiani
et al. [6], in which a sample of 306 italian adolescents answered
to a 30-item on-line questionnaire about their general lifestyle
and habits during quarantine. Data analysis showed the following
results: students who found it hard to stay at home, being female,
doing physical activity, and engaging in different activities than
before were all associated with reporting subjective change in
one’s psychological wellbeing (compared to pre-COVID-19 status);
almost all adolescents used technology to remain in contact with
partners and friends, and being able to work at home and do
personal homework quietly was associated with a lower likelihood
of reporting a subjective change in one’s psychological wellbeing.
Thus, these results suggest several “active” and planning” adaptive
coping strategies that adolescents adopted to release quarantine
stress factors, since the use of technology to connect with others is
related to lower levels of loneliness and greater sense of wellbeing,
and physical activity reduces the risk of depression, anxiety and
psychological distress [7].
In addition to all psychological distress factors, quarantine
may have a negative impact on children’s weight, due to the lack
of chances for practicing physical activity and playing outside.
Therefore, in addition to the quarantine distress, some children
and adolescents could be stressed by diet plans physical health
problems related to being overweight. In addition, it is possible
that depressive and anxiety mood may help to increase the person’s
overweight status: it is in fact known that persons who show
depressive symptoms have increased appetite, tent to overeat and
reduce physical activity [8]. Moreover, the body-size dissatisfaction
may put these children and adolescents at risk for further distress
and psychopathology [9].
In sum, the psychological impact of COVID-19 around the
world could be perceived as a general sense of fear and anxiety that
affects not only adult lives but also children’s and youth existences,
and in the opinion of some authors, worrying much more young
people than older persons. Nonetheless, the nature and size of
psychological effect of Coronavirus emergency still need to be
investigated, since it could be possible that new forms of mood
disorders are emerging from several stressors related to lockdowns,
social isolations, and new hygienic habits that Governments are
imposing to the population. The aim of this article is to rapidly
investigate the main psychological symptoms related to COVID-19
that had been reported in literature until now, and to offer some
recommendations about children and adolescents, which could be
particularly affected by the current emergency.
Materials and Methods
Authors performed a manual research on Google Scholar to identify the most relevant studies that described COVID-19 psychological impact among general population and youth. The search terms that were used were “Psychological impact”, “COVID-19”, “adolescents”, “children”, and “quarantine”. Only publications in English were selected and thematically organized. The authors described the most major findings about psychological impact of quarantine on young children and school students and provided final recommendations to the above.
Results
According to one of the most recent publications, young people
reported greater psychological distress and lower psychological
well-being in relation to normative data available before the
pandemic, with doubled rates of probable mental illness compared
to before the spread of COVID-19 [7]. In another research, it has been
shown that COVID-19 exposure is associated with higher prevalence
of depression and anxiety symptoms among adolescents, especially
among those who declared to have low social support. The risk
of depression in adolescents increases also after staying at home
for a long time and with lack of sport availability. Moreover, other
factors that can affect negatively on youth mental health could be
the indefinite closure of schools and the uncertainty of academic
development [3].
In addition to depression and anxiety, other symptoms caused
by COVID-19 outbreak were stress, frustration, uncertainty,
generalized fear and behaviors that may vary from a panic behavior
or collective hysteria to pervasive feelings of hopelessness and
desperation, or even to suicidal behavior. Furthermore, other
studies reported a higher prevalence of psychological symptoms,
emotional disturbance, mood alterations, irritability, insomnia, posttraumatic
stress symptoms, anger, confusion, grief, numbness, and
emotional exhaustion after quarantine. Other authors reported that
some individuals, especially young children, can develop specific
and uncontrolled fears about their health, worries to infect others
and fear to infect their family members, and that social isolation
leads to feelings of boredom, loneliness, distress, frustration and
uncertainty for the future [10] all these symptoms could have a
great negative impact on both physical and mental well-being of children and adolescents, depending on several vulnerability
factors such as the developmental age, current educational status,
having special needs, pre-existing mental health condition, being
economically under privileged and child/parent being quarantined
due to infection or fear of infection.
Additionally, it was found that children, especially those aged
between 3 to 6 years old, are more likely to show symptoms of
clinginess, irritability, inattention, agitation, separation related
anxiety, poor appetite, disturbed sleep and nightmares during the
current pandemic. Finally, the absence of the structured setting
offered by schools led to a disruption in the children routine,
causing feelings of boredom, lack of innovative ideas, lower levels of
expressed affect, higher rates of attention seeking and dependence
on parents. These aversive effects related to the pandemic can be
particularly challenging for children with special needs (such as
those affected by autism, ADHD, cerebral palsy or developmental
delays), which aren’t able to tolerate uncertainty situations and
have difficulties in following instructions [11].
From the adolescent’s point of view, social distancing measures
reduced interactions with friends and quarantine led to an increase
in the time spent at home with family, and thus challenging
adolescents’ intimacy and autonomy needs with less privacy and
few personal spaces, which can contribute to psychological distress.
In addition, adolescents generally experience more intense
emotions than adults, with higher frequency and volatility: due
to this exaggerated emotionality, COVID-19 related stressors may
contribute to adolescents’ fluctuations towards increasing negative
effects and decreasing positive effects, which predict symptoms of
depression and anxiety [12].
Discussion and Conclusion
To conclude, an increasing number of italian journals and italian psychiatrists are talking about a new type of internalizing symptom called “limbo anxiety”, which refers to the sense of uncertainty and general anxiety about the future since the COVID-19 outbreak. This new diagnostic label could lead to new clinical considerations about which diseases will be presented in the next version of DSM, since it is now well known that the Pandemic has somehow changed people’s mental-health well-being. Meanwhile the scientific community is waiting for the new DSM version, several authors wrote some simple recommendations which can improve children and adolescent’s well-being:
a) Increase awareness about COVID-19 by giving factbased
information through presentations and video material
provided by authorized organizations like WHO, UNICEF or
Governments. Parents need to speak with a neutral language
with children about the information they learned, and to
talk about how children are processing the information to
provide them emotional tools useful to cope with the current situation (Shah et. al. 2020). Besides, with adolescents the
communication must be more opened and non-directive, to
guarantee a better knowledge about COVID-19 and measures
of containment.
b) Employ “positive parenting”, to create consistent daily
routines with enough chances to play, read, rest and engage
in physical activities or in creative pursuits like art, music or
dance, since behavioral activation can improve problem solving
skills and development.
c) Teach coping mechanisms and promote healthy behaviors
to encourage children and adolescents to self-regulate their
own emotions without depending on others.
d) Value the peer support system by encouraging children
and adolescents to keep in touch with their friends and talk
with them about their problems and feelings [13].
e) Finally, Mindfulness Based Therapy (MBT) is a
psychological intervention which focuses on the cultivation of
non-judgmental awareness in the present moment, famous to
be particularly helpful in alleviating stress; thus this type of
therapy could be extremely useful for children and adolescents
who show significant symptoms of COVID-19 related
psychological distress [14].
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgment
The authors would like to thank the survey participants and their families for their cooperation and commitment as well as acknowledge support from the nonprofit organization and school networks.
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