Covid-19 is a novel, highly contagious but preventable disease
caused by a coronavirus (SARS-COV-2) [1]. The Covid-19 pandemic,
which was declared a global pandemic by the World Health Organization
in March 2020, has impacted the lives of families across the globe
including physical, emotional and mental health [2]. Several stressors
including prolonged isolation, infection fears and financial loss are
known to impact mental health outcomes during the pandemic [3].
Although children appear to be at lower risk for the severe medical
complications of Covid-19, the impact of school closures and social
isolation have a devastating impact particularly during adolescence,
which presents a sensitive period for social interaction [4,5]. During
the Covid-19 pandemic, children and adolescents experienced great
stress related not only to the fear of getting ill, but also the loss of
loved ones, which increased the risk for long-term health outcomes
[6]. In this review we will identify the risk factors for, and the current
data on the impact of the Covid-19 pandemic on the mental health of
children and adolescents.
1. School closures and routine disruption.
2. Parental (caregiver) stress.
3. Increased screen time and limited physical activities.
4. Limited access to mental health care.
School Closures and Routine Disruption
School closures and limited outdoor activities reduced social interaction
and resulted in social isolation, which may negatively impact
children’s mental health [7] and increase experience of loneliness and
psychological stress [8]. School closures have impacted the 55 million
students in kindergarten through 12th grade in the United States, but
particularly impacted the three million children who were receiving
mental health services exclusively through school or school-based
programs which were lost during school closures [9]. Prolonged
school closure and home confinement have significant impact on
children’s mental health with 56% of those experiencing lock down
related psychosocial problems attributed to school closures [10,11].
Furthermore, school closures have led to the loss of mental health
services for 13.2% of adolescents in USA who received some form of
mental health services from school prior to the pandemic. The loss of
school routine and social isolation might have a devastating effect on
young people with mental illness and children with special needs who
experienced significant stress and symptom relapse, or can trigger an
exacerbating episode of anxiety and depression [12-15]. In addition,
school closures resulted in decreased child protection referrals due to
inability of the educational system to identify cases of neglect, abuse
and human trafficking [16,17].
Parental Stress (Stress Related to Parental Role)
Family life can be affected by the economic recession, parents remote
working from home in addition to caring and educating these
children, which increase parental stress [18]. Financial burden on
families caused by pandemic predicts a higher level of anxiety and
depression [19]. 26.9% of parents reported worsening of their own
mental health since the onset of the pandemic, especially mothers,
unmarried parents and families of younger children [20]. Parenting
stress is directly associated with children’s depression [21]. Furthermore,
caregiver and parent stress, together with loss of access
to mental health services and children’s social isolation, leads to an
increased risk of child abuse during the quarantine and school closures
[22,23]. Parents’ stress about COVID-19 and other related conditions
could increase anxiety in children [24]. On the other hand the
presence of social support and good parent-child relationship protect
against children’s mental illnesses during the pandemic despite
school closures and resultant social isolation [25].
Increased Screen Time and Limited Physical Activity
During the Covid-19 pandemic, there was a significant increase in
sedentary time and decreased physical activity which were negatively
correlated with global mental health, anxiety, depression and quality
of life [26,27]. There was an increase of four hours/day in screen exposure
during the Covid-19 pandemic lockdown among children and
adolescents which have been linked to increase in cardiovascular disease
risk among children [28,29]. Social media can be useful for maintaining
social interaction and coping with isolation [30,31]. However,
inappropriate social media and videogames can lead to emotional and
behavioral symptoms such as inattention, delinquency, low self-esteem,
decreased physical activity and eating disorder [32,33]. Furthermore,
excessive Covid-19 related media exposure was associated
with increased anxiety level and stress [34].
Limited Access to Mental Healthcare
During the Covid-19 pandemic, hospital emergency rooms often
became the site for mental health evaluations of children and adolescents
with a 24% increase in ED visits for mental health concerns in
children age 5-11 years and a 31% increase in ED visits for mental
health concerns in children age 12-17 years [35,36].
It’s well-known that stressful early life events such as the
Covid-19 pandemic can lead to psychological breakdowns [37]. In
addition, adolescence is a critical period for emergence and exacerbation
of anxiety and depressive symptoms [38]. The significant impact
of Covid-19 on young people’s mental health can be manifested in
learning, friendship and family relationships [39] which place generations
at risk for long term effects if not addressed [40]. Increased
prevalence of anxiety, depression, post-traumatic stress disorder and
somatic symptoms have been reported during the pandemic. In addition,
worsening symptoms in children and adolescents with pre-existing
conditions have been reported.
Anxiety and Depression
1. Children impacted by social isolation and loneliness are
more likely to experience symptoms of anxiety and depression
persisting into post-pandemic condition with the prevalence
of anxiety and depression in children and adolescents
having doubled compared to pre-pandemic levels [41].
2. Shortly after lockdown Xie and colleagues [42], reported that
34% of children endorsed depressive symptoms while 19%
endorsed anxiety symptoms.
3. Among Chinese children Duan and colleagues [43], reported
depressive symptoms were endorsed in 22.28% of children
and adolescents.
4. Zou and colleagues [44] reported prevalence the rate for depressive
symptoms among Chinese adolescents age [18,45]
was 43.7%, while prevalence of anxiety was 37.4%.
5. Luma and colleagues [46], reviewed 23 studies with 57,925
children and adolescents from two countries during the pandemic
and reported that the pooled prevalence of depression
and anxiety symptoms were 29% and 26% respectively.
6. Furthermore, psychological stress has been reported in more
than 10% of primary and secondary school students in a Chinese
province with high rate of Covid-19 [47].
7. Among college students, depressive symptoms were reported
in 34% while anxiety symptoms were reported in 31%
[48].
Post-Traumatic Stress Disorder (PTSD)
1. Using parents’ report Ma and colleagues [49] reported that
over 20% of children age 7-15 scored above the study cutoff
for clinical PTSD.
2. Yue and colleagues [50] found high risk for PTSD in 3.16% of
their samples of Chinese primary school children.
Somatic Symptoms
Due to greater concern about health risk posed by Covid-19,
somatic symptoms were reported in 35% of college students while
somatic symptoms were only reported in 2.39% of primary school
students [51].
Children with Attention Deficit Hyperactivity Disorder
(ADHD) and Special Educational Needs
Over half of parents of school children reported decline in their
ability to focus during Covid-19 school closures with limited academic
adjustment resulted in difficulties in completing school-related
tasks [52,53]. Similarly, parents of children with special educational
needs reported that their children appear to be experiencing worry,
loss, and change in their mood and behavior due to Covid-19 pandemic
lockdown [54].
Children with Eating Disorders
41% of young people under clinical care experienced reactivation
in their eating disorder symptoms post-lockdown [55].
Children with Autism Spectrum Disorder (ASD)
Majority of parents of children with ASD reported increased difficulties
in managing their child’s behavior [56,57].
1. The coronavirus disease 2019 (Covid-19) pandemic profoundly
disrupted the lives of children and adolescents
around the world.
2. The increased emotional stress, feeling of hopelessness and
fear in children and adolescents during the pandemic can
evolve into mental health illness such as anxiety, depression,
posttraumatic stress disorder, and increased drug use.
3. Prolonged social isolation and school closures in effort to
control the pandemic are possible reasons for the significant
impact of the pandemic on children and adolescents’ wellbeing.
4. The impact of the pandemic on children and adolescents’
mental health is significantly greater for children with special
needs.
5. In addition, increased stress and economic adversity caused
by the pandemic might potentially increase the risk of children’s
maltreatment which, in many cases, went unreported.
Research on the mental health effects of the Covid-19 pandemic
on children and adolescents confirm the presence of significant anxiety
and depression, as well as increases in these symptoms compared
with pre-pandemic level. The economic and emotional stress the parents
experienced during the pandemic increased their mental health
symptoms and might have increased the risk of children’s maltreatment.
Early identification of mental health issues in children and adolescents
using available screening tools is extremely important. Ongoing
data collection for children’s mental health is needed to monitor
the persistent impact of Covid-19 on children and adolescents’ mental
health to improve their mental health outcome in the current and future
pandemics. Furthermore, there is a growing need to implement
policies that will help children and adolescents cope with short and
long-term mental health effects of the pandemic. Ongoing research is
also needed to understand the true toll of the pandemic on children
and their families. In addition, ensuring the availability and access to
mental health care services for children and their families with the
implementation of technology-based, remote health service and prevention
strategies will be vital.
ISSN: 2574 -1241
Abstract
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