Abstract
Objective:
Mental health problems among children and adolescents are increasingly observed during the outbreak of COVID-19, leading to significant healthcare concerns. Survey studies provide unique opportunities for research during this pandemic, while there are no existing systematic reviews in this setting. The objective was to summarize existing survey studies addressing the effects of the current COVID-19 pandemic on the mental health of children and adolescents.
Methods:
For this systematic review, we performed an electronic search in multiple databases from December 2019 to December 2020. The quality appraisal of the included studies was performed with the Critical Appraisal Skills Programme Qualitative Checklist. Because of the high methodological heterogeneity between studies, a narrative synthesis of the qualitative data was used.
Results:
In total, 35 survey studies with 65,508 participants, ranging from 4 to 19 years of age, are included in this review. Anxiety (28%), depression (23%), loneliness (5%), stress (5%), fear (5%), tension (3%), anger (3%), fatigue (3%), confusion (3%), and worry (3%) were the most common mental health issues reported. Children and adolescents with psychiatric and/or developmental disorders, such as severe obesity, chronic lung disease, attention deficit hyperactivity disorder, cystic fibrosis, and obsessive-compulsive disorders, were especially vulnerable to the mental health effects of the COVID-19 pandemic. Age, gender, psychological quality, and negative coping strategies were identified as risk factors for the development of mental health problems. Social and family support, along with a positive coping style, was associated with better outcomes.
Conclusion:
The impact of the COVID-19 pandemic on mental health of children and adolescents is multifaceted and substantial. Survey studies regarding child and adolescent mental health amid COVID-19 indicated that anxiety, depression, loneliness, stress, and tension are the most observed symptoms. Positive coping strategies with family and social support may be important to achieving better outcomes. Due to limited available evidence, more well-designed studies in this area are urgently needed.
Introduction
The 2019 novel coronavirus disease (COVID-19) outbreak has profoundly impacted the daily lives of most of the global population. With daily epidemiological updates, the outbreak has consistently received a great deal of attention from the media worldwide. The pandemic has unavoidably produced an enormous amount of mental health stress for individuals and families around the world.
Although most children and adolescents infected with COVID-19 appear to have had mild to moderate symptoms, and limited mortality rates, 1 a recent review has identified various mental health problems among those exposed to the COVID-19 pandemic, including anxiety, stress, depression, panic, irritation, impulsivity, somatization, sleep problems, emotional lability, post-traumatic stress disorder (PTSD), and suicidal behavior. 2 Necessary actions of transmission reducing (e.g. quarantine and social distancing) may enhance physical safety of children and adolescents but at the same time come with increased risks of psychological impacts in this vulnerable age group. Rising numbers of confirmed cases and deaths, fear of infection, lack of education access due to school closures, disruption of daily routines due to home confinement, and social distancing, as well as family financial loss have all contributed toward increased feelings of anxiety, stress, and uncertainty among children and adolescents.3,4
A narrative review was performed on the knowledge of the pandemic and child and adolescent psychiatry practice experience, indicating that child and adolescent psychiatric care during all phases of the pandemic is an unmet urgent need for long-term mental health impacts of children and adolescents. 5 Imran et al. 3 conducted an overview of distress in different age groups of children and adolescents in 2020, and provided relevant interventions and resources for child mental health and wellbeing promoting during this pandemic outbreak. The lockdown measures (in response to the COVID-19 pandemic) resulted in psychological distress in children and adolescents, especially in those vulnerable groups suffering from mental health issues. 6 As a result, various psychological interventions were needed to address the pandemic-related mental health disorders of school returning children under 12 years old. Cognitive behavior therapies and school-based interventions were the most common interventions. 7
Concerns regarding the impact of the pandemic on children and adolescents are rapidly growing. Ideally, this impact would be investigated via direct in-person studies. However, given the physical distancing requirements, in-person studies have not been feasible. Rather, survey studies have recently been utilized as an important tool for assessing and understanding the mental health impact of children and adolescents during the pandemic. However, there are no existing systematic reviews comprehensively summarizing existing available surveys on the impact of COVID-19 on the mental health of children and adolescents. In this context, this systematic review tried to synthesize currently existing survey studies regarding the mental health impact of children and adolescents’ mental health problems related to COVID-19, with the aim (1) to provide Healthcare Providers and Public Health officials with an up-to-date overview in regard to the current literature about child and adolescent mental health during the COVID-19 pandemic and (2) to provide researchers with an outline of the current studies leading to identification of the need for the design of future studies.
Methods
Data source and search strategy
A comprehensive electronic search through multiple databases from December 2019 to December 2020, limited to the English language, was conducted. The databases included Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Ovid Cochrane Central Register of Controlled Trials, Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily, Web of Science, PsycInfo, Scopus databases, and Google Scholar. The search strategy was conceived, developed, and executed by a Mayo Clinic, Rochester campus librarian with input from the study’s principal investigator. Both controlled vocabularies and keywords describing child and adolescent mental health problems related to COVID-19 pandemic were used to search. The actual strategy listing all search terms used and how they are combined is available in the Appendix.
Inclusion and exclusion criteria
Any survey study regarding information about child and adolescent mental health amid COVID-19 was included in this review. In accordance with age definitions put forth by the World Health Organization (WHO) 8 and United Nations, we included participants aged from 0 to 19 years (children and adolescents). 9 All types of survey data including questionnaires and interviews, and different countries of origin were eligible for inclusion. There was no limitation in intervention, comparison, or outcome evaluation. Articles that exclusively reported data on participants above 19 years old, not related to epidemiological and clinical aspects of interest, or not written in the English language were excluded.
Study selection and data extraction
Two independent authors screened titles and abstracts of all publications and excluded all irrelevant articles. Eligibility criteria were applied to the full-text articles through the selecting studies. Pre-defined information of each study, including the first author, country, publication date, population, design, intervention, mental health type, and result, was extracted into a password-protected Microsoft Excel spreadsheet. Selection and extraction were completed by two authors independently. Any disagreement regarding eligibility was addressed through a discussion with a third author.
Methodological quality assessment
Studies selected for retrieval were evaluated by two authors independently for methodological quality before they were included in the review using the Critical Appraisal Skills Programme (CASP) 10 Qualitative Checklist for qualitative studies (https://casp-uk.net/casp-tools-checklists/). Quality of each study was assessed with 10 criteria. Studies were rated as “low quality,” “medium quality,” and “high quality.” Two authors assessed the quality independently, with any discrepancy between them being resolved by consultation with the third author.
Data synthesis
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used to guide the reporting of this review.9,11 Due to the heterogenous nature of the data from the preliminary studies, a descriptive summary with Microsoft Excel tables was produced to summarize the literature.
Results
Study selection
A total of 1403 potentially eligible titles and/or abstracts were identified by the search strategy. Among them, 2 records were excluded because they were identified as duplicate records, and other 1366 irrelevant records were removed after screening the abstracts and title. After removing the duplicates and irrelevant articles, 37 full-text publications were further screened. Thirty-five survey studies met the pre-defined inclusion criteria. Details of the screening process are summarized in Figure 1. Due to the variations in themes, mental health impacts, methods, and outcome measurements between studies, a meta-analysis was not conducted; rather, a narrative synthesis of the data was performed.
PRISMA flowchart for literature search.
Study characteristics
The study characteristics of the 35 included articles are summarized in Tables 1 and 2. The total number of participants included was 65,508, with age ranging from 4 to 19 years old. Twenty-seven of the included studies were surveys, while the other eight involved interviews. In terms of the outcome measurements employed in these studies, 71% (25/35) studies12–36 used validated psychometric tools that have been previously standardized and/or established for their psychometric properties, and 29% (10/35)37–46 used questionnaires developed for their respective studies.
Characteristics of Included trials.
ADHD: attention deficit hyperactivity disorder; PTSD: post-traumatic stress disorder; OCD: obsessive-compulsive disorder.
Aims, Measurements, and Conclusions of Included Studies.
UCLA: University of California, Los Angeles.
The CASP summary of the quality appraisal of each study was presented in Table 1. From the 35 papers, 1 study 21 was rated as “medium quality” and the other 34,12–20,22–46 as “high quality.” All the 35 studies had clear aims, appropriate methodology, research design, recruitment strategy, data collection, and clear study finding statement with high reliability and validity. No study meets the criteria for the consideration of the researcher–participant relationship. Three studies did not provide ethical approvement.19,24,41 Rigorous data analysis was clearly presented in all but two studies.21,37 The research value was adequately discussed in most studies. Moreover, all studies received a positive research value except one study 21 that did not clearly meet the criteria due to insufficient survey details. As expected, due to quarantine restrictions and distancing requirements, most survey data were collected online (72.7%),13,15–20,22,23,26,27,29,31–36,39–42,45,46 or via telephone(15.2%).12,14,28,38,44 The remaining were gathered person to person (12.1%).24,25,37,43 The response rate varied from 25% to 100%.
There was great geographical diversity of publications, with 12 publications derived from China, 5 from the United States, 4 from Turkey, and 1 from Australia, Belgium, Brazil, Canada, Egypt, Germany, India, Indonesia, Iraqi, Israel, Italy, Japan, the Netherlands, and the United Kingdom, respectively. Approximately 91% of included surveys stated ethical approval and 84.5% of them reported that written informed consent had been obtained.
After reviewing available data in the literature, four main themes were addressed across the included articles: (1) mental health effects of COVID-19 on children and adolescents; (2) mental health impacts of COVID-19 on vulnerable children and adolescents; (3) risk factors for adolescents’ mental health during the COVID-19 pandemic; and (4) therapeutic interventions and strategies. Details of clinical characteristics are summarized in Table 1 and 2.
Impact of COVID-19 on child and adolescent mental health
The outbreak of COVID-19 has had a multifaceted and substantial impact on child and adolescent mental health, with the most frequently reported psychological reactions being anxiety (28%), depression (23%), loneliness (5%), stress (5%), fear (5%), tension (3%), anger (3%), fatigue (3%), confusion (3%), and worry (3%). Mental health symptoms were assessed using various validated measures as outlined in the summary of included studies. In terms of the outcome measurements employed in these studies, 71% (25/35) studies12–36 used validated psychometric tools that have been previously standardized and/or established for their psychometric properties, and 29% (10/35)37–46 used questionnaires developed for their respective studies.
Focus on vulnerable children and adolescents
The effects of the COVID-19 pandemic are problematic and potentially enduring on the mental health of children and adolescents, particularly in those with underlying psychiatric and/or developmental disorders. 4 Anxiety, absence of peer contact, lack of stress regulation, domestic violence, and child maltreatment threats are significant concerns for the mental health of this population. 5 In our review, five publications addressed populations who might be more vulnerable than others to mental health disorders amid the pandemic, including children and adolescents with severe obesity, 12 chronic lung disease, 13 attention deficit hyperactivity disorder, 34 cystic fibrosis, 28 and obsessive-compulsive disorder. 44 Study results illustrated the significant need to focus on these vulnerable groups. Healthcare support for these vulnerable children and adolescents and their parents during this pandemic could help mitigate the potential negative effects.
Risk factors associated with adverse adolescents’ mental health
Our review identified four broad categories of risk factors that might be associated with poor adolescent mental health functioning during the pandemic. Female gender and higher grade levels are two risk factors. Both factors were also found to be associated with higher risk for depression and anxiety during the pandemic. 36 Next, young adolescents who prefer outdoor social activities might be at higher risk for experiencing anxiety or depressive symptoms during the COVID-19 pandemic. 27 Furthermore, psychological qualities such as emotional reactivity and experiential avoidance among adolescents might increase the risk of developing psychosocial disorders, a finding which was supported by a survey among 598 Turkish adolescents. 30 Finally, the utilization of negative coping strategies, including behavioral avoidance, denial, and substance use, is a risk factor for depression, anxiety, and stress symptoms in high school students. 33
Therapeutic interventions and strategies
No proven effectiveness studies were identified in our literature search. However, several of the included studies did recommend possible interventions according to risk factors, psychologic needs, coping strategies, personal experience, and social responses. These interventions include the following:
Positive coping strategies among children and adolescents
COVID-19 poses large-scale and substantial stress on the mental health of children and adolescents. Literature evidence indicates that positive coping strategies are closely related to mental health outcomes during the COVID-19 pandemic. Positive coping strategies include actively reducing stress, developing accurate knowledge about the pandemic, 41 connecting with friends and family members, 39 engaging in physical activities,14,22,35 limiting leisure screen time, 14 and cognitive restructuring. 33 These strategies are associated with better mental health outcomes during the pandemic.
Family support
COVID-19 results in a restructuring of the daily life of each family member. Both children and adult family members must handle the stress of social distancing, staying at home, schooling from home, and working from home. Negative mood, such as anxiety, depression, and stress due to the long-term lockdown, may increase family tension and the likelihood of conflict between children and other family members.13,18,21,28,34,39 It is important to deal with the psychological changes from a family perspective during the pandemic, especially for high-risk populations.
Social response and preparedness
Additional social support, including schools, social media, healthcare, and government support, is urgently needed during the pandemic. 29 When properly supported, children and adolescents (especially those with disabilities) and their families and schools can appropriately face the most immediate and potentially harmful mental health changes associated with the pandemic.12,18,23,42 Education support has been reported as an important intervention for children and adolescents’ mental health during the pandemic. Schools are established as supportive environments for adolescents staying connected with their peers and teachers during the pandemic. 45 Teachers are encouraged to assist children in finding ways to maintain their social networks. 40 During the pandemic, information changes rapidly, and television and social media largely consist of news about the disease. Social media are among the most widely used sources, which can be used as a constructive coping strategy for adolescents to manage negative emotions evoked by the COVID-19 crisis. 16 Furthermore, the local, state, and federal governments need to pay more attention to the psychological health of children and adolescents during the pandemic. A higher prevalence of mental health problems impacts children with lower level knowledge and social support during the pandemic.29,36 Adolescents who adhered more closely to the government restrictions of stay-at-home orders and who felt more socially connected during the pandemic lockdown were less likely to experience anxiety, depression, or decreased life satisfaction. 40 Quarantine-related financial loss was found to be a risk factor for developing psychological symptoms. Children were significantly concerned about family-related financial loss, parental employment status, future uncertainties, and resource vulnerabilities (daily needs like food, water, housing, Internet) during the quarantine period. Adequate financial support and enhanced knowledge about pandemic planning can improve their mental health.29,43
Discussion
This review suggests that the outbreak of COVID-19 has had a multifaceted and substantial impact on child and adolescent mental health. The included survey studies specifically examined the potential mental health impacts of social distancing, school closure, and quarantine on children and adolescents. Many of the included studies provide numerous valuable observations and suggestions on feasible preventive strategies to limit the pandemic-related mental health consequences. Suggested strategies to help ameliorate an increase in mental health problems include expanding government economic support, clinical preventive support, and early intervention preparedness.
Given the initial uncertainties about disease transmission, survey-based studies have been particularly useful for assessing the mental health of children and adolescents during the pandemic. We identified 35 surveys, 90% of which were delivered online or by phone, thus averting any concerns related to face-to-face visits. Several of the surveys suggested that most of the participants were comfortable with the non-face-to-face survey methodology. Similarly, non-face-to-face interventions (e.g. tele-psychotherapy and online solutions) were the most common interventions employed to address the unique needs of the COVID-19 public health crisis.
Children and adolescents who were isolated or quarantined during the pandemic were more vulnerable to develop acute stress disorder, adjustment disorder, or grief. 47 Further, lacking social communication was a risk factor associated with adolescents being drawn into compulsive Internet use during the COVID-19 pandemic. This point was highlighted in a large cross-sectional anonymous survey, conducted among Chinese children and adolescents aged 6–18 years, where 2.68% of participants self-identified as excessive Internet users and 33.37% as problematic Internet users. Age, female gender, stress, and depression were significantly associated with Internet addiction. 18 Our findings also support previous conclusions and suggest that family and social support are required to provide more acceptable ways of supporting mental health for children and adolescents.
There is preliminary evidence to support the acceptability of synthesizing survey research for current knowledge about child and adolescent mental health associated with the COVID-19 pandemic. Following the CASP checklist tool for qualitative research, study quality was rated generally as moderate to high, increasing the reliability within the inputs to this synthesis. The findings of this review represent a sound and comprehensive methodological synthesis of current surveys regarding children and adolescents’ mental health issues related to the COVID-19 pandemic that can be incorporated within current optimal clinic practice and research.
Strengths and limitations
We believe this is the first systematic review comprehensively summarizing all existing survey studies addressing children and adolescents’ mental health issues associated with COVID-19. Strength and challenges of the COVID-19 mental health research response has been reviewed recently by Demkowicz et al., 48 especially raising the question whether speed may compromise quality. In our opinion, this review is objective, well structured, and rigorously followed pre-defined criteria.
However, the current review does have some limitations. First, we conducted an electronic database search for literature published in the English language only, thus possibly omitting some eligible articles published in other languages. Second, with the lack of randomized controlled trial evidence, our review indicates that the available data are not robust enough to identify any single optimal treatment to address the negative effects that COVID-19 has on the mental health of children and adolescents. Third, there are currently 216 countries, areas, or territories with confirmed cases of COVID-19, while our included articles originated from only 11 affected countries. There is an urgent need for more representative studies, particularly in areas most impacted by the COVID-19 crisis. Finally, in the included surveys, most children were healthy, non-referred individuals. Thus, the generalizability to lesser studied groups, like those with pre-existing mental health problems or development issues, is limited. It is also important to note that although children expressed positive attitudes toward electronic healthcare, it does not necessarily mean that electronic healthcare is superior to face-to-face interventions.
Conclusion
Multiple survey studies indicate that mental health issues among children and adolescents are closely related to the COVID-19 pandemic, as well as to various mitigating strategies (social distancing, quarantine, and school closure). Anxiety, depression, stress, loneliness, and tension are the most reported changes. Positive coping strategies along with family and social support in this context are urgently needed as clinical practice guidelines and additional research. However, the available supporting evidence is limited, and more well-designed studies are needed.
Supplemental Material
sj-docx-1-smo-10.1177_20503121221086712 – Supplemental material for Effects of COVID-19 pandemic on mental health of children and adolescents: A systematic review of survey studies
Supplemental material, sj-docx-1-smo-10.1177_20503121221086712 for Effects of COVID-19 pandemic on mental health of children and adolescents: A systematic review of survey studies by Monique Theberath, David Bauer, Weizhi Chen, Manisha Salinas, Arya B Mohabbat, Juan Yang, Tony Y Chon, Brent A Bauer and Dietlind L Wahner-Roedler in SAGE Open Medicine
Footnotes
Author contributions
BAB and JY had the idea for the study and designed the study. MT, DB, and WC searched, screened, and extracted the data. JY analyzed the data. MS and JY wrote the first draft of the article. MS, TYC, ABM, DB, and DLW-R reviewed and edited the article. All authors approved the final article.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was made possible in part due to the support from The HEAD Foundation, Singapore.
Supplemental material
Supplemental material for this article is available online.
References
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