Editorial: Effects of the COVID-19 pandemic on child and adolescent mental health

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].