key: cord-0892134-pwe95zoi
authors: Singh, Dr Shweta; Roy, Assistant Professor.Miss Deblina; Sinha, Clinical Psychology Trainee Miss Krittika; Parveen, Clinical Psychology Trainee Miss Sheeba; Sharma, Clinical Psychology Trainee. Ginni; Joshi, Clinical Psychology Trainee. Gunjan
title: Impact of COVID-19 and Lockdown on Mental Health of Children and Adolescents: A Narrative Review with Recommendations.
date: 2020-08-24
journal: Psychiatry Res
DOI: 10.1016/j.psychres.2020.113429
sha: 731943bec53a0a1d7bd1469df4a328bcbaf1510b
doc_id: 892134
cord_uid: pwe95zoi

BACKGROUND: COVID-19 pandemic and lockdown has brought about a sense of fear and anxiety around the globe. This phenomenon has led to short term as well as long term psychosocial and mental health implications for children and adolescents. The quality and magnitude of impact on minors is determined by many vulnerability factors like developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection or fear of infection. AIMS: This paper is aimed at narratively reviewing various articles related to mental-health aspects of children and adolescents impacted by COVID-19 pandemic and enforcement of nationwide or regional lockdowns to prevent further spread of infection. METHODOLOGY: We conducted a review and collected articles and advisories on mental health aspects of children and adolescents during the COVID-19 pandemic. We selected articles and thematically organized them. We put up their major findings under the thematic areas of impact on young children, school and college going students, children and adolescents with mental health challenges, economically underprivileged children, impact due to quarantine and separation from parents and the advisories of international organizations. We have also provided recommendations to the above. CONCLUSION: There is a pressing need for planning longitudinal and developmental studies, and implementing evidence based elaborative plan of action to cater to the psycho social and mental health needs of the vulnerable children and adolescents during pandemic as well as post pandemic. There is a need to ameliorate children and adolescents’ access to mental health support services geared towards providing measures for developing healthy coping mechanisms during the current crisis. For this innovative child and adolescent mental health policies policies with direct and digital collaborative networks of psychiatrists, psychologists, paediatricians, and community volunteers are deemed necessary.

This paper is aimed at reviewing articles related to mental-health aspects of children and adolescents impacted by COVID-19 pandemic and lockdowns. There is a need to carry out longitudinal and developmental studies and plan strategies to enhance children's and adolescent's access to mental health services during and after the current crisis. For this direct and digital collaborative network of psychiatrists, psychologists, pediatricians, and community volunteers are of vital importance.

Background: COVID-19 pandemic and lockdown has brought about a sense of fear and anxiety around the globe. This phenomenon has led to short term as well as long term psychosocial and mental health implications for children and adolescents. The quality and magnitude of impact on minors is determined by many vulnerability factors like developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection or fear of infection.

Aims: This paper is aimed at narratively reviewing various articles related to mental-health aspects of children and adolescents impacted by COVID-19 pandemic and enforcement of nationwide or regional lockdowns to prevent further spread of infection.

Methodology: We conducted a review and collected articles and advisories on mental health aspects of children and adolescents during the COVID-19 pandemic. We selected articles and thematically organized them. We put up their major findings under the thematic areas of impact on young children, school and college going students, children and adolescents with mental health challenges, economically underprivileged children, impact due to quarantine and separation from parents and the advisories of international organizations. We have also provided recommendations to the above.

Conclusion: There is a pressing need for planning longitudinal and developmental studies, and implementing evidence based elaborative plan of action to cater to the psycho social and mental health needs of the vulnerable children and adolescents during pandemic as well as post pandemic. There is a need to ameliorate children and adolescents' access to mental health support services geared towards providing measures for developing healthy coping mechanisms during the current crisis. For this innovative child and adolescent mental health policies policies with direct and digital collaborative networks of psychiatrists, psychologists, paediatricians, and community volunteers are deemed necessary.

Key Words: COVID-19; lockdown; mental health; children; adolescents

There are more than 2.2 billion children in the world who constitute approximately 28% of the world's population. Those aged between 10 to 19 years make up 16 % of the world's population (UNICEF, 2019) . COVID-19 has impacted the lives of people around the world including children and adolescents in an unprecedented manner. Throughout the world, an essential modus of prevention from COVID-19 infection has been isolation and social distancing strategies to protect from the risk of infection (Shen et al., 2020) . On these grounds, since January, 2020, various countries started implementing regional and national containment measures or lockdowns. In this backdrop one of the principal measures taken during lockdown has been closure of schools, educational institutes and activity areas. These inexorable circumstances which are beyond normal experience, lead to stress, anxiety and a feeling of helplessness in all.

It has been indicated that compared to adults, this pandemic may continue to have increased long term adverse consequences on children and adolescents (Shen et al., 2020) . The nature and extent of impact on this age group depend on many 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. The following sections discuss about findings of studies on mental-health aspects of children and adolescents impacted by COVID-19 pandemic and lockdowns being implemented at national or regional levels to prevent further spread of infection.

We searched the electronic data bases of MEDLINE through PubMed, Cochrane Library, Science-direct and Google Scholar databases, from January,2020 till June,2020. We carried out the search with the following methods like, MeSH or free text terms and Boolean were done by five independent reviewers. A manual search was also conducted of the references of the related articles to gather information about the relevant studies. Initial

PubMed search with the term with " COVID-19 in children" showed only 12 results. Among these, only four articles were related to "Psychological effects of COVID in children". Therefore in order to make the review more comprehensive and informative, we also included studies that reported the effect on older children and impact of COVID1-19 on their lives. This was done keeping in mind the varied terminologies used to describe the phenomenon of 'Children and COVID-19". After using the above strategy, our search showed 112 results. Only articles in English language peer reviewed journals were included.

Grey literature such as conference proceedings were not included due to possibility of insufficient information. We included case studies and review articles and Advisories by the WHO (World Health Organization), APA (American Psychiatric Association) and NHS ( National Health Services) and Government of India Ministry of Health. Based on these inclusion criteria we included 22 articles. Three independent authors participated in study selection and all authors reached a consensus on the studies to be included. Being a narrative review, we did not attempt computation of effect sizes or do a risk of bias assessment for included papers.

The studies included were categorized under eight headings divided in various thematic sections and discussed with studies and reports found. The data is qualitatively analysed and reported in the paper. A summary of the papers included in this narrative review is presented in table 1.

[ Table 1 is uploaded seperately] Impact on young children:

Stress starts showing its adverse effect on a child even before he or she is born. During stress, parents particularly pregnant mothers are in a psychologically vulnerable state to experience anxiety and depression which is biologically linked to the wellbeing of the foetus (Biaggi et a 2016; Kinsella and Monk, 2009 ). In young children and adolescents the pandemic and lockdown have a greater impact on emotional and social development compared to that in the grown-ups. In one of the preliminary studies during the on-going pandemic, it was found younger children (3-6years old) were more likely to manifest symptoms of clinginess and the fear of family members being infected than older children (6-18 years old). Whereas, the older children were more likely to experience inattention and were persistently inquiring regarding COVID-19. Although, severe psychological conditions of increased irritability, inattention and clinging behaviour were revealed by all children irrespective of their age groups (Viner et al., 2020a) . Based on the questionnaires completed by the parents, findings reveal that children felt uncertain, fearful and isolated during current times. It was also shown that children experienced disturbed sleep, nightmares, poor appetite, agitation, inattention and separation related anxiety (Jiao et al., 2020) .

Globally, the pre-lockdown learning of children and adolescents predominantly involved one-to-one interaction with their mentors and peer groups. Unfortunately, the nationwide closures of schools and colleges have negatively impacted over 91% of the world's student population (Lee, 2020). The home confinement of children and adolescents is associated with uncertainty and anxiety which is attributable to disruption in their education, physical activities and opportunities for socialization (Jiao et al., 2020) . Absence of structured setting of the school for a long duration result in disruption in routine, boredom and lack of innovative ideas for engaging in various academic and extracurricular activities. Some children have expressed lower levels of affect for not being able to play outdoors, not meeting friends and not engaging in the in-person school activities (Lee, 2020; Liu et al., 2020; Zhai & Du, 2020) . These children have become more clingy, attention seeking and more dependent on their parents due to the long term shift in their routine. It is presumed that children might resist going to school after the lockdown gets over and may face difficulty in establishing rapport with their mentors after the schools reopen. Consequently, the constraint of movement imposed on them can have a long term negative effect on their overall psychological wellbeing (Lee, 2020).

A study found that older adolescents and youth are anxious regarding cancellation of examinations, exchange programs and academic events (Lee, 2020) . Current studies related to COVID-19 demonstrate that school shut downs in isolation prevent about 2-4% additional deaths which is quite less if compared to usage of other measures of social distancing. Moreover, they suggest to the policy makers that other less disrupting social distancing strategies should be followed by schools if social distancing is recommended for a long duration (Lee, 2020; Sahu, 2020; Viner et al., 2020a) . However, in current circumstances, it is controversial whether complete closure of school and colleges is warranted for a prolonged period.

It has been reported that panic buying in times of distress indicate an instinctual survival behaviour (Arafat et al., 2020) . In present pandemic era there has been a rise in the hoarding behaviour among the teenagers (Oosterhoff et al., 2020a) . It is also found that among youth social distancing is viewed primarily as a social responsibility and it is followed more sincerely if motivated by prosocial reasons to prevent others from getting sick (Oosterhoff et al., 2020a) . Further, due to prolonged confinement at home children's increased use of internet and social media predisposes them to use internet compulsively, access objectionable content and also increases their vulnerability for getting bullied or abused (Cooper, 2020; UNICEF, 2020b) . Worst of all, during lockdown when schools, when legal and preventative services do not functioning fully, children are rarely in a position to report violence, abuse and harm if they themselves have abusive homes.

There are about 1 in every 6 children within the age group of 2-8 years who have some or the other neurodevelopmental, behavioural or emotional difficulty (CDC, 2019). These children with special needs [autism, attention deficit hyperactivity disorder, cerebral palsy, learning disability, developmental delays and other behavioural and emotional difficulties] encounter challenges during the current pandemic and lockdown (CDC, 2019). They have intolerance for uncertainty and there is an aggravation in the symptoms due to the enforced restrictions and unfriendly environment which does not correspond with their regular routine. Also, they face difficulties in following instructions, understanding the complexity of the pandemic situation and doing their own work independently. With the closure of special schools and day care centres these children lack access to resource material, peer group interactions and opportunities of learning and developing important social and behavioural skills in due time may lead to regression to the past behavior as they lose anchor in life, as a result of this their symptoms could relapse (Lee, 2020). These conditions also trigger outburst of temper tantrums, and conflict between parents and adolescents. Although prior to the pandemic, these children had been facing difficulties even while attending special schools, but in due course they had learnt to develop a schedule to adhere to for most of the time of the day (APA, 2020; Cortese et al., 2020; UNICEF, 2020a). To cater to these challenges, it is difficult for parents to handle the challenged children and adolescents on their own, as they lack professional expertise and they mostly relied on schools and therapists to help them out (Dalton et al., 2020).

Since every disorder is different, every child has different needs to be met. The children with autism find it very difficult to adapt to the changing environment. They become agitated and exasperated when anything is rearranged or shifted from its existing setup. They might show an increase in their behavioral problems and acts of self-harm. It is a huge challenge for parents to handle autistic children due to lockdown. The suspension of speech therapy and occupational therapy sessions could have a negative impact on their skill development and the achievement of the next milestone, as it is difficult for them to learn through online sessions (UNICEF, 2020a). The children with Attention Deficit Hyperactivity Disorder (ADHD), struggle to make meaning of what is going around them from the cues they get from their caregivers. It is difficult for them to remain confined to a place and not to touch things, which might infect them. Due to being confined to one place the chances of their hyperactivity increases along with heightened impulses and it becomes difficult for the caregivers to engage these children in meaningful activities (Cortese et al., 2020).

Obsessive compulsive disorder (OCD) among the children and adolescents is estimated to be of 0.25%-4% among children and adolescents (CDC, 2019). Children with OCD are suspected to be one of the most affected ones by this pandemic. Due to obsessions and compulsions related to contamination, hoarding, and somatic preoccupation, they are expected to experience heightened distress. Cleanliness is one key protective measure against the spread of COVID-19. According to United Nations' policy guidelines to fight the infection one has to be careful about washing their hands six times a day, and whenever they touch anything (APA, 2020; United Nations, 2020). The lockdown, which has made the healthy population distressed about possessing enough food and prevention related resources like masks and sanitizers, has made it worse for people with hoarding disorder (APA, 2020; Mukherjee et al., 2020)

Social inequality has been associated with the risk of developing mental health challenges.

The pandemic and lockdown world has experienced global economic turn-down which has directly worsened the pre-existing social inequality. In developing countries, with the In order to cover up the loss of education during lockdown, many schools have offered distance learning or online courses to students. However, this opportunity is not available to underprivileged children as a result of which they face a lack of stimulation and have no access to online resource material to study. A study pointed out that in underprivileged families, in comparison to boys, girls have decreased access to gadgets, this may diminish their involvement in digital platforms of education (McQuillan & Neill, 2009 ). Due to this gender inequality, increasing number of girls are prone to bear the consequences of school dropouts once the lockdown is lifted (Cooper, 2020; PTI, 2020).

COVID 

With the objective of universal prevention and mental health promotion, the International 

It is imperative to plan strategies to enhance children and adolescent's access to mental health services during and after the current crisis. For this direct and digital collaborative network of various stakeholders is required. Recommendations for ensuring mental well-being of children and adolescents during the COVID-19 pandemic and lockdown and the role of parents, teachers, pediatricians, community volunteers, the health system and policy makers are being discussed. In addition a brief summary of the roles is given in Table 2 .

[ Table 2 is uploaded seperately]

In the times of paramount stress and uncertainty, a secure family environment which the parents can provide is a strong protective factor (Schofield et al., 2013) . There is evidence to 5. Efforts should be made so that a consistent routine is followed by the child, with enough opportunities to play, read, rest and engage in physical activity. It is recommended that family plays board games and engages in indoor sports activities with the child to avoid longer durations of video games. Parents should ensure that particularly the bedtime of a child is consistent. It is possible that before the bed time children may need some more time and attention.

6. Focus should be on the 'good behaviour' more than 'bad behaviour' of a child.

Parents must tell more about options regarding what to do rather than what not to do. Provide more praise and social reinforcements to children compared to material reinforcements. 7. It is quite possible that parents observe some amount of change in the behavior in children during the times of a pandemic. If the behavior problems are minor and not harmful for children and others, parents should consider ignoring and stop paying attention to them, this may lead to decrease in the recurrence in behavior and would also help in giving space to each other.

Apart from areas discussed above, certain areas which need especial focus in the phase of adolescence, are being described below: 3. This is an opportunity for older children to learn responsibility, accountability, involvement, and collaboration. By taking some responsibilities at home on an everyday basis, for instance maintenance of their belongings and utility items. They can learn some of the skills including cooking, managing money matters, learning first aid, organizing their room, contributing to managing chores like laundry, cleaning and cooking.

4. Excessive internet use e.g. internet surfing related to COVID-19 should be avoided as it results in anxiety. Similarly, excessive and irresponsible use of social media or internet gaming should be cautioned against. Negotiations with adolescents to limit their time and internet-based activities are recommended. More non-gadget related in door activities and games are to be encouraged.

5. In such conditions taking up creative pursuits like art, music, dance and others can help to manage mental health and well-being for everyone. Inculcating self-driven reading by making them select books of their choice and discussing about them helps in adolescent development.

6. Adolescence is a phase of enthusiasm and risk-taking, hence some may feel invincible and try not to follow guidelines related to distancing and personal hygiene. This has to be addressed with adolescents assertively.

7. It is crucial to value the peer support system of the adolescents. Parents should encourage adolescents who are introverts to keep in touch with their peers and communicate with them about their feelings and common problems they face. This may also lead a way for appropriate problem-solving.

8. It is advised to parents to take care of their own mental health needs and try to cope with stress adaptively.

In the present times when most schools and colleges are organizing online academic activities, teachers are in regular touch with students, and therefore are in a position to play a critical role in the promotion of psychological well being among youngsters. Their role during COVID-19 pandemic and lockdown are as follows:

1. Teachers can devote some time related to educating about COVID-19 and preventive health behavior by using the guidelines of the international organizations, according to the maturity level of the students. They can explain to the students about the need to act with responsibility during the current pandemic. They can model and enact through their behavior the preventive measures.

3. They can conduct creative online academic and non-academic sessions by making their classes more interactive, engaging students in the form of quizzes, puzzles, small competitions, and giving more creative home assignments to break the monotony of the online classes. Standard educational material can be used. For instance, UNESCO has offered many online educational sources (UNESCO, 2020)

They can discuss what is wellbeing and how it is important for students. They can assist in teaching simple exercises, including deep breathing, muscle relaxation, distraction, and positive self -talk. Virtual workshops can be conducted in which 'life skills' related to coping in stress can be in focus by using more practical examples.

5. Teachers can make children understand the importance of prosocial behavior and the importance of human virtues like empathy and patience among others. This can help them to understand their role in the society and understand how social distancing is not equivalent to emotional distancing.

6. The teachers need to interact with parents online or through phone regarding feedback about students and their mental health. Because of the digital divide they can call parents, make their contact available to parents and devote a time slot when they can be available to parents to communicate.

7. They can serve as a doorway for identification and referral to specialty mental health providers. They have a role act as a catalyst between the parent based on their interaction with students and findings of screening tools. If they observe any problem in the child, they can talk to parents and refer children and adolescents to mental health professionals.

8. With the support of school authorities, teachers need to make arrangements to ensure that the reading material related academics and life skills is made available to the underprivileged children who do not have access to the internet. If possible arrangements can be made for them to use internet.

During a child's formative years when their personalities are shaped, parents are in regular touch with pediatricians, as parents reach out to their local pediatricians whenever they encounter health/ behavioral complaints associated with their children. Parents expect answers from them as they trust them. Hence a pediatrician's role is paramount in promoting PTSD, depression, substance abuse in adolescents should also be addressed on similar lines. There is a requirement for creative solutions, often on a case-by-case basis.

9. Psychiatrists need to carefully weigh the risks and benefits of psychotropic medications for children and adolescents e.g. anti-depressants, anxiolytics, anticonvulsants, etc., and if possible, arranging medicines for those who cannot arrange.

10. There is a need for mental health care workers carry out longitudinal and developmental studies on short term and long term mental health impact of the COVID 19 pandemic and lock down on children and adolescents.

It has been recognized by the world that the traditional pre-COVID-19 models and policies for children and adolescents' mental health are no longer applicable during COVID 19 era.

Hence, the need is felt for the transformation of policies that can take into account not only lock down duration but also times following the lockdown. The following recommendations may be useful for guiding the functioning of the health system and policy making related to mental health care of children and adolescents :

1. The focus of the health care system should be prevention, promotion, and treatment according to the public mental health system to meet population-mental health needs of the general population at large.

No single umbrella policy would be able to take into account various mental health aspects of children and adolescents dwelling in different environments. Hence the health system and policies should be based on contextual parameters that are different for each country or region depending on the degree of infection and the phase of infection they are in.

3. Since there is a dearth of mental health care workers in most developing countries. There is a need for inclusive approaches in which health care workers e.g. pediatricians, general physicians, schools, non-governmental organizations sectors are involved.

Moreover, brief basic mental health care training for these arms should be planned.

4. Separate rules for the rural, suburban, and concrete domiciles in growing countries spotting the variance among college districts, which includes city, suburban, and rural districts. 

The studies included in the review were collected after setting criteria to have a comprehensive view of the global vision in managing the crisis of children in the COVID-19

pandemic. The majority of the studies included in the review were based on online selfreports (Bhat et al., 2020; Jiao et al., 2020; Oosterhoff et al., 2020b) . The adults and older children were the respondents of the study (Lee, 2020; Liu et al., 2020; Viner et al., 2020b; Wang et al., 2020 (Wade et al., 2020) .

The review articles for this review have been selected during the time of global lockdown,

where the issues and challenges were new and the global crisis was at peak times. In our review, we were unable to track the measures of management targeted towards the children.

The strategies reported in the studies were isolated to geopolitical conditions. The recommendations provided in this review can be modified to suit the needs of the places according to their local resources and geopolitical scenarios. Due to strict selection criteria and the short period of data collection and the only use of electronic databases for our research, there is a possibility of missing studies relevant to the care of children and adolescents.

Although the rate of COVID-19 infection among young children and adolescents is low The children who receive training, therapy, and other treatments are at high risk of being derailed from therapy and special educations. Economically underprivileged children are particularly prone to exploitation and abuse. Children quarantined are at high risk for developing higher risk for mental health-related challenges.

There is a need to ameliorate children and adolescent's access to mental health services by using both face to face as well as digital platforms. For this collaborative network of parents, psychiatrists, psychologists, pediatricians, community volunteers, and NGOs are required. There is a need for 'tele mental health compatibility' and be accessible to the public at large. This would be crucial to prevent during and post-pandemic mental challenges in the most vulnerable and underprivileged section of the society. The focal point of the health care system and policymaking should be prevention, promotion, and interventions corresponding to the public mental health system to meet the mental health needs of the population at large by taking the regional contextual parameters into account.

Disclosure of Prior presentation of study data: this paper has not been submitted in full or part in any conference and is not being considered for publication elsewhere. Creating material for community volunteers and NGOs for identifying high risk children e.g. underprivileged children, children of migrants, provide psychological first aid, coordinating with care givers and mental health care professionals.

Quarantined parents/children Parents If child is separated to keeping contact as much as possible, being supportive and reassuring

Coordinating with care givers, referring to mental health care professionals Foster care givers Being supportive, reassuring and educating

Constructing and administring online questionnaires in order to detect psychological distress and other symptoms for children if they or their parents are quarantined, providing extra support to them and developing ad hoc supportive interventions.

Impacts of COVID-19 on vulnerable children in temporary accommodation in the UK. The Lancet Public Health

Closure of Universities Due to Coronavirus Disease 2019 (COVID-19): Impact on Education and Mental Health of Students and Academic Staff

Professional foster carer and committed parent: Role conflict and role enrichment at the interface between work and family in long-term foster care

Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: Experts' consensus statement

Children's Mental Health in Times of Economic Recession: Replication and Extension of the Family Economic Stress Model in Finland

Global population of children 2100

Children with autism and COVID-19

Policy Brief: The Impact of COVID-19 on children

School closure and management practices during coronavirus outbreaks including COVID-19: A rapid systematic review. The Lancet Child & Adolescent Health

School closure and management practices during coronavirus outbreaks including COVID-19: A rapid systematic review. The Lancet Child & Adolescent Health

Why we need longitudinal mental health research with children and youth during (and after) the COVID-19 pandemic

Detection of SARS-CoV-2 in Different Types of Clinical Specimens

Healthy parenting

WHO | COVID-19: Resources for Adolescents and Youth

World Health Organization

Mental health care for international Chinese students affected by the COVID-19 outbreak

The authors whose names are listed below certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants, participation in spakers' bureaus arrangements, consultancies, memberships, stock ownerships, or other equity interest, or expert testimony and patent licencing arangements) or non financial interests such as ( personal or professional relationships, affiliations, knowledge or beliefs)in the subject matter or materials discussed in this manuscript. All the authors confirm that, all of them has contributed in the conception of design; analysis, interpretation of data; drafting the article; critically revisiting the article for important intellectual inputs; and approval of the final version. This paper has not been submitted elsewhere or is under review at another journal or publishing venue. The authors have no affiliation with any organization, with a direct or indirect financial interest in the subject matter discussed in the manuscript.

Authorities to be more transparent in their negotiations and to allow candidates sufficient notice to prepare emotionally as well. Students to be timely provided counselling.