key: cord-0913395-nclddu7i authors: Luijten, M. A. J.; van Muilekom, M. M.; Teela, L.; van Oers, H. A.; Terwee, C. B.; Zijlmans, J.; Klaufus, L.; Popma, A.; Oostrom, K. J.; Polderman, T. J. C.; Haverman, L. title: The impact of lockdown during the COVID-19 pandemic on mental and social health of children and adolescents date: 2020-11-04 journal: nan DOI: 10.1101/2020.11.02.20224667 sha: a989484c2e7e049756e87e92ad1ff90b5fe1a8c8 doc_id: 913395 cord_uid: nclddu7i Importance: It is unknown how a lockdown during the COVID-19 pandemic impacts childrens and adolescents mental and social health. Objective: To compare mental and social health of children and adolescents during the COVID-19 lockdown versus before, identify associated factors, describe the change in atmosphere at home and qualitatively assess the impact of COVID-19 regulations on daily life. Design: Cross-sectional study comparing two Dutch representative samples of children and adolescents (8-18 years); before COVID-19 (Dec2017-July2018) and during the COVID-19 lockdown (April/May 2020). Setting: Population-based Participants: Children and adolescents aged 8-18 years (M=13.4, 47.4% male), representative of the Dutch population on key demographics. Exposure(s): COVID-19 pandemic lockdown Main Outcome(s) and Measure(s): Patient-Reported Outcomes Measurement Information System (PROMIS) domains: Global Health, Peer Relationships, Anxiety, Depressive Symptoms, Anger and Sleep-Related Impairment. Single item on atmosphere at home and open question regarding the impact of the regulations on the childs/adolescents daily life Results: Children and adolescents reported significantly worse PROMIS T-scores on all domains (absolute mean difference range, 2.1-7.1; absolute 95% CI range, 1.3-7.9) during the COVID-19 lockdown as compared to before COVID-19. More children reported severe Anxiety (during 16.7% vs. before 8.6%; relative risk 1.95; 95% CI 1.55-2.46) and Sleep-Related Impairment (during 11.5% vs. before 6.1%; relative risk 1.89; 95% CI 1.29-2.78). Fewer children reported poor Global Health (during 1.7 vs. before 4.6%; relative risk 0.36; 95% CI 0.20-0.65). More mental and social health complaints during the COVID-19 lockdown were found in children and adolescents growing up in a single-parent family, having >three children in the family, a negative change in work situation of parents due to COVID-19 regulations, and having a relative/friend infected with COVID-19. A small effect was found on atmosphere at home during the lockdown compared to before (mean difference, -3.1; 95% CI, -4.1 - -2.1). A large majority (>90%) reported a negative impact of the COVID-19 regulations on their daily life. Conclusions and Relevance: This study showed that governmental regulations regarding lockdown pose a serious mental and social health threat on children and adolescents that should be brought to the forefront of political decision making and mental health care policy, intervention and prevention. The COVID-19 pandemic has an enormous impact on society as a whole, and certainly also on children and adolescents. Although children and adolescents are less affected by morbidity and mortality 1 , the restrictions imposed by governments worldwide profoundly impact their daily life, including their mental and social health. 2 In the Netherlands, the first COVID-19 patient was identified on February 27 th 2020 and restrictions were imposed by the government starting on March 12 th 2020. People were asked to stay inside and work from home as much as possible, to comply to social distancing (1.5 meter) and all large events were canceled. On March 15 th , a 'partial' lockdown was implemented. 3 All schools and child care facilities were closed (unless one or both parents had an occupation classified as essential), as well as sports and leisure facilities, bars, and restaurants. However, children were still allowed to play outside, and visitors up to three persons at home were permitted. On May 11 th primary schools were partially reopened and on June 2 nd secondary schools followed. During the lockdown, children and adolescents were experiencing physical isolation from their classmates, friends, teachers, and other important adults (e.g., grandparents). This might not only result in feelings of loneliness, but could potentially lead to precarious situations for children from unsafe domestic situations, due to a lack of escape possibilities. In addition, children and adolescents may experience mental health problems due to the COVID-19 pandemic itself, such as increased anxiety, as they might fear that they or their loved ones will get infected or they might worry about the future of the world. Several cross-sectional and longitudinal studies on the effects of the COVID-19 pandemic on mental health in adults have now been published. Increased levels of anxiety, depression, suicidal ideation and (post-traumatic) stress, decreased psychological well-being, and a high percentage of sleep problems have been reported. [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] Poor mental health was associated with female gender, younger age, low educational level, living alone/being divorced, having no work, low income, a socially disadvantaged background, and having an infected relative with COVID-19. [4] [5] [6] [7] [8] [9] [10] [11] [12] However, studies on the effects of the COVID-19 lockdown on social and mental health of children and adolescents are yet sparse. Several opinion papers prelude on the most probable effects, and they have painted an image of loneliness, anxiety and depression following social isolation. 14, 15 Additionally, these papers have described increased tension at home and child abuse as possible consequences during the lockdown. 16, 17 Several authors fear that the lockdown will magnify existing health disparities and that certain communities (e.g., with migrant background and low socioeconomic status) will be more vulnerable to develop mental and social health issues. 15, 18, 19 Notably, it has been hypothesized that some children may also experience positive consequences of the lockdown such as personal and social alleviation, family cohesion and reduction of stress. 20 One systematic review on the effects of previous pandemics on mental health of children and adolescents is available, indicating that social isolation and quarantining has a negative impact on . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. ; https://doi.org/10.1101/2020.11.02.20224667 doi: medRxiv preprint anxiety, depressive and fear symptoms. 2 Additionally, only three cross-sectional survey studies are currently available, all from China, focusing on the impact of the COVID-19 pandemic and lockdown specifically. They reported prevalences of anxiety and depressive symptoms of 19% and 23% for primary school children, 21 of 37% and 44% for high school children, 22 and clinically elevated depressive symptoms scores for >22% of children and adolescents 23 during the COVID-19 lockdown. These prevalences were reported to be higher compared to pre-COVID-19 established cut-offs and percentages in China, however none of these differences were statistically tested. Especially girls, older children, children living in an urban region and children having a COVID-19 infected friend/relative appeared to be most prone to mental health problems. 22, 23 A better understanding of how the governmental restrictions during the COVID-19 pandemic affect children's and adolescents' mental and social health can help guide future interventions and inform policy makers. The current study compares mental and social health of a representative sample of Dutch children and adolescents during the COVID-19 lockdown to earlier collected before COVID-19 reference data. The aims of this study were to: (1) quantify differences in mental and social health of children and adolescents before and during the COVID-19 lockdown, (2) identify factors that are associated with poorer mental and social health during the COVID-19 lockdown, (3) examine the change in overall atmosphere at home before and during the COVID-19 lockdown, and (4) qualitatively assess the impact of the COVID-19 lockdown on their daily life of children and adolescents. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. ; https://doi.org/10.1101/2020.11.02.20224667 doi: medRxiv preprint Before COVID-19 As part of a larger Patient-Reported Outcome Measurement Information System (PROMIS) validation study, two studies were conducted between December 2017 and July 2018 in the Dutch general population to collect representative data of children and adolescents (8-18 years) on physical, mental and social aspects of health. A two-step random stratified sampling method was used to ensure representativeness on key demographics. Parents participating in existing panels were approached by two independent online research agencies ('Kantar Public' or 'Panel Inzicht'). Both panels consist of families living across the Netherlands, that provided informed consent to be approached through e-mail for completing questionnaires for a small financial compensation. During the COVID-19 lockdown, between April 10 th and May 5 th 2020, data were collected by 'Panel Inzicht' from another sample of children and adolescents from the Dutch general population. The aim was to collect data on the same measures in a representative sample of approximately 1000 children with similar characteristics (within 2.5% of the previously mentioned key demographics) as the before COVID-19 sample. Data collection procedures were similar as in 2018, with the addition of a few COVID-19 specific questions for children, adolescents and parents. Children and parents provided informed consent and the study was approved by the Medical Ethics Committee Amsterdam UMC. Parents completed questions about themselves (region of residence, country of birth, educational level, marital status, and number of children) and their child (age, gender). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. ; https://doi.org/10.1101/2020.11.02.20224667 doi: medRxiv preprint PROMIS item banks and scales were developed and validated, to measure generic unidimensional domains (e.g., anxiety) of physical, social or mental health using modern psychometric techniques. 26 The item banks can be administered as Computerized Adaptive Test (CAT), where items are selected based on responses to previously completed items, resulting in a reliable score with a few items. Three closed-ended questions were added for parents about whether there was a negative change in work situation of one of the parents/caregivers due to COVID-19 regulations (e.g., loss of income, reduced number of working hours, unemployment), whether a friend or relative had been infected with COVID-19 and if the child still attended child care/school during lockdown (e.g., both parents performing essential occupations). Children and adolescents were asked to complete three COVID-19-specific questions: 'How did you experience the atmosphere at home before the schools were closed?' and 'How do you experience the atmosphere at home now?' rated on a visual analogue scale (VAS) ranging from 0 'Not pleasant at all' to 100 'Very pleasant', and an open-ended question 'How are the corona-regulations for you?'. For all statistical analyses the Statistical Package for Social Sciences (SPSS), version 26.0, was used. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. ; https://doi.org/10.1101/2020.11.02.20224667 doi: medRxiv preprint Percentages of children and adolescents reporting 'severe' symptoms or 'poor' functioning on the PROMIS measures before and during the COVID lockdown were compared. Severe symptoms or poor functioning was defined as a T-score 1.5 SD above or below the mean T-score before COVID-19 respectively, except for Peer Relationships, where 2 SD was used as cut-off for poor functioning (see www.HealthMeasures.net). Differences in proportions of severe scores were tested using chi-squares tests of independence and the relative risk (RR) with 95% confidence intervals (95% CI) were reported. The RR represents the risk of a child measured during the COVID-19 lockdown having a severe score compared to before COVID-19. A ratio >1 indicates more risk. Third, to determine which variables were significantly associated with mental and social health during the COVID-19 lockdown, a multivariable linear regression analysis was performed for each PROMIS domain. The following variables were included as independent variables: age, gender, parental country of birth, marital status, region, number of children in the family, parental educational level, change in work situation due to COVID-19 regulations, infected relative/friend with COVID-19 and if the child still attended child care/school during lockdown. No multicollinearity was present between these variables (all correlations <.50). Per domain the effect size of all independent variables was reported, expressed as unstandardized regression coefficient B (95% CI). Fourth, to investigate changes in atmosphere at home a paired T-test was used to test the difference between the two single items. Mean difference (95% CI) was reported. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. ; https://doi.org/10.1101/2020.11.02.20224667 doi: medRxiv preprint During the COVID-19 lockdown, 844 children participated. This sample showed similar characteristics (most variables within 2.5% from each other) compared to the sample collected before COVID-19 (total N=2401). Significant differences were found on four variables ( Table 1) ; age (during M=13.4 (SD=2.80) versus before M=13.1 (SD=3.14), mean difference=0.3; 95% CI, -0.54 --0.06), both parents born in the Netherlands (during 88.2% versus before 79.8%, χ 2 (1)=29.884, p<0.001), parents with a low educational level (during 9.0% versus before 12.8%, χ 2 (2)=7.470, p=0.024), and families with one child (during 25.5% versus before 15.5%, χ 2 (2)=44.728, p<0.001). [Insert Table 1 ] During the COVID-19 lockdown, children and adolescents reported worse T-scores than children and adolescents before the COVID-19 lockdown on all PROMIS domains, after controlling for age, parental country of birth, parental educational level and number of children (absolute mean difference range, 2.06-7.05; absolute 95% CI range, 1.25-7.86) ( Table 2 ). Largest differences were found for Anxiety (mean difference=7.1, 95% CI, 6.2-7.9) and Depressive Symptoms (mean difference=4.9; 95% CI, 4.0- Significantly more children reported severe Anxiety (during 16.7% versus before 8.6%; RR, 1.95; 95% CI, 1.55-2.46) and severe Sleep-Related Impairment (during 11.5% versus before 6.1%; RR, 1.89; 95% CI 1.29-2.78) during the COVID-19 lockdown than before COVID-19 (Table 3) . Fewer children reported poor Global Health (during 1.7% versus before 4.6%; RR, 0.36; 95% CI, 0.20-0.65). [Insert Table 2 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint [Insert Table 4 here] Children and adolescents reported a worse atmosphere (mean difference=-3.1; 95% CI, -4.1 --2.1) at home during the COVID-19 lockdown (M=78.2, SD=17.9) than before COVID-19 (M=81.4, SD=16.0). The majority (~90%) of children indicated that the COVID-19 lockdown had a negative impact on their daily life. The most often mentioned issues (>50 children) were: 1) missing contact with friends, 2) not allowed to go to school, 3) missing freedom, 4) not allowed to participate in sports, 5) missing joyful activities (e.g., birthdays, holidays, parties, shopping), 6) difficulties with homeschooling 7) missing extended family, and 8) boredom (Table 5) is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. The results of this study confirm the suspicions of child and youth care professionals that the COVID-19 lockdown has negative effects on mental and social health of children and adolescents. In opinion papers, professionals elaborated on the vulnerability of this group and expected more feelings of loneliness, anxiety and depression, as well as a more tense atmosphere at home. 14-17 Concerns were also expressed that the COVID-19 lockdown would lead to an increase in inequality and that children and families with lower social economic status would be more susceptible to mental health issues. 15, 18, 19 Although this study could not definitely confirm these concerns, children from single parent families, from families with three or more children, and with parents who had a negative change in work situation reported more mental and social health problems during the COVID-19 lockdown. While the Dutch partial lockdown was substantially different from the Chinese full lockdown, our results are in line with the three studies from China, 21-23 who also reported higher anxiety and depressive symptom during the COVID-19 lockdown. Likewise, one of the Chinese studies also found that having an infected relative/friend with COVID-19 was predictive of more anxiety. 23 In addition to the effects on anxiety and depressive symptoms, our study results show negative effects of the COVID-19 lockdown on anger, sleep-related impairment and peer relationships. Although the mean T-score on Global Health was lower (worse) in the sample during the lockdown as compared to before COVID-19, a lower percentage of children and adolescents reported poor Global Health during COVID-19. This finding is puzzling and prompts further study in a followup design that is underway in our department. Some limitations of this study need to be taken into account. Although the aim was to obtain two representative samples that were completely comparable, small differences were found on age, parental country of birth and educational level, and family composition. However, these differences is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. ; https://doi.org/10.1101/2020.11.02.20224667 doi: medRxiv preprint were corrected for in our comparisons between the groups. In addition, the data collection during COVID-19 took place in April and May (2020), whereas the study data collection before COVID on anxiety and depression mainly took place in January and February (2018). Worse mental health is often reported during winter times. 35 This difference could have led to an underestimation of the actual impact of the COVID-19 lockdown. We found that children and adolescents from families with certain risk factors (e.g. single parent families) are more vulnerable to mental and social health problems. These children and adolescents should be in sight of health care professionals. However, in this study children and adolescents with existing mental or somatic problems were not included, while it is conceivable that these groups are even more vulnerable. More research is needed to study the mental and social health of these groups as well as to gain insight in the longitudinal effects, and to clarify if lower mental and social health scores are mainly due to the COVID-19 pandemic or the lockdown. During the finalization of this paper, the Netherlands, and many other countries, are facing a second COVID-19 wave. This study showed that governmental regulations regarding lockdown pose a serious mental and social health threat on children and adolescents that should be brought to the forefront of political decision making and mental health care policy, intervention and prevention. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. ; https://doi.org/10.1101/2020.11.02.20224667 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. ; https://doi.org/10.1101/2020.11.02.20224667 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. ; https://doi.org/10.1101/2020.11.02.20224667 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. ; https://doi.org/10.1101/2020.11.02.20224667 doi: medRxiv preprint Table 4 . Variables associated with mental and social health in children and adolescents during the COVID-19 lockdown. Note. B = Unstandardized regression coefficient of multivariable linear regression model. **p-value <.01, *p-value <.05. + Higher scores indicate better functioning. •Higher scores indicate more symptoms. °Educational level parents divided into three categories: Low = primary, lower vocational education, lower and middle general secondary education; Intermediate = middle vocational education, higher secondary education, pre-university education; High = higher vocational education, university. ^Region: North = Groningen, Friesland, Drenthe, East = Overijssel, Gelderland, Flevoland, South = Zeeland, Noord-Brabant, Limburg, West = Utrecht, Noord-Holland, Zuid-Holland. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 4, 2020. ; https://doi.org/10.1101/2020.11.02.20224667 doi: medRxiv preprint Table 5 . 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