INTRODUCTION
The COVID-19 pandemic has had a profound impact on nearly every aspect of daily life since first emerging in late 2019. At the time of writing, over 850 thousand people have died from COVID-19, with over 180 thousand of them being in the United States [1]. Children are a small proportion of those infected, and it is believed that 90% of infected pediatric patients are asymptomatic or have mild/moderate disease, and severe cases are generally seen in patients less than 1 year of age or with underlying illnesses [2].
Beyond the medical effects of COVID-19, the pandemic has had devastating economic and social consequences [3]. Most nations instituted lockdown, and schools were closed or limited in most countries to prevent the spread of infection [4]. Over 1.7 billion learners have had their education affected due to school closures and other circumstances during the pandemic, and nearly 1.3 billion students have continued to have restricted learning [5].
During this period of economic difficulty and social isolation, much has been discussed regarding potential psychological implications of the pandemic to frontline health care workers and the general population [6]. This review serves as a summary of the literature on how COVID-19 and the ensuing lifestyle changes may have had an impact on various mental health condition in children and adolescents.
METHODS
Inclusion Criteria
Studies discussing the impact of COVID-19 or ensuing restriction measures on child or adolescent mental health disorders including anxiety, depression, PTSD, ADHD, sleep disorders, somatic symptom disorders, eating disorders, and autism
Studies discussing the impact of COVID-19 or ensuing restriction measures on abuse and neglect in populations under 18 years of age
Original studies, systematic reviews, editorials, meta-analyses, case reports, and randomized controlled trials
Results were limited to those published in 2020 to account for published articles on the current pandemic
Exclusion Criteria
Articles focused on populations aged 18 years or older
Articles focused on the nonclinical implications of the COVID-19 pandemic
Information Sources
Studies were identified by searching PubMed and Google Scholar. The search was performed on September 7, 2020.
Search String
(((((((((((((((((((coronavirus) OR (covid)) OR (covid-19)) OR (pandemic)) OR (quarantine)) OR (social distancing)) OR (isolation)) AND (child)) OR (pediatric)) OR (adolescent)) OR (lockdown)) AND (mental health)) OR (psychiatric))
RESULTS
A total of 39 articles were included in this review. A discussion of the potential role that the COVID-19 pandemic or its resulting effects on society may have played on specific disorders is detailed below, based on this review of literature.
Anxiety Disorders
Anxiety disorders are some of the most prominent and common mental health concerns in youth during the COVID-19 pandemic. Jefsen et al. noted that anxiety symptoms were the most common pandemic-related symptoms at their institution, with 34% of patients exhibiting such symptoms [7]. Similarly, 54% of children involved in online mental health counseling services in Wuhan, 21% of parents of children enrolled in online schooling in Beijing [8], and 18.9% of students in the Hubei province [9] reported anxiety symptoms.
Several aspects of the COVID-19 pandemic have worsened anxiety, including fear of the virus [7] and financial instability [10]. Media exposure to COVID-19 may be associated with worsening anxiety symptoms, with Kilincel et al. noting 2.41 times higher anxiety scores in youth using mostly television as an information source, and having a COVID positive family member was associated with 3.81 times increase in anxiety scores [11]. Children in isolation may resist treatment due to environmental change and fear of death [12]. Compared to before the pandemic, Duan et al. reported increased scores in five dimensions of anxiety, most notably the fears of physical injury in children and social phobia in adolescents [13]. Conversely, some patients with social anxiety or performance anxiety may exhibit decreased symptoms due to a lack of exposure to triggers. This improvement is likely temporary and may worsen upon return to these exposures [14].
Older youth are identified as having increased risk of anxiety during the pandemic [13,15]. Adolescents with psychiatric history had anxiety scores 4.39 times higher [11]. A history of adverse childhood experiences, particularly family neglect, is associated with worse anxiety problems during the pandemic [16]. Oosterhoff et al. note that youth who engaged in social distancing practices to avoid getting sick or to avoid judgment reported more symptoms of anxiety, while those engaging in social distancing because they preferred to stay home had fewer [17]. Awareness of COVID-19 prevention and projections of cases was identified as protective against anxiety [15].
Management during the pandemic includes adjusting practices to ease concerns. Some patients are unwilling or unable to come to outpatient appointments [18]. For these children, traditional online therapy may be most helpful, and there may be a role for online video game therapy [8]. Limiting news exposure to the COVID-19 pandemic may prevent worsening of anxiety associated with fears of the virus [7].
Obsessive Compulsive Disorder (OCD)
Tanir et al. note that in their study of patients with OCD, 54.09% had increased symptom severity and frequency compared to before the pandemic, of which 55.7% had been in remission before the pandemic, with cleaning and washing compulsions being most common. Factors that predicted OCD symptoms included talking about COVID, preoccupation with COVID, knowing a person who had been diagnosed with COVID, and the duration of OCD prior to the pandemic [19]. Management during the pandemic include limiting news consumption to minimize worries, and for patients with specific cleaning and handwashing compulsions, exposure therapy may need to be paused to prevent worsening during the pandemic [20].
Depression and Mood Disorders
During the COVID-19 pandemic, depression has seen an increase. Duan et al. noted 22.28% of students aged 7 to 18 in mainland China reported scores indicating clinical depressive symptoms, compared to 13.2% in China and 2 to 6% in Western countries prior to the pandemic [13]. Thirteen percent of children in online counseling services in Wuhan reported depression between February and March [8], as did 22.6% of students in the Hubei province [9].
Jefsen et al. noted that youth with mood disorders may experience worsening due to fear of COVID-19 [7]. It is suggested without school routines, patients with depression may be prone to locking themselves in their rooms and not perform daily activities, and the adjustment when school resumes may be difficult [21]. Conversely, while the impact on these mood disorders on suicidality are unclear, some nations have reported a decrease, which may be associated with a decrease in pressure from peers or school [22].
Demographically, students in Wuhan had higher depression scores and a higher risk of depressive symptoms compared to those in Huangshi [9]. Duan et al. identified living in the Hubei province or in urban areas as factors associated with increased depressive symptoms [13]. Zhou et al. noted that in senior high school, older years were associated with higher risk of depressive symptoms [15].
Youth who engaged in social distancing because they would have otherwise stayed home noted fewer depressive symptoms, whereas those who engaged in social distancing because a friend told them to noted greater depressive symptoms [17]. Factors associated with increased depressive symptoms included smartphone/internet addiction, residing in the Hubei Province (the province of the initial outbreak), residing in urban areas, knowing people infected with coronavirus, having graduation affected by the pandemic, separation anxiety, fear of physical injury, and emotion-focused coping, whereas decreased internet usage before the pandemic and problem-focused coping were associated with lower symptoms [13]. Students who were not as worried about the pandemic had lower depressive scores and symptoms, whereas those who were less optimistic had higher depressive scores and symptoms [9].
Attention Deficit Hyperactivity Disorder (ADHD)
Patients with ADHD have been widely affected by the pandemic. Bobo et al. note that in France, 34.71% of children experienced worsening of ADHD, while 30.96% did better and 34.33% showed no changes [23]. For many newly diagnosed patients, there was an initial delay in medications due to a lack of baseline appointments and cardiovascular screening with a reduction in referral rate by 80%, and there was similarly decreased medication titration due to the lack of teacher reports [24].
The pandemic has caused notable sleep issues for families of patients with ADHD, with sleep onset pushed forward by three hours, and melatonin being less effective [24]. Parents have also reported an increase in opposition and aggression, and some have indicated that difficulties with confinement, lack of free movement, difficulties with academics, and family conflicts have arisen [23]. Conversely, Chawla et al. suggest that while there are several disruptions caused by the pandemic, it can prevent bullying of patients with ADHD by peers [25]. Bobo et al. note that a majority of patients have improvement or maintenance of ADHD symptoms, attributed to a lack of academic constraints, flexible schedule, and improvement in self-esteem from decreased negative feedback from peers [23].
Jefsen et al. recommend maintaining a clear structure in family life to ensure routine [7]. Continued management via telehealth is recommended, as parents have generally found it to be a positive experience [23]. The European ADHD Guidelines Group suggest that managing ADHD appropriately is important as untreated behavioral symptoms can increase the risk of COVID-19 from not engaging in social distancing and precautionary regulations [26].
Autism Spectrum Disorder (ASD)
Much of the discussion regarding autism spectrum disorder concerns the changes to daily structure. Becker et al. indicate that youth with ASD may face challenges due to social distancing, caregivers working from home, and home education [27]. Furthermore, disruption of scheduled therapy sessions is likely to lead to irritability, aggression, and social withdrawal [28].
Colizzi et al. report that 93.9% of parents considered restrictions as challenging/very challenging, with 77% considering it more challenging than before the pandemic. Furthermore, 35.5% of parents considered behavioral issues to be more intense, and 41.5% more frequent. Common difficulties included managing free time (78.1%), structured activities (75.7%), autonomies (31%), and meals (23%). Increased age and living with a separated/single parent were associated with decreased intensity of behavioral issues, whereas a lack of indirect school support was associated with more [29].
Children with autism may be less likely to engage in social distancing measures and wear facemasks due to their lack of understanding. For patients with autism who need to be isolated or hospitalized, no visitor policies may impair autism management [30]. Parental anxiety due to job loss, economic uncertainty, decreased access to healthcare, and waitlists for early intervention programs are likely to prove problematic [31].
It is hypothesized there is a link between immune dysregulation in ASD and COVID-19. ASD may create an increased Th1 response, creating a pro-inflammatory environment. This may serve as a risk factor for COVID-19, as other pro-inflammatory conditions have been implicated in COVID-19 and developing ARDS [32]. It has also been proposed that the pro-inflammatory cytokines caused by COVID-19, specifically IL-6, may decrease IGF-1 in pregnant women and possibly increase risk for autism [33].
Recommendations include maintaining a clearly structured family life [7] and creating pandemic response programs specifically for children and families, utilizing virtual care platforms and virtual helplines [31]. Narzisi advises parents of children with autism to explain what COVID-19 is and to utilize resources such as games, online therapy, weekly consultations, and school contact [34].
Sleep Disturbance
Sleep pathologies have been notably impacted by COVID-19. Twenty-two percent of children in online counseling services in Wuhan reported insomnia between February and March [8]. Financial and health issues, uncertainty about the future, and increased exposure to cyberbullying may be stressors leading to sleep issues. Furthermore, decreased sunlight exposure due to social distancing, increased screen time and blue-light usage, and associating the bedroom with arousal due to online learning may worsen sleep [27].
Sleep issues may be worse in children who have comorbid psychiatric issues [24]. Sleep disruption caused by COVID-19 may also worsen mood and anxiety issues, or create oppositional symptoms similar to ADHD [27]. Sleep issues such as nighttime awakenings, nightmares, and difficulty napping may also serve as symptoms indicating underlying stress during the pandemic [28].
Becker and Gregory suggest that for some youth, the pandemic may have improved sleep. The change in schedule may allow for more flexibility for children who do better in the evening, and the lack of commute may allow for them to have more time engaging in their schooling. The pandemic may have allowed some students a break from bullying they undergo at school, and newfound time with family may create a feeling of safety that can improve sleep [27].
Abuse/Neglect
Abuse and neglect have been a particular concern during the pandemic. The American Academy of Pediatrics and American Psychological Association note that parental stress, isolation, and financial stressors may lead to domestic violence and child abuse [35]. A surge of child abuse cases was reported in Texas during the pandemic, and parents have reported increased incidents of yelling, shouting, and slapping their children [28]. The Jianli County in the Hubei province of China saw reports of domestic violence triple in February year-over-year [21].
Baron et al. report a 27% lower than expected rate of child mistreatment allegations in Florida from February and March, indicating school closures may have the consequence of underreporting child mistreatment [36]. Several U.S. states have had decreased reports to child mistreatment hotlines [37]. Witt et al. suggest that protective care agencies may have decreased resources during the pandemic, making involvement more difficult [38]. For the 2020-2021 school year, recommendations include virtual check-ins for abuse, distributing information about mistreatment reporting via social media to decrease the under-reporting [36], and adapting tools to detect child abuse in distant learning environments [37].
Other Disorders/Concerns
Post-Traumatic Stress Disorder (PTSD)
There is little discussion regarding PTSD specific to youth during the COVID-19 pandemic, and most research from prior pandemics has been focused on adults [39]. Guessoum et al. suggest the long-term PTSD effects on children and adolescents will likely be attributed to containment and fear of infection, and are likely to present differently compared to natural disasters [3]. Guo et al. found that during the pandemic, adverse childhood experiences have served as predictors of PTSD symptoms, with a history of family neglect being the most significant [16]. In youth aged 14-35, 14.4% endorsed symptoms of PTSD, but noted no difference based on age [40]. Similarly, Liang et al. demonstrated a 12.8% prevalence of PTSD in a population aged 14-35 one month after the COVID-19 outbreak in China [41].
Somatic Symptoms
Liu et al. report in Chinese students, 2.39% of school children and 34.85% of college students have reported somatic symptoms, with 26.26% of college students reporting mild symptoms and 8.59% moderate, and 2.39% of primary school students reporting mild symptoms. Predictors for somatic symptoms include concerns regarding the threat to health for school-aged and college students, and concerns regarding prevention only for college students [42]. Colizzi et al. reported a case of a 16-year-old with a history of eating disorder and paraparesis of unknown origin who presented with symptoms including fever to 38.7° C, tachycardia, delirium, and olfactory and gustatory changes. The patient was in contact with a person potentially infected with COVID, but was COVID negative upon testing. During his admission, he exhibited anxiety, loss of control, and poor insight and judgment regarding his illness. He was eventually treated with olanzapine and paroxetine, which improved his somatic symptoms and concern over his illness [43].
Eating Disorders
Graell et al. report in a cohort of patients with eating disorders, 41.9% had recurrence of eating symptoms during the pandemic, and for those hospitalized, 68.2% noted isolation as a potential cause for the admission. Adolescents had a more significant change in eating disorder symptoms compared to children, and other factors included social isolation in 40.9% of patients and family conflicts in 31.8%. While admission numbers were similar compared to the previous year, patients were more likely to have comorbid psychiatric illness and exhibit affective disorders and suicide risk [44].
DISCUSSION AND CONCLUSION
The COVID-19 pandemic has had far-reaching impacts beyond the medical effects of the disease. Protective measures including stay-at-home orders, mask mandates, and school closures were put in place in nearly every nation in the world. In children and adolescents in particular, the changes to daily structure, confinement, family stress, and lack of socializing can both worsen pre-existing mental health conditions and create newfound issues. Conversely, for some patients, these changes can create a temporary reprieve from stressors, particularly from school and peer relationships.
Anxiety disorders and depression were some of the most discussed mental health conditions impacted by the COVID-19 pandemic in the literature, with anxiety generally being cited as the most common mental health issue [7,8]. Fears about the COVID-19 virus itself and fears about finances and schooling are major factors that have played into anxiety and depression during the pandemic.
Similarly, ADHD and ASD, two common pediatric mental health disorders, have been well discussed during the pandemic. The primary concerns for both are the changes in daily structure and interaction with families due to precautionary restrictions. Many parents find it difficult to manage their children in this time period due to having other obligations and a lack of school resources. The financial burden on some families makes it difficult to manage working from home and children’s responsibilities. However, some have found that the relief from school and peers may have had an improvement in symptoms.
The literature also demonstrates impacts on various other mental health conditions in children and adolescents, as well as concerns for increased child abuse and neglect. Furthermore, the pandemic will likely have long lasting impacts on mental health as periods of economic stress, health concerns, and social isolation are prolonged. The effects on childhood development, trauma, and other mental health disorders during the pandemic will likely be a topic of discussion for many years to come.
