Mental health of Adolescents during

Lockdown period of Covid 19

Abstract

COVID-19 was declared a pandemic in March 2020, resulting in many

countries worldwide calling for lockdowns. This study aimed to review the
existing literature on the effects of the lockdown measures established as a
response to the COVID-19 pandemic on the mental health of children and
adolescents. Embase, Ovid, Global Health, PsycINFO, Web of Science, and
pre-print databases were searched in this PRISMA-compliant systematic review
(PROSPERO: CRD42021225604). We included individual studies reporting on
a wide range of mental health outcomes, including risk and protective factors,
conducted in children and adolescents (aged ≤ 19 years), exposed to COVID-19
lockdown. Data extraction and quality appraisal were conducted by independent
researchers, and results were synthesised by core themes. 61 articles with
54,999 children and adolescents were included (mean age = 11.3 years, 49.7%
female). Anxiety symptoms and depression symptoms were common in the
included studies and ranged 1.8–49.5% and 2.2–63.8%, respectively. Irritability
(range = 16.7–73.2%) and anger (range = 30.0–51.3%), were also frequently
reported by children and adolescents. Special needs and the presence of mental
disorders before the lockdown, alongside excessive media exposure, were
significant risk factors for anxiety. Parent–child communication was protective
for anxiety and depression. The COVID-19 lockdown has resulted in
psychological distress and highlighted vulnerable groups such as those with
previous or current mental health difficulties. Supporting the mental health
needs of children and adolescents at risk is key. Clinical guidelines to alleviate
the negative effects of COVID-19 lockdown and public health strategies to
support this population need to be developed.

Introduction

In January 2020, WHO first identified the novel coronavirus (COVID-19), later
declaring the spread of COVID-19 as a global pandemic in March 2020 [29].
Subsequently, many countries imposed national lockdowns, closing schools and
workplaces, leaving people to learn virtually, enforcing social distancing
measures, and implementing restrictive measures that prevented individuals
from going to public places or from meeting people from other households [45].
Quarantines and lockdowns are states of isolation that are psychologically
distressing and unpleasant for anyone who experiences them [14, 50]. Young
people, who are at higher risk of developing mental health problems than adults
[32], may be particularly vulnerable to the adverse effects of isolation, including
school closures, due to the disruption lockdown causes on their physical activity
and social interaction [101].

Previous systematic reviews and meta-analyses have looked at the impact of

COVID-19 on the mental health of the general population [108] and healthcare
workers [31]. One previous systematic review looked at the psychological
burden of quarantine associated with exposure to contagious diseases on
children and adolescents but included only three articles on COVID-19 [49]. To
our knowledge, this is the first comprehensive systematic review focusing
exclusively on the impact of the COVID-19 pandemic response lockdown on
child and adolescent mental health.

This systematic review aims to summarise the literature exploring the effects of
COVID-19 lockdown on a wide range of mental health outcomes in children
and adolescents. We further explore the risk factors and protective factors for
developing mental health outcomes in the context of COVID-19 lockdown.

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.
Discussion

COVID-19 is an unprecedented infectious disease which has taken a

massive toll on deaths. Sudden changes in lifestyle, including lockdown,
quarantine, or physical distancing coupled with the loss of loved ones,
may take a toll on mental and emotional health. Although there has been
several studies in the past trying to elucidate how quarantine and
isolation affect mental health, the extent on how far adolescents’ mental
health is affected is unknown [17]. In this systematic review, three
included studies show that COVID-19 impacts on adolescents’ mental
health with one study citing that there was no significant impact.

The cohort result from Qu et al. [14] should be interpreted carefully.

There was 25.09% drop-out from the participants in the first round to
the second round, so the result from first and second round might not be
able to be compared directly. The study also found that the incidence and
severity of anxiety and depressive symptoms dropped significantly after
home confinement. It meant that mental health was not affected in
overall adolescent population, but only in exposure risk population.
Furthermore, there was only 2.2% subjects that reported a risk of
exposure. As this study analyzed COVID-19 exposure risk as
independent variable, the low number of subjects in exposure risk might
not be able to represent a real general population. Despite its limitations,
this study had a baseline data to compare pre-home confinement and
intra-home confinement, which made it one of the best quality studies
among the others.

Zhou et al. [11] presented a similar finding with Qu et al. [14] that living
in community with high number of COVID-19 cases was a risk factor
towards depression and anxiety. These two studies also used same
questionnaires to assess depressive and anxiety symptoms. However,
Zhou et al. [11] found that awareness of COVID-19 was a protective
factor against depressive and anxiety symptoms while Qu et al. [14]
stated that some protective factors, such as good parent-child
relationship, few adverse experiences, good family structure, and high
resilience could be outweighed by exposure of COVID-19. These different
results showed that there were a lot of factors that might affect the rise of
depressive and anxiety symptoms in adolescent in COVID-19 pandemic
era.

Study by Seçer and Ulaş was unique because it is the only study which
assessed obsessive-compulsive disorder (OCD) due to fear of COVID-19
[16]. The reasoning behind it was due to the fear of this disease,
adolescents will start a washing and hoarding obsession. Although the
study did not mention the number of positive cases in the area, the
common denominator of fear of COVID-19 is still maintained in this
study. Seçer and Ulaş [16] went a step further by theorizing that
emotional reactivity might be one of the various psychopathologies that
might explain depression, anxiety, and OCD in adolescents while
experiential avoidance mediates fear of COVID-19 and OCD symptoms.
However, while trying to establish a causality, this paper is a cross-
sectional study which means that further studies need to consider other
study designs in order to establish the direct link between fear of
COVID-19 with OCD symptoms, if possible.

Although the study done by Oosterhoff et al. [15] found that there was no
association between degree of social distancing and mental or social
health, this study found that motivations for social distancing were
differentially associated with degree of social distancing as well as
depressive symptoms, anxiety symptoms, burdensomeness, and
belongingness. Adolescents who were social distancing because they
wanted to avoid social judgment reported more anxiety symptoms which
might be explained by the fact that past researches shows that
symptomatic youths are more sensitive towards social judgment or peer
rejection [18]. This study also found that adolescents who prefer to stay
at home reported lower anxiety and depressive symptoms because
adolescents who chose to stay at home might be struggling less with
reduced social contact [15]. However, some motivations studied have low
samples such as “no alternatives” (17.8%), “friends said I should”
(13.9%), “avoid judgment” (7%), and others (4.4%) which could affect the
significancy of the associations studied. High compliance towards social
distancing in the sample population could be seen from the motivations
of social responsibility (78.1%) and not wanting others to get sick
(77.9%). It implies that the adolescents in the population studied have a
good knowledge of COVID-19 which confers protective factor towards
depression and anxiety just like in the study done by Zhou et al. [11].

Onset of depression is affected by both genetic factors and external

environmental factors such as stressful life events [19, 20]. Adolescents
are especially vulnerable to stressful life events and could lead to lower
levels of motivation, lower concentration, poorer achivement [21],
psychological distress, anxiety, depression [22], and suicide [23]. In fact,
mental health conditions account for 16% of the global burden of disease
and injury in people aged 10–19 years old and half of all mental health
conditions starting at 14 years old, but most cases were undetected and
untreated [24]. Moreover, non-emergency medical services were halted
or redirected towards more emergency cases and hence medical care for
affected adolescents will be affected [25]. Fear of COVID-19 significantly
increased negative affect, anxiety, and depression [26]. Qu et al. [14]
stated that long-term confinement had no adverse mental health impact
on adolescents from regions with a low incidence of COVID-19.
Compared to Qu et al. [14], the exposure risk of COVID-19, living area,
and fear of COVID-19 which could be the risk factors for mental health
changes on adolescents are not measured in Oosterhoff et al.’s study [15].
A study done by Fitzpatrick stated that the fear of COVID-19 is not
distributed uniformly across the USA, and there were specific
concentrated COVID-19 fear in more crowded populated communities,
communities with higher presumptive and reported cases of COVID-19,
and urban locations [27]. Most studies were also originated from high-
income countries, which may affect the generalizability of the findings to
low-income and middle-income countries which are often under-
presented in terms of generating evidences through empirical studies
[28]. Therefore, the result which was conducted in high income
countries such as the Oosterhoff’s [15] study cannot be generalized to
other low- and middle-income countries that were exposed to COVID-19.

Adolescents who are infected by COVID-19 would also need psychiatric

care as 10% of infected children who experienced trauma due to infection
and its consequences might be diagnosed with PTSD [29]. Psychiatrists
and pediatricians need to be aware of warning signs of mental health
problems in COVID-19 infected children such as mood swings and
psychosis-like symptoms as psychiatrists need to work directly with
young patients and their families in order to screen and detect mental
disorders as soon as possible with adequate personal protective
equipment [25].

Zhou et al.’s [11] study suggested that the level of knowledge, prevention,
and control measures for COVID-19 are protective factors against the
development of depressive and anxiety symptoms. However, there are
media/press sources that might give false information and reports about
COVID-19 which could lead to anxiety and depressive symptoms of the
public. A study by Zhong et al. also suggested that health education
aimed at increasing knowledge of COVID-19 are important to keep
optimistic attitudes [30]. This is related to a statement from Zhou’s
study that said positive and optimistic attitudes towards COVID-19
epidemic’s development are also protective factors against depressive
and anxiety symptoms [11].

The government and health authorities’ role are important in COVID-19

crisis to provide adequate information and deny any false information to
keep the public informed. In crisis situation like this, it is convenient to
educate and provide public with the accurate information through digital
media platform. A study by Liu suggested that the uses of digital media
might initiate preventive behaviors directly or indirectly. It states that
seeking information about COVID-19 from online news media, media
social networking (MSNs), social live streaming services (SLSSs) was
associated with increased preventive practices [31]. Since there are a lot
of misinterpreted informations from the internet, it is important to
obtain information from a credible website such as the national Centers
for Disease Control (CDC), World Health Organization (WHO), or from
other sources endorsed by these authorities, rather than a general search
on the internet or social media [32].

A rapid systematic review done by Imran et al. found that quarantine is

associated with significant negative impact on mental health of children
and adolescents which might persist for months or years after the
quarantine. Although the cause of quarantine is very diverse (from
natural disasters such as Tsunami in Aceh 2004 to children requiring
ventilators at home), this study proposed some interventions that could
be done to reduce the impact of mental health during quarantine such as
provision of psychosocial support, dissemination of accurate
information, limit exposure to news, positive parenting, social
connectivity, as well as behavior activation complemented with sleep
hygiene, exercise, and healthy eating [33]. Another systematic review
done by Loades et al. [34] which assessed the impact of social isolation
and loneliness due to COVID-19 on children’s and adolescent’s mental
health found that children and adolescents are more prone towards high
rates of depression and anxiety during and after enforced isolation ends
which might last up to 0.25 to 9 years later.

Our study is limited by exclusion of articles written in languages other

than English as well as unexplored gray literatures. The studies included
also did not measure any baseline characteristics except for study done
by Qu et al. [14]. Moreover, this systematic review could not be
proceeded to meta-analysis due to the heterogenous use of variable
analysis. Therefore, we recommend future studies to use a more
homogenous questionnaire as well as their odds ratio presentation
clearly to depict the effect of COVID-19’s mental health impact in
adolescents. Lastly, correlation between those who were at low risk of
contracting COVID-19 and the lesser impact on mental health risk may
be independent of the actual risk and was just based on individual’s
subjective perceptions.

Taken together, this is the first systematic review that shows the impact
of COVID-19 on mental health among adolescents. Hence, this study
might be important in the aspect of a more holistic approach towards
adolescents who are affected by COVID-19, whether directly or
indirectly. In the long term, there might be a surging incidence and
prevalence of mental health disorders which might be attributed to
COVID-19 and hence awareness and interventions are needed which
might require cooperations between the adolescents, families, medical
care workers, and the governments.

Material and methods

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 operators were employed
for PubMed; COVID-19 and Children [All Fields] OR (Children and COVID-
19 effects [Terms] OR & Psychological effects of COVID-19 on children
&Quot;[All Fields] OR (&Quot; COVID effects on children &Quot;[All Fields]
AND " &Quot;[All Fields]) OR effects on Children of COVID-19 "
Psychological effects of COVID, Children "[All Fields]) OR
("COVID-19 and children "[MeSH Terms] OR "
Psychological effects of COVID-19, Children "[All Fields]. This search
strategy and terms were modified for other databases as appropriate. The
searches 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.
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 al., 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).

Impact on school and college going students

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 and 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.
Advisories of international organizations
With the objective of universal prevention and mental health promotion, the
International organizations and advisory bodies have issued various guidelines
taking into account the mental health needs of children during the COVID-19.
They have suggested parents to interact constructively with the children by
communicating with them about the current pandemic, according to their
maturity level and their ability to comprehend the crisis. Parents should plan
their children's tasks one at a time, involve them in various home activities,
educate them about following hygiene habits and social distancing, engage in
indoor play and creative activities. In addition to these activities, adolescents are
advised to be involved in household chores and understand their social
responsibilities (WHO, 2020b). Interventions supervised by adults can help them in
understanding their concerns. The activities of children and adolescents should
include more structure in home schooling activities. Children should be
encouraged to socialize with their friends and classmates through digital forums
under adult supervision (WHO, 2020a).
The advisory committees have also provided guidelines for managing children
with special needs and neurodevelopmental disorders (UNICEF, 2020a,
2020b; WHO, 2020a). The children prone to risk for trauma and heightened
anxiety. The children need early identification prompt management involving
the parents and experts to prevent long term mental health morbidity.