Mental Health of Children and Adolescents Amidst COVID-19 and Past Pandemics: A Rapid Systematic Review

Working with a research librarian from the University of Alberta, we searched MEDLINE, EMBASE, Web of Science Index Medicus, CINAHL, Lilacs, CENTRAL (Cochrane Library), eLENA (WHO), and the WHO COVID-19 databases. Nonindexed databases, including Google Scholar, and the preprint databases MedRxiv [14] and ChinaXiv [15] were also searched. To identify missing papers, bibliographies of all included studies and all relevant systematic reviews were hand-searched. Restrictions on language and date were not utilized. Search results were uploaded to COVIDENCE following the removal of duplicates (see Supplementary Material File S1 for detailed search strategy).

Studies were included if they were conducted on school-age children and adolescents (5 to 19 years) in low-middle and high income countries. Studies that involved broader age groups were included provided that they had subgroup data for 5- to 19-year-olds. Studies were excluded if participants specifically involved children and adolescents with mental health diseases, those who are homeless, and those with substance abuse issues.

Studies on recent COVID‑19 and past pandemics were included (e.g., Severe Acute Respiratory Syndrome Coronavirus, H1N1 influenza, equine influenza, Ebola, Middle East Respiratory Syndrome-Related Coronavirus). Additionally, studies were included focusing on interventions delivered to school-age children, adolescents, and their families to improve their mental health.

The primary outcomes include anxiety and depression, and the secondary outcomes include fear of infection, frustration, boredom, fear of pandemic-related uncertainty, fear of running out of basic supplies, and finances. Knowledge gaps were identified, along with the applicability of the findings of the current pandemic to improve the mental health of school-aged children and adolescents.

Articles were included if the study exclusively examined the impact of COVID-19 and past pandemics/epidemics on children’s and adolescents’ mental health. Detailed inclusion and exclusion criteria are shown in Table 1. Using Covidence, a Web-based tool that helps to identify studies and involves data-extraction processes [16], two reviewers (NP and SM) independently screened all potential articles. In case of disagreement, both reviewers read the paper and discussed it until a consensus was reached. Following, independent screening of the full texts of eligible articles was conducted and papers that satisfied all of the following inclusion criteria were included in this review.

Relevant data were extracted from each study, including the year and country of publication, the study design, the target population, pandemic exposure, interventions, and the outcomes that the researchers measured (see Table 2). One reviewer (NP) used a form that the research team had developed to extract data. A second reviewer (SM) verified all of the data extraction and checked for accuracy and completeness. Disagreements were resolved through discussion.

The methodological quality of the studies was assessed by using the Mixed Methods Appraisal Tool. It appraises the methodological quality of five categories of studies: qualitative research, randomized controlled trials, nonrandomized studies, quantitative descriptive studies, and mixed-methods studies [35].

A tailored approach to synthesis the data was employed, using an evidence table to report the key components of each study (Table 2). Data were aggregated and analyzed according to the study’s outcomes and objectives. Descriptive (narrative) analyses of the included studies were conducted. Due to the heterogeneity of the papers, such as in the study design, the type of pandemic, the age groups of the participants, and the reported outcomes, conducting a meta-analysis was not possible. Therefore, findings were synthesized according to the type of pandemic, the reported outcomes, and the study design.

Characteristics of the included studies are shown in Table 1. The included studies were conducted in four different pandemic/epidemic periods globally: Ebola (n = 3) [17,18,19], Equine Influenza (n = 1) [20], H1N1 (n = 1) [21], and COVID‑19 (n = 13) [22,23,24,25,26,27,28,29,30,31,32,33,34]. Most of the studies (n = 14) were cross-sectional [20,22,23,24,25,26,27,28,29,30,31,32,33,34], two were interventional [17,19], one was qualitative [18], and one was a mixed-method [21] study. The population age range varied between 5 and 19 years, inducing both boys and girls. The majority of the COVID‑19 studies (n = 9) were conducted in China [18,20,21,23,24,26,27,28,29,31,32,33,34] and the remaining four in Canada [25], India [30], Italy [22], and the United States [29]. The study on the Ebola pandemic was conducted in West Africa, the H1N1 epidemic study was conducted in the United States and Canada, and the study on equine influenza was conducted in Australia. The sample sizes ranged from 22 to 8079 subjects (mean = 1238) in the quantitative and intervention studies.

We assessed the methodological quality of the quantitative and qualitative articles by using the Mixed-Method Appraisal Tool. The qualitative researchers comprehensively discussed their methodologies, including the data-collection methods: the findings from the data were adequate, their interpretation of the results was sufficient, and data sources, collection, analysis, and interpretation were coherent [18]. We divided the studies that involved mixed methods into two components: qualitative and quantitative [21]. The qualitative researchers discussed their data collection and analysis method; however, the results were not transparent [17,22]. In contrast, intervention studies reported the representativeness of the data confounders, type of interventions, and outcomes [18,35]. On the whole, the mixed-method studies did not discuss in depth their interpretation of the data and failed to identify discrepancies [21]. The cross-sectional studies included some in which the researchers did not explicitly identify their inclusion and exclusion criteria [22,23]. Buzzi et al. (2020) did not test the reliability and validity of their instruments, and some researchers did not take into consideration other variables, inclusive of the confounders [26,31,32,34]. The included studies also demonstrated selection bias [29,31] and gender and demographic bias, which limited the generalizability of the findings [20]. In the interventional studies, the number of people who dropped out of research was fairly high, and required information on the compliance with the intervention was missing [17,19].

Sixteen of the 18 studies examined the impact of the pandemic on children’s and adolescents’ mental health [18,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34]. The majority of the researchers of the studies (n = 13) administered cross-sectional online surveys to evaluate the impact of the COVID-19 pandemic on children’s and adolescents’ mental health. In their cross-sectional survey, Taylor et al. (2008) evaluated the factors that influenced psychological distress during the equine influenza [20]. Sprang and Silman (2013) used a mixed-method design to investigate children’s psychosocial responses to the H1N1 pandemic, and in their qualitative study [21], Denis-Ramirez et al. (2017) explored the psychosocial impact of the Ebola epidemic in the daily lives of children in low-resource communities [18]. The most-reported outcome in these studies was the negative impact of a pandemic/epidemic on psychological health, which the researchers measured as anxiety, depression, fear, stigma, and posttraumatic stress symptoms. These studies reported that pandemics cause stress, worry, helplessness, and social and risky behavioral problems among children and adolescents (e.g., substance abuse, suicide, relationship issues, academic issues, absenteeism from work). Studies on the COVID‑19 pandemic reported that the current pandemic has significantly affected the emotional and behavioral experience of children and adolescents [22,23,24,25,26,27,28,29,30,31,32,33,34]. Depression and anxiety were higher among children and adolescents in other pandemics, and specifically COVID‑19 [22,23,24,25,26,27,28,29,30,31,32,33,34]. The researchers also reported that age, gender, knowledge about COVID‑19, degree of worry about epidemiological infection, and confidence about overcoming the outbreak significantly influenced the participants’ psychological status [28]. Studies also reported that female adolescents showed higher depression and anxiety levels during COVID‑19 than male adolescents did [23,24,25,32,33].

Studies (n = 4) also reported that the anxiety levels among the adolescent population were significantly higher than those in children [23,27,28,33]. In addition, adolescents in senior high school had the greatest depressive and anxiety symptoms [20,23,27,33], Liang et al.’s (2020) cross-sectional survey showed that the mental health of adolescents and youths is significantly related to being less educated (OR: = 8.71, 95%, CI: 1.97–38.43), the use of negative coping styles (OR: = 1.03, 95%, CI: 1.00–1.07), suffering from posttraumatic stress disorder (OR: = 1.05, 95%, CI: 1.03–1.07), and working as an employee (OR: = 2.36, 95%, CI: 1.09–5.09). Wang et al. (2020) reported that physical symptoms (myalgia and dizziness) and low evaluation of self-health status have a great impact on psychological well-being during the COVID‑19 pandemic, with a p-value of <0.05 [32]. Tian et al. (2020) included 1060 respondents, of whom more than 70% displayed moderate to high levels of psychological suffering such as phobic anxiety, obsessive-compulsive disorder, interpersonal sensitivity, and psychoticism [31]. Taylor et al. (2008) revealed that those who were living in red zones, which were highly infectious zones during the equine influenza (OR: = 2.00; 95%, CI: 1.57–2.55), and the amber or buffer zones (OR: = 1.83; 95% CI: 1.36–2.46) were more prone to psychological distress than those who lived in white zones, which were unaffected [20].

Seven studies reported that lifestyle transformation such as school closure, physical distancing, quarantine, isolation, and the threat of being infected is associated with depression and anxiety disorders among children and adolescents [18,21,24,25,29,30,34]. The psychological distress of fear, helplessness, worry, anxiety-related insomnia, isolation, boredom, and sadness was more common in the quarantine group [30]. These findings indicate that pandemic disasters, the subsequent disease-control measures, and containment responses can create conditions that families and children find traumatic. Sprang and Silman (2013) measures posttraumatic stress disorder using Posttraumatic Stress Disorder Reaction Index (PTSD-RI), and the PTSD Check List among children who experienced social distancing measures during the H1N1 pandemic [21]. The study found posttraumatic stress disorder in up to 30% of the children who were quarantined compared to those who had not been in isolation or quarantine during the H1N1 pandemic (1.1%; x² = 49.56, p < 0.001) [21].

Ellis et al. (2020) used a regression model to interpret their findings and revealed that depression in female adolescents was significantly higher (β 0.15, p < 0.001) and that loneliness was also significantly more prevalent in female adolescents (β 0.08, p < 0.001) [25]. Researchers also reported that during the epidemic children and adolescents have spent more time online or on social media than they did before the crisis [24,25]. Ellis et al. found that the association between COVID‑19 stress and depression was strongest among adolescents who reported the highest social media use after the pandemic (β 0.96, p < 0.001) compared to adolescents with lower and average use [25]. The respondents in Ellis et al.’s (2020) and Duan et al.’s (2020) studies reported that adolescents spent 5–10 h per day online, which is a potential risk factor for addiction to the Internet or smartphone [24,25]. Duan et al. (2020) noted that smartphone addiction (OR 1.41, 95% CI: 1.10–1.18) and Internet addiction (OR 1.84, 95% CI: 1.21–2.81) are significantly associated with clinical depressive symptoms among children and adolescents [24].

In their qualitative study, Denis-Ramirez et al. (2017) reported the psychological impact of stigma in children who were orphaned because of the Ebola epidemic: They were excluded from social interactions because of their association with Ebola. The prevailing fear and stigma of Ebola undermined the willingness of community members to help orphaned children, and it had severe psychological repercussions for children orphaned by Ebola. Many of the children who participated in the study depicted orphaned children as ostracized, discriminated against, and labeled as “Ebola children.” The psychological effects of the stigma include the feeling of being alone, frustration, worry or sadness, rejection, and exclusion by family, friends, and communities [18].

We found only two studies on interventions to promote the mental health of children and adolescents during previous epidemics [17,19]. Decosimo et al. (2019) implemented a community psychosocial program with the aim of improving the mental health capacity of children aged 3–18 years during the Ebola epidemic [17]. The children received the interventions in settings where childhood trauma was prevalent. These interventions included expressive-art therapies, yoga therapy, and play therapy to help children to build healthy relationships, teach them child-specific trauma-coping skills, and build a safe space for children to express themselves. Of the 40 chosen sites, the children at 24 received a five-month intervention (Treatment Group 1), whereas at the remaining 16 sites they received three months of intervention (Treatment Group 2). Decosimo et al. (2019) found a statistically significant difference in the mean scores of 0.06 in treatment group 1 and 0.11 in treatment group 2, with a p-value of <0.001 pre- and postintervention. They also found a significant difference in the psychological stress symptoms over time before and after the children received the intervention. The findings indicate that the longer programming did not differ statistically from the shorter programming [17].

Kamara et al. (2017) focused on the mental health of children and adolescents aged 0–17 years during the Ebola virus epidemic in Sierra Leone, when the psychiatric hospital was closed to admissions to prevent disease transmission [19]. To provide mental health services in Sierra Leone, Kamara et al. (2017) established a nurse-led mental health and psychosocial support service at one of the largest government hospitals in the country, which had approximately 300 beds. To equip the nurses to provide mental health services, the WHO, CBM International, and local partners gave them psychological first-aid training focused on supporting those affected by the Ebola virus disease. These nurses prescribed medications in collaboration with physicians, and the children received counseling and a problem-solving approach to deal with their psychological suffering. The most commonly diagnosed mental health problems among the children and adolescents included distress, anxiety, depression, grief, and other social problems. Kamara et al. (2017) found that training nurses to manage mental health issues is an effective measure to strengthen the local capacity [19].

While this rapid review was rigorous and applied a criterion for bias that allowed the evaluation of the methodology of the studies, there are limitations. Due to the short period of data collection there is a possibility of missing studies relevant to the mental health care of children and adolescents. Moreover, there is the possibility of publication bias i.e., only significant findings being published. One of the difficulties in comparing the studies in this review was the heterogeneity in the outcome measures. Therefore, we were not able to conduct meta-analyses. Moreover, the majority of the studies included in the review were based on online self-reports. The cross-sectional studies are useful in understanding the immediate or short-term impact apparent at a certain point of time. However, the limitations of these cross-sectional studies are that these studies cannot reach a conclusion about the long-term impact of pandemics. It is important to note that this rapid review could not prospectively examine changes in mental health outcomes as a result of this pandemic. Therefore, long-term impacts of the COVID-19 pandemic and elevated rates of mental health symptoms due to the pandemic could not be concluded in our study findings.

Our findings illustrate that pandemic or crisis situations could be associated with subsequent mental health problems in young people. With the objective of universal prevention and mental health promotion, it is important that children and adolescents should be informed about the pandemic situations. With the aim to increase children’s awareness about pandemics, it is crucial for parents, teachers and healthcare providers to communicate with young children in an age appropriate manner by using simple terminologies about COVID-19. Children need to be given fact-based information with the help of presentations and video material provided by authorized international organizations like WHO and UNICEF or government resources which have been tailor made especially for children. Adolescents are expected to have better knowledge about COVID 19 compared to young children. Therefore, communication has to be more open and non-directive with them.

Most of the adverse effects come from the school closure, isolation, limited physical activities, social distancing, and imposition of a restriction of liberty. Efforts should be made so that a consistent routine is followed by the child and adolescents during school closure, with enough opportunities to play, read, rest, and engage in physical activity. It is recommended that families play board games and engage in indoor sports activities with their children to avoid longer durations of video games. Parents should ensure that particularly the bedtime of a child is consistent. 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 indoor activities and games are to be encouraged. There is also a need for evidence based elaborative strategies and a plan of action to cater to the mental health needs of children and adolescents during the period of pandemic.

Teachers have a role to play in the promotion of mental health among students. They can discuss what wellbeing is 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. There is a need to enhance children’s and adolescents’ access to mental health services by using both face to face as well as digital platforms. There is a need for more virtual mental well-being programs in order to mitigate significant COVID-19 related mental health crises in children and adolescents for the duration of the current crisis and beyond. Finally, there is a pressing need for carrying out longitudinal and developmental studies to be able to apprehend multiple layers of dynamic determinants playing a role during this time of global crisis.

All data generated or analyzed during this study are included in this published article.