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date: 26 September 2022

Child Development, Major Disruptive Events—Public Health Implicationsfree

Child Development, Major Disruptive Events—Public Health Implicationsfree

  • Tracy VaillancourtTracy VaillancourtUniversity of Ottawa
  •  and Peter SzatmariPeter SzatmariUniversity of Toronto

Summary

The COVID-19 pandemic has upended nearly all the safeguarding systems in the lives of children and youth, such as family life, school, extracurricular activities, sports, unstructured social opportunities, health care, and church. With many of the typical promotive and protective factors disrupted all at once, and for so long, the mental health of children and youth has deteriorated in many areas, but not all, and for many children and youth, but not all. It is important to acknowledge, however, that the mental health of children and youth was in crisis before the pandemic, with 1 in 7 children and youth worldwide having a mental disorder. Given the continued decline in this area of health, children and youth may well be on the cusp of a “generational catastrophe” that could involve lasting harms if immediate action is not taken. Of particular concern are marginalized and vulnerable children and youth—they are the ones unduly enduring the brunt of this global crisis. Accordingly, child and youth mental health recovery must be prioritized, along with the reduction of inequity within and across countries. A commitment to public health strategies that never include harming children and youth as a tolerated side effect must also be made.

Subjects

  • Epidemiology
  • Global Health
  • Special Populations

Introduction

COVID-19 is not the first large-scale disruption that has threatened the lives of children and youth, nor will it be the last. Indeed, the scientific literature is replete with examples of how natural disasters (e.g., McFarlane, 1987; McFarlane & Van Hooff, 2009), wars (e.g., Freud & Burlington, 1943), terrorism attacks (e.g., Mullett-Hume et al., 2008), and even pandemics (e.g., HIV/AIDS; Andrews et al., 2006) have negatively impacted children and youth. This is not said to downplay the seriousness of the COVID-19 pandemic on child development but rather to highlight that we are not in the dark when it comes to understanding the effects of trauma and stress on risk and resiliency (see reviews by Bonanno, 2004; Bonanno et al., 2011; Cicchetti, 2010; Danese et al., 2020; Masten & Motti-Stefanidi, 2020; Masten & Narayan, 2012; Palamarchuk & Vaillancourt, 2021; Southwick et al., 2014).

It is known, for example, that risk is never equally shared among children and youth. Some children and youth will experience the current pandemic against a backdrop of trauma and individual vulnerability with few supports, while others will be protected because their environment is predictable, safe, supportive, and structured (Masten & Motti-Stefanidi, 2020). Age and developmental timing matter for outcomes in the context of hardship (Masten & Motti-Stefanidi, 2020; Masten et al., 2015; Yoshikawa et al., 2020). Changes in cognition, social-emotional development, and physical maturity interact with stressors to confer a mélange of vulnerability and resilience at a specific point in development. As one example, most younger children will be shielded from the overwhelming media coverage of COVID-19 and the anxiety such coverage can produce, while many older children will be immersed in social media, and thus bombarded with messages (and misinformation) that often depict the worst of the pandemic. This type of media framing will not only shape their knowledge about the pandemic, it will also influence their risk perception, as has been shown to be the case with other sensitive topics like mental illness stigma and cyber bullying (Corrigan et al., 2013; Moreno et al., 2019).

Studies from other disasters reveal there is a dose effect whereby “children who are exposed to more adverse events or more intense devastation, loss, or disruption show stronger reactions as do children who have past or ongoing histories of adversity” (Masten & Motti-Stefanidi, 2020, p. 100). Of note are studies demonstrating that greater exposure to death of family and friends or family separation are particularly troubling for children and youth (see Masten & Motti-Stefanidi, 2020; Masten & Narayan, 2012 for reviews). This is significant considering the number of deaths children and youth have faced during this pandemic, which is likely underestimated (Moriarty et al., 2021), and further challenged with the uncertainty of the future death toll with the Omicron variant. Aburto et al. (2021) quantified the life-expectancy losses of the COVID-19 pandemic across 29 countries and concluded that the pandemic “triggered significant mortality increases in 2020 of a magnitude not witnessed since World War II in Western Europe or the breakup of the Soviet Union in Eastern Europe” (p. 1). As of February 22, 2022, 5.89 million COVID-19 deaths were recorded worldwide, with the United States facing the largest total number of COVID-19 losses (World Health Organization [WHO], 2022). This leaves far too many children and youth parentally bereaved, with more to come. For example, a 17.5% to 20.2% increase in parental deaths due to COVID-19 was expected in the United States when modeled in the first year of the pandemic (Kidman et al., 2021). As of June 2021, 140,000 American children and youth had lost a caregiver to COVID-19 (Hillis et al., 2021). More recent numbers place this figure at over 167,000; that is, more than 1 out of 450 American children under the age of 18 “lost a parent or in-home caregiver to COVID-19” (Treglia et al., 2021, p. 7). Moreover, according to latest estimates, 5.2 million children and youth worldwide were orphaned or lost a caregiver to COVID-19 (Unwin et al., 2022). This type of loss is not equally shared, as is never the case. American children and youth of racial and ethnic minority groups, for example, have experienced the highest burden of COVID-19–associated death of parents and caregivers (i.e., four-times greater loss than White children and youth; Treglia et al., 2021).

Finally, children and youth are nested within multiple ecological systems (family, school, friends, church, local government and economy, culture, etc.; Bronfenbrenner, 1979), with far less autonomy than adults. This lack of independence makes them more exposed than adults to the dynamic process in which multiple systems interact outside of their control. In the case of COVID-19, the virus, and the response to it, has upended nearly all the safeguarding systems in the lives of children and youth such as family life, school, extracurricular activities, sports, unstructured social opportunities, health care, church, and so forth. Adults are also negatively impacted by these failing systems, which makes children and youth even more vulnerable.

There is a general belief that children and youth are inherently resilient. The concern is that the pandemic may be overwhelming the normal adaptive capacity of children and youth because so many of the typical promotive and protective factors have been disrupted, to varying degrees, all at once, and have been for so very long. For example, the capacity of parents and caregivers to provide support to children and youth has been tested during the pandemic (e.g., Babore et al., 2021; Roos et al., 2021; Wamser-Nanney et al., 2021). This is problematic because the evidence overwhelmingly supports the role of positive parenting as essential for the promotion of healthy child development (Baumrind, 1968, 1971; National Academies of Sciences, Engineering, and Medicine [NASEM], 2019; e.g., Bornstein et al., 2018; Whittle et al., 2017), especially in the context of risk or adversity (Masten & Palmer, 2019; Sandler et al., 2015). Parents and caregivers need to be at their best so that their children and youth can flourish (Luthar & Eisenberg, 2017; NASEM, 2019). This point is well illustrated by a study by Luthar et al. (2021), who found that the distress of American adolescents during the pandemic was uniquely associated with “feelings of stress around parents and support received from them” (p. 565). Many parents are not faring well during the pandemic, especially mothers with income disruptions, difficulties obtaining childcare, and problems balancing the demands of home school and work responsibilities (Racine, Hetherington, et al., 2021).

Schools have also played a central buffering effect for children and youth, providing young people with a sense of community and support (Vaillancourt, McDougall, et al., 2021; Vaillancourt, Szatmari et al., 2021). However, to date, over 90% of children and youth worldwide have experienced partial or full school closures during this pandemic (UNESCO, 2022). This is also concerning because, like positive parenting, this social infrastructure represents one of the most important protective factors for children and youth (Vaillancourt, McDougall, et al., 2021). As reviewed by Vaillancourt, McDougall, et al. (2021), schools not only afford opportunities for learning and engagement, but they also provide food and therapy for students in need, they are the first point of contact for mental health services and the most common setting for mental health support, and they keep children and youth safe because educators are the primary reporters of child abuse and neglect. Despite the important role schools play in resilience and recovery, many children and youth worldwide are still not in school, two years into the pandemic. UNESCO’s global monitoring of school closures caused by COVID-19 (2022) shows just how widespread the issue continues to be, especially for children and youth living in poorer countries with lower access to vaccines, personal protective equipment, rapid antigen tests, online or alternative learning options, and the like. Many have argued that “schools must be the first to open and the last to close” based on the idea that schools tend to be protective institutions for most children and youth (e.g., Vaillancourt, Szatmari, et al., 2021; Viner, Bonell, et al., 2022). According to Lewis et al. (2021), school closures were “not evidence based” given the widespread harms they caused children and youth. This point notwithstanding, the data emerging on school closures in relation to children’s mental health are equivocal, and thus, more studies are needed on this topic.

It is clear from this introduction that children and youth worldwide are facing many prolonged threats and challenges during the COVID-19 pandemic. Despite the negative impact of the pandemic on many facets of child development (see Vaillancourt, Beauchamp, et al., 2021 for review), the focus of this review is on the role of the pandemic on child and youth mental health.

Child and Youth Mental Health Pre-COVID-19

It is important to note that before COVID-19 was declared a global pandemic, mental disorders in children and youth were the leading cause of disability globally (Erskine et al., 2015), accounting for 13% of the total burden of disease (WHO, 2021) in this age group. In economically advanced countries like Canada, China, the United Kingdom, and the United States, the prevalence for mental disorders in children and youth was around 1 in 5 (Georgiades et al., 2019; Li et al., 2022; Perou et al., 2013; Sadler et al., 2017; Whitney & Peterson, 2019), and globally, the rate was 1 in 7 (Global Health Data Exchange, 2019). A meta-analysis of prevalence rates of mental disorders in children and adolescents that included 41 studies from 27 countries that represented every world region indicated a world prevalence rate of 13.4% (Polanczyk et al., 2015). Mental disorders in childhood and adolescence are not only common and cause significant distress and impairment, but they are also often chronic in nature and predict future difficulties (Lewinsohn et al., 1999; Ormel et al., 2015; Shevlin et al., 2017). For example, Krygsman and Vaillancourt (2022) found that children who followed an elevated trajectory of social anxiety symptoms from age 10 to age 18 were 20 times more likely to be depressed in adulthood and 16 times more likely to have social anxiety disorder and agoraphobia. This high level of continuity is problematic because, like in children and youth, mental health problems are the leading cause of disability worldwide in adults (Copeland et al., 2015; Whiteford et al., 2013).

Research Quality

Since COVID-19 was declared a global pandemic, there has been an urgent need to disseminate findings on its impact “so that appropriate steps can be taken to provide suitable services for those in need” (Vaillancourt, Brittain, Krygsman, Davis, et al., 2021, p. 10). Although important, the rapid pace of research on child and youth mental health has led to some confusion about the extent and direction of effects. For example, there is a disconnect between the “magnitude of psychological distress” reported by children and youth during the pandemic and the “frequency with which they have presented to the hospital” (Korczak et al., 2022). This data divide is likely driven, in part, by changes in the way mental health care has been delivered during the pandemic (e.g., virtually in many settings; Lantos et al., 2022; Saunders et al., 2022) and the timing of assessments (e.g., later assessments showing more impairment or symptoms than earlier assessments; Racine, McArthur, et al., 2021; Stewart et al., 2021). The discrepancies in findings are also likely due to several reoccurring issues that need to be considered when evaluating the evidence.

One, many of the studies on child and youth mental health have failed to distinguish symptoms from clinical diagnoses of mental disorders, and this lack of distinction has led to the erroneous assumption that clinical disorders have invariably increased during the pandemic. Two, many of the studies purporting to examine change have not been longitudinal in nature, precluding comments on intra-individual change. True change can be assessed only with repeated assessments that predate the pandemic and are, ideally, population based (Vaillancourt, Brittain, Krygsman, Davis, et al., 2021). Three, cross-sectional COVID-19 data have “often relied on retrospective recall approaches, which confound current mood states and experiences with the recall of past events” (Vaillancourt, Szatmari, et al., 2021, p. 1634). This approach can confuse perceptions of change with current stress, leading to false conclusions. Four, most analytic approaches have examined average change over time (variable-centered approach) and not change in subgroups (person-centered approach). Heterogeneity should always be expected (Cicchetti & Rogosch, 1996). For example, although, on average, the general mental health of children and youth has declined during the pandemic (Bussières et al., 2021), for some children and youth, their mental health improved. Cost et al. (2022) reported that while 67%–70% of children and youth experienced worsening mental health in at least one domain, 19%–31% of children and youth showed improvement in at least one domain. In this study, increased stress from being socially isolated was associated with poorer mental health across all domains assessed (ORs 11.12-55.24), suggesting the importance of examining mediators and moderators. Five, few studies have examined mechanisms and processes (i.e., mediators and moderators). Rather, most have focused on rates of change without consideration of why and how change has occurred, and for whom (Vaillancourt, Brittain, Krygsman, Davis, et al., 2021). Some common triggers of mental health problems in children and youth have improved during the pandemic, and thus, may have contributed to better outcomes. As one example of possible mediation, bullying victimization, a common cause of mental health problems in children and youth (Moore et al., 2017), decreased substantially during the pandemic (Bacher-Hicks et al., 2022; Vaillancourt, Brittain, Krygsman, Farrell, et al., 2021), and of moderation, adolescent girls seem to have been more adversely affected by the pandemic than adolescent boys (e.g., Saunders et al., 2022). Six, not all regions of the world have contributed to the understanding of mental health research at the same rate. For example, before the pandemic, Arab countries produced 1% of the global output on peer-reviewed mental health publications (Maalouf et al., 2019), and during the pandemic, few studies on this topic have emerged from this region. Hence, it is not clear how the pandemic has affected children and youth worldwide.

With this backdrop in mind, research interpretations in child and youth mental health need to be contextualized, and tolerance is needed for when new data emerge questioning current assumptions. These important caveats notwithstanding, the current state of knowledge on child and youth mental health is reviewed.

Child and Youth Mental Health During COVID-19

The resilience literature has revealed much about how children and youth thrive under seemingly unbearable conditions; it has also shown that the mental health of children and youth should not be ignored, given how sensitive this aspect of wellness is to being exposed to stressors. Although much has been written in the media and in academic opinion pieces about how COVID-19 has triggered a global mental health crisis, does empirical evidence support this assertion?

A meta-analysis of children aged 5 to 13 years representing 28 empirical studies with prospective or retrospective longitudinal data reported that the general mental health of children was negatively impacted, but the magnitude was small (g = 0.28, p < 0.001; Bussières et al., 2021). A population-based cross-sectional study of physician-based mental health service utilization in Canadian children and youth showed that at the beginning of the pandemic, outpatient care visits declined below what would be expected based on pre–COVID-19 utilization patterns (January 1, 2017–February 29, 2020), but by July 2020, rates increased above expected, and this growth continued to 10% to 15% above expected as of February 2021 (Saunders et al., 2022). Although these studies suggest a deterioration of mental health during the pandemic, the data are far more nuanced. For example, in the Saunders et al. (2022) study, emergency department (ED) visits for mental health issues decreased during the pandemic (see also Radhakrishnan et al., 2022).

Internalizing Problems

The bulk of studies on child and youth mental health during the pandemic have focused on internalizing problems like depression and anxiety disorders and symptoms of these disorders. A meta-analysis of 29 studies including 80,879 children and youth from around the world reported that 1 in 4 experienced clinically elevated depression symptoms during the pandemic and 1 in 5 experienced clinically elevated anxiety symptoms (Racine, McArthur, et al., 2021). In this meta-analysis, elevated symptoms were higher in studies collected later in the pandemic and in girls and lower quality studies produced higher estimates of impairment than better quality studies. In another meta-analysis that included 23 studies from China and Turkey that involved 57,927 children and youth, the pooled pandemic prevalence rates for depression and anxiety symptoms were 29% (95% CI: 17%, 40%) and 26% (95% CI: 16%, 35%), respectively (Ma et al., 2021). Placing these rates into context, pre-pandemic, the prevalence rate of depression was 12.5% in Turkish youth (Toros et al., 2004), and 2.5% for mood disorders and 16.7% for anxiety disorders in Turkish children (Ercan et al., 2019). In Chinese children and youth, the pooled prevalence for depressive symptoms was 19.8% (Rao et al., 2019) and the adjusted point prevalence for anxiety disorders was 4.7% (Li et al., 2022). Other large-scale studies of youth showed pre-pandemic prevalence rates of 12.9% for depression (Lu., 2019; American youth) and 11.6% for anxiety symptoms (Tiirikainen et al., 2019; Finnish youth). Population-based studies have also showed that the prevalence of depression has increased significantly since the turn of the 21st century (e.g., Lu, 2019; Weinberger et al., 2018). Thus, the higher pandemic rates obtained by Ma et al. (2021) may represent a continuation of this positive linear trend.

Longitudinal studies, the gold standard for assessing change in the absence of randomized control trials (Vaillancourt, Brittain, Krygsman, Davis, et al., 2021), pointed to increases in symptoms of anxiety, and especially depression, during the pandemic (Barendse et al., 2021; Bignardi et al., 2020; De France et al., 2021; Feinberg et al., 2022; Hafstad et al., 2021; Hawes et al., 2021; Magson et al., 2021; Rosen et al., 2021; Santa-Cruz et al., 2022; Thorisdottir et al., 2021; Zhang et al., 2020), although exceptions do exist (e.g., Bélanger et al., 2021; Bignardi et al., 2020 [anxiety]). A systematic review and meta-analysis of longitudinal cohort studies that compared the mental health of children and youth before versus during the COVID-19 pandemic in 2020 indicated that while anxiety and general mental health rates in the early months of the pandemic were comparable to rates before the pandemic, depression and mood disorder symptom increases were larger during the pandemic (standardized mean change May to July 2020 = 0.20, 95% CI: 0.099 to 0.302; Robinson et al., 2022). Moreover, among individuals with a preexisting mental health condition, a change in symptoms was not found, potentially reflecting a ceiling effect.

Eating Disorders

Eating disorders have increased dramatically during the pandemic. In Western Australia, a 104% increase in emergency department (ED) visits and admissions for children with anorexia nervosa was observed at the beginning of the pandemic compared with three previous years of data (Haripersad et al., 2021). In Canada, a higher number of new diagnoses and hospitalizations for anorexia nervosa in children and adolescents during the first COVID-19 wave was found compared to pre-pandemic rates (Agostino et al., 2021). Specifically, the increase was from 24.5 to 40.6 cases per month. Using Ontario health administrative databases, a 66% increase for ED visits and a 37% increase for hospitalization was detected for Canadian pediatric eating disorders (Toulany et al., 2021). In the United States, eating disorder admissions for children and youth more than doubled during the first year of the pandemic when compared to the same time frame (April 1 through March 31) for the three previous years (Otto et al., 2021). Data from the Centers for Disease Control and Prevention (CDC’s) Morbidity and Mortality Weekly Report indicated that weekly ED visits for adolescent girls aged 12 to 17 increased for eating disorders during 2020, 2021, and January 2022 (Radhakrishnan et al., 2022). In fact, eating disorders (and tics) increased at each assessment period with the proportion of visits doubling for ED (and tripling for tics). These increases are worrisome because anorexia nervosa has historically had the highest rate of mortality of all child and youth mental disorders (Harris & Barraclough, 1998), with excess death still very high when compared to the overall population (e.g., 5–7 times, Iwajomo et al., 2021; see also Arcelus et al., 2011; Smink et al., 2012).

Externalizing Problems

Most of the research on child and youth mental health has focused on internalizing problems, but externalizing problems need to also be considered in earnest, as they also account for a significant proportion of disease burden (Baranne & Falissard, 2018). Moulin et al. (2021) examined the symptoms of hyperactivity/inattention and emotional difficulties in a community sample of young French children using parent interviews during the fifth week of home confinement. A minority of children presented with symptoms of emotional difficulties (7.1%) and close to a quarter presented with symptoms of hyperactivity/inattention. Because the study is cross-sectional, it is unclear if these rates represent a change from baseline. In a Canadian study of parent-reported mental health symptoms and screen use during the pandemic, higher screen time was linked with higher symptoms of conduct problems in children (aged 2–4; β‎ = 0.22 [95% CI, 0.10–0.35] and aged ≥4 years: β‎ = 0.07 [95% CI, 0.02–0.11]; Marchetti et al., 2020). Symptoms of hyperactivity/inattention were also higher in children with higher screen time, but this effect was small (β‎, 0.07 [95% CI, 0.006–0.14]). In older children (> 11 years), higher TV/digital media time and video game time were associated with more symptoms of inattention and hyperactivity/inattention, respectively. In an Italian study examining parental distress in relation to child hyperactivity/inattention during the first COVID-19 lockdown, two pathways were supported—parent distress predicted child hyperactivity/inattention and parent verbal hostility and child emotional symptoms mediated the relation between parent distress and child hyperactivity/inattention. In a U.K. longitudinal study of parent-reported mental health symptoms in children assessed twice between March and May 2020, Waite et al. (2021) reported a 20% increase in hyperactivity/inattention and 35% increase in conduct problems in preadolescent children. In adolescents, these changes were much lower (4% for hyperactivity/inattention and 8% for conduct problems).

Rosen et al. (2021) examined the mental health of American children and youth by combining two longitudinal samples that included three assessments: before the pandemic, during stay-at-home orders, and six months later. Results indicated notable increases in internalizing (31.7% beginning of pandemic vs. 56.7% six months later) and externalizing symptoms (17.4% beginning of pandemic vs. 56.2% six months later). Controlling for pre-pandemic symptoms, age, sex, and income, more pandemic-related stressors early in the pandemic were associated with internalizing (β‎ = 0.24) and externalizing (β‎ = 0.29) symptoms later in the pandemic. In another American study, Feinberg et al. (2022) assessed the mental health of parents and their children using data collected before the pandemic (2017–2020) and during the pandemic (April 2020 to May 2020). Parent mental health deteriorated (d = 0.82) along with their child’s (d = 1.31 for internalizing and d = 1.59 externalizing problems). Finally, in a small longitudinal study from Chile, Santa-Cruz et al. (2022) assessed symptoms of internalizing and externalizing problems in children with a diagnosed health disability. Using parent reports, children were assessed twice in Kindergarten and Grade 1 (beginning and end of academic year in 2018 and 2019) and again in October of 2020, eight months after the beginning of the quarantine. Results indicated increases in internalizing (d = −0.48) and externalizing problems (d = −0.27) when comparing the K/Grade 1 rates to the COVID-19 rates.

The research on externalizing problems suggests increases during the pandemic, although more longitudinal studies are needed to determine the true change. Moreover, the bulk of studies on externalizing problems have relied on parent reports, which could confound their distress with the reporting of their child’s symptoms (e.g., Bennett et al., 2011).

Suicidality

Before the pandemic, suicide was the leading cause of death among youth in high income countries, accounting for 17.6% of all deaths (UNICEF, 2020). Worldwide, suicide was the fourth leading cause of death in adolescents (WHO, 2019). Since the pandemic, the data on suicidal thoughts and behavior have yielded mixed results. According to the CDC, ED visits for suspected suicide attempts began to increase in May 2020 among American adolescents aged 12–17 years (Yard et al., 2021). This was particularly true for adolescent girls, where suspected suicide attempts were 50.6% higher compared to the same period in 2019. For boys, the increase was 3.7%. However, in a cross-sectional study of suicide-related ED visits for American children and youth, ED visits initially decreased during the pandemic and then increased to similar 2019 levels (Ridout et al., 2021). There were some exceptions to this general trend, however. Suicide-related ED visits were higher during the pandemic for girls, for children and youth with no psychiatric history, and for children and youth with comorbid psychiatric conditions identified at the time of the ED encounter. In another American study examining routine suicide-risk screening during pediatric ED visits, rates of suicide ideation and attempts were higher for some months of 2020 when compared to 2019 rates “but were not universally higher” across the pandemic period (Hill et al., 2021, p. 1). In a French study examining the temporal trends in suicide attempts in children aged 15 or younger, Cousien et al. (2021) found a “dramatic increase” in suicides, attempts, and ideation after the start of the pandemic (late 2020 and early 2021). They also noted a decrease in suicide attempts in the early months of the pandemic, which they suggest could be due to difficulties in accessing care and greater parental monitoring. In contrast, a Canadian cohort study of adolescents and young adults examining ED visits or hospitalizations for self-harm or overdose reported a decrease in the initial 15-month period of the pandemic (Ray et al., 2022). A comparison of suicide attempts of Mexican adolescents one year before and after the pandemic began found similar rates in suicide attempts (Valdez-Santiago et al., 2022). In this nationally representative sample, girls, rural youth, and youth living with a family member who lost their job because of COVID-19 were more likely to have attempted suicide than their counterparts. Attending class online was associated with a lower rate of suicide attempts than not attending school, but this effect was small. Finally, assessing suicide risk in all patients aged 12 to 24 from a children’s hospital, Lantos et al. (2022) found that the “rate of positive suicide screens was higher in T2 than in T1,” but this difference was small in magnitude (e.g., 12.2% vs. 11.1%, adjusted odds ratio, 1.24; 95% confidence interval, 1.15–1.35).

Most of the data on child and youth suicidal behavior point to a decline in rates during the pandemic. It will be important to pinpoint the mechanisms for these reductions so that they can be used to inform future prevention efforts in this area. Examining group-based differences will be also important because variable-centered approaches like the ones used in the previously mentioned studies do not capture heterogeneity. For example, examining suicidal patterns among American youth using data from a national text-based crisis platform before and during COVID-19 yielded four latent classes: (a) depression/isolation/self-harm (10.4%), (b) interpersonal stress/mood-anxiety (18.2%), (c) suicidal thoughts/depressed (19.0%), and (d) adjustment/stress (52.4%; Runkle et al., 2022). During the pandemic, suicidal thoughts and active rescues increased in the depression/isolation/self-harm and suicidal thoughts/depressed subclasses, which was more pronounced in younger children and LGBTQ+ youth.

Assessing the Specific Impact of COVID-19 on Child and Youth Mental Health

One notable challenge in assessing the specific impact of COVID-19 on child and youth mental health is that risk factors tend to collate and operate in a context of intersectionality. That is, within the multiple ecological systems in which children and youth are developing, inequity and disadvantage interact with each other, and with other risk factors, to confer greater risk and poorer outcomes. In fact, there are a multitude of pathways leading to adaptive and maladaptive endpoints, and the relative impact of stressors, such as a pandemic, on adjustment will vary within the “system” alongside other conditions and attributes (Cicchetti & Rogosch, 1996). For example, pre-pandemic, children and youth who lived in poverty were more likely to experience mental health challenges than their more affluent peers (Guhn et al., 2020). But poverty intersects with other mental health risk factors like exposure to family violence, parental stress, parental psychopathology, employment loss, food insecurity, and loneliness (Achterberg et al., 2021; Berger, 2005; Bøe et al., 2013, 2018; McCloskey et al., 1995), which have increased during the pandemic (Katz et al., 2021; Lee et al., 2021; Rodriguez et al., 2021). Moreover, poverty also intersects with ethnicity and discrimination, which confer risks to children and youth, including the provision and benefit of evidence-based mental health treatment (Castro-Ramirez et al., 2021).

Although school closures undertaken to control the spread of COVID-19 have been experienced by most children and youth worldwide (UNESCO, 2022), their impact on the social, emotional, and academic development of children and youth has varied—some have flourished, but many have suffered. For those who have not fared well, the negative influence of school closures (Verlenden et al., 2021; Viner, Russell, et al., 2022) has been unfairly experienced by those who were already marginalized and vulnerable to begin with (Asbury et al., 2021; Engzell et al., 2021; Grewenig et al., 2021; Hawrilenko et al., 2021; see Tan, 2021 for review). School closure as a virus mitigation strategy has also had a negative impact on families (Rizeq et al., 2021), learning progress (Engzell et al., 2021), economies (Psacharopoulos et al., 2021), and perhaps even net mortality (Bayham & Fenichel, 2020), thus increasing vulnerability in children and adolescents and widening inequalities. For example, Yamamura and Tsustsui (2021) examined how school closures influenced the mental health of parents of school-aged children and found that for mothers who were less educated, and had younger children, their mental health was negatively affected (see also Racine, Hetherington, et al., 2021). They also found that the mental health of women improved after schools were reopened. The negative impact on fathers’ mental health was found only for highly educated men with young children. This small indirect effect is not trivial given the importance of maternal mental health for child health and development (Bornstein et al., 2018; Whittle et al., 2017). Indeed, the most consistent recommendation from evidence-based interventions to “maximize resilience in children and families” is the need to “support the well-being of primary caregivers—typically the mother” (NASEM, 2019, p. 237; see also Luthar & Eisenberg, 2017). As another example, virus mitigation strategies such as school closures may have contributed to decreased reporting of child maltreatment and neglect across the world (Katz et al., 2021). Because educators are the primary reporters of child abuse and neglect (Children’s Bureau, 2020), decreases in reporting should be expected, with potentially great effect. Child maltreatment and neglect are formidable threats to child development, impacting all aspects of their functioning (e.g., Negriff et al., 2020).

It is also important to comment on children and youth with developmental delays and disabilities and their unique risks during the pandemic. Many of these children have preexisting neurological or neurodevelopmental disabilities that influence cognitive and academic functioning. Before the pandemic, many children and youth required inclusive and special education services. When schools close, these services are not always available, and when available, are weakened by having to move to online delivery, thus placing children and youth at risk for learning loss (Whitley et al., 2021) and lower community participation. Children and youth with physical health conditions are also at greater risk during the pandemic than before the pandemic. In one study, larger declines in self-reported mental health were found in Canadian youth and young adults with physical health conditions compared to individuals without physical health conditions (Hawke et al., 2020). Among French children and youth with Autism Spectrum Disorder, COVID-19 containment and mitigation measures were found to have a negative impact on sleep and stereotyped behavior, although improvement in communication was observed for a third of children (Berard et al., 2021).

These examples are used to illustrate how risk factors are interwoven and tend to cluster and accumulate in children and youth (and their families) who are most in need. Although this has always been a consequence of major disruptive events, COVID-19 is unique in that all children and youth worldwide are under threat to varying degree, not just the most vulnerable. In fact, according to UNICEF (2021), “the COVID-19 pandemic has been the biggest threat to children in [its] 75-year history.”

Public Health Implications

Before COVID-19 was declared a global pandemic, the mental health of children and youth was in crisis (Global Health Data Exchange, 2019). With the post-pandemic excess of mental illness morbidity in children and youth, pre-pandemic service gaps (Durbin et al., 2015; Mental Health Commission of Canada, 2017; Merikangas et al., 2011) will need to be addressed promptly at a systems level. In this context, evidence-practice gaps also need to be addressed. Over 90% of children and youth live in low- to medium-income countries, yet the bulk of research on treatment for mental health disorders in children and youth occurs in high-income countries (Kieling et al., 2011). Prevention and intervention programs need to be more culturally sensitive than they have been.

According to the U.S. Surgeon General Advisory (2021), “supporting the mental health of children and youth will require a whole-of-society effort to address longstanding challenges, strengthen the resilience of young people, support their families and communities, and mitigate the pandemic’s mental health impacts.” Toward this aim, one of their core recommendations is to ensure that all children and youth have access to “high-quality, affordable, and culturally competent mental health care.” Although laudable, a pandemic recovery requires a commitment from governments to publicly fund evidence-based mental health services that include targeted screening among high-risk groups, and diagnosis and treatment services that are delivered in environments where children and youth can access them easily, like in schools, in the community, and in primary health care settings (Vaillancourt, Szatmari, et al., 2021). In these settings, meeting the needs of under-resourced and vulnerable populations must be prioritized. These systems should also be flexible enough to meet the challenges of recurrent pandemics in the future. Furthermore, because resilience in children is contingent on the caregivers in their lives being healthy (NASEM, 2019), it is important that resources be devoted to evidence-based efficacious programs that can help parents and caregivers recover as well.

All countries should develop (or adopt) a national child and youth mental health strategy that includes a comprehensive plan for future pandemics (Vaillancourt, Szatmari, et al., 2021). Most countries had pandemic preparedness planning guidelines (e.g., Henry, 2018) and yet, were still ill-prepared for the COVID-19 pandemic. Pandemic planning guidelines must include evidence-based mental health strategies that include the views and values of all relevant stakeholders, including parents, those with lived experience (i.e., children and youth), mental health care providers, educators, researchers, and decision makers. This strategy must also include knowledge translation and capacity building for parents and others working with children and youth so they can better identify and respond to those who are at risk and better assess the quality and veracity of information they are receiving. Pandemic mitigation strategies should not only be economic, they must also consider strategies to mitigate the mental health impact on families, children, and youth. Finally, because we are a global community, and inequity undermines resilience, inequity needs to be addressed within and across countries. According to UNICEF (2021), an “unequal recovery from COVID-19 to further marginalize the disadvantaged and increase inequality even more” cannot be allowed. For example, low-income countries do not have the resources to vaccinate large portions of the population, and, as a result, they become potential “hot spots” for the generation of new variants that can have global effects.

Key Evidence Gaps

Moving forward, key evidence gaps that undermine the response to this pandemic (and future pandemics) and its impact on child and youth development need to be addressed. The research on mental health and COVID-19 has been reactive, and, as such, very little of it has provided a platform to rapidly collect data once the pandemic started. In addition, much of the research has focused on changes in prevalence rates among either the general population or specific subgroups. This assessment of change was often estimated retrospectively, or using cross-sectional designs, precluding the evaluation of true intra-individual change (see Vaillancourt, Brittain, Krygsman, Davis, et al., 2021 for a discussion). Research is also needed to (a) better understand individual variation in risk for poor mental health outcomes among different subgroups of the population, (b) assess the impact of different public health strategies on infection rates and mental health simultaneously, and (c) compare different types of online or hybrid learning models on mental health outcomes across different populations. Because vaccination is so important, and because children often need parental consent to be inoculated, a better understanding of vaccine hesitancy and interventions that can address this public health danger is needed. Finally, because there is little understanding of the risk, presentation, and treatment of long-COVID syndrome among children and youth, research is needed on this important topic.

In sum, population-level, longitudinal mental health data are needed to be better prepared in the future and so that the allocation of resources can be better targeted (Vaillancourt, Szatmari, et al., 2021). Population monitoring will require better planning capacity and timely data collection so new pandemic threats can be responded to rapidly and so that the responses are evidence-based. The pandemic has highlighted the importance of longitudinal studies on children and youth; this design affords the collection of data before, during, and after disruptive events, which are needed for planning and recovery. Keeping ongoing tabs on child and youth development, including mental health, should be common practice in all countries.

Conclusion

This review points to a complex decline in child and youth mental health during the pandemic, an established area of crisis before the pandemic. The current situation was deemed so dire that the American Academy of Pediatrics (2021) declared a national emergency in child and adolescent mental health, stating that the worsening crisis is “inextricably tied to the stress brought on by COVID-19 and the ongoing struggle for racial justice and represents an acceleration of trends observed prior to 2020.” Because we have relied so heavily on the resilience of children and youth, we may well be on the cusp of a “generational catastrophe” (UNESCO, 2022) that may take generations to recover from.

During disruptive major events like the COVID-19 pandemic, the health, education, and protection needs of children and youth must be the main concern of all nations. Our collective future depends on the wellbeing of our most vulnerable—children and youth. Accordingly, we must act now and swiftly. We cannot, in good conscience, continue to ignore the emerging evidence of who has been harmed, nor can we disregard that the needs of children and youth will very likely outlast COVID-19.

Acknowledgments

The authors declare no known conflicts of interest. This work was supported by Canadian Institutes of Health Research Canada Research Chairs Program.

Further Reading

  • Korczak, D. J., Madigan, S., & Vaillancourt, T. (2022). Data divide: Disentangling the role of the COVID-19 pandemic on child mental health and well-being. JAMA Pediatrics.

This commentary provides important insight into why discrepancies may exist between studies examining the impact of the pandemic on child and youth mental health.

This study highlights the importance of addressing the mental health of children and youth during the pandemic, as well as the need to attend to their caregivers at home and at school.

This meta-analysis examines the global prevalence of internalizing symptoms (depression and anxiety) in children and adolescents during the pandemic.

This review highlights important recommendations for addressing the increase in mental health problems in children and youth, with applications that can be used worldwide.

This systematic review of 36 studies from 11 countries involving 79,781 children and adolescents and 18,028 parents examined the role of school closures during the first wave of the COVID-19 pandemic on children and youth. Results indicated that there was a negative impact on the mental health symptoms and health behavior of children and youth.

References