Understanding why the COVID-19 pandemic-related lockdown increases mental health difficulties in vulnerable young children

An exploratory cross-cultural study of community-based health literacy interventions to promote the mental well-being of disadvantaged and disabled young Africans: a multi-method approach

Background

This study explores the impact of community-based health literacy interventions on the health and mental well-being of disadvantaged young Africans in Zambia, Sierra Leone, Rwanda, and South Africa. The pandemic has exacerbated mental health problems amongst children and young people, underscoring the urgent need for equitable access to mental healthcare resources. Emphasizing the importance of equitable access to mental healthcare resources, the research addresses educational and income disparities in low- and middle-income countries (LMICs), particularly amongst young Africans with disabilities or vulnerabilities.

Methods

The study comprised 1,624 young Africans, of whom 1,592 were surveyed, while 191 later participated in in-depth interviews and focus groups. Additionally, 32 participants exclusively joined focus groups. Participants were recruited to complete the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS), WHO-5 Well-being Index, Pandemic Anxiety Scale (PAS), and Self-rating of Happiness, as well as semi-structured interviews or focus groups.

Results

The findings highlight the significance of tailored health literacy interventions in addressing mental health challenges and promoting well-being in marginalized African communities. In the sample, 43.1% (686) reported to have at least a physical disability or serious health condition and 51.4% (818) had special educational needs (SENs). Mental health scores were significantly lower in participants with two or more physical disabilities and pre-existing mental health problems. Factors significantly associated with poor mental health included poor health literacy, physical disabilities, and pre-existing mental health problems. Four main themes were generated from the thematic analysis: early childhood trajectories and mental illness experiences; positionality, open communication, and mental illness experience; mental illness experience, emotional honesty, and social stratification; and spirituality, cultural beliefs, and mental illness experience.

Conclusion

The study emphasizes the need for context-specific, culturally appropriate health literacy interventions to support the mental health and well-being of young Africans in LMICs. By focusing on the lived experiences of disadvantaged groups, the research contributes to a better understanding of effective strategies for promoting health literacy and addressing health inequalities in African communities during and after health emergencies.

Impact of COVID-19 on referrals to paediatric liaison psychiatry at Children's Health Ireland at Crumlin as the pandemic moved to endemic status

BACKGROUND

Rates of acute mental health presentations in youth were increasing pre-pandemic internationally. Longitudinal studies following COVID-19 attest to ongoing deterioration in youth mental health, recognising adverse unintended consequences following public health restrictions.

AIMS

To examine whether the initial post-COVID-19 increase in mental health presentations persisted following the reclassification of COVID-19 to endemic status, accompanied by the removal of most restrictions.

METHOD

All referrals to paediatric liaison psychiatry (PLP) between January 2018 and December 2022 in a Dublin tertiary children's hospital were included in the study. An interrupted time series analysis with autoregressive integrated moving average models was conducted, examining referrals with respect to different phases of COVID-19 and application of public health restrictions.

RESULTS

Some 1385 referrals to PLP were received over the 5-year study. There was a significant decrease in PLP referrals immediately post-COVID-19, followed by a significant and sustained increase as the pandemic progressed and moved to endemic status. Public health restriction phases had a unique effect on those presenting with suicidal ideation, with a significant increase in the number of referrals. There was no effect of restrictions on other clinical profiles.

CONCLUSIONS

Increased referrals for youth with mental health difficulties, reported during the COVID-19 pandemic, persisted into the early endemic stage, after COVID-19 public health restrictions ceased. Specific impacts of restrictions on suicidal ideation referrals require further study. Investment in child and adolescent mental health services remains a priority, and future pandemic response strategies need to examine unintended consequences of any enforced public health measure.

The trajectory of depression and anxiety among children and adolescents over two years of the COVID-19 pandemic

Longitudinal research examining children's mental health (MH) over the course of the COVID-19 pandemic is scarce. We examined trajectories of depression and anxiety over two pandemic years among children with and without MH disorders. Parents and children 2-18 years completed surveys at seven timepoints (April 2020 to June 2022). Parents completed validated measures of depression and anxiety for children 8-18 years, and validated measures of emotional/behavioural symptoms for children 2-7 years old; children ≥10 years completed validated measures of depression and anxiety. Latent growth curve analysis determined depression and anxiety trajectories, accounting for demographics, child and parent MH. Data were available on 1315 unique children (1259 parent-reports; 550 child-reports). Trajectories were stable across the study period, however individual variation in trajectories was statistically significant. Of included covariates, only initial symptom level predicted symptom trajectories. Among participants with pre-COVID data, a significant increase in depression symptoms relative to pre-pandemic levels was observed; children and adolescents experienced elevated and sustained levels of depression and anxiety during the two-year period. Findings have direct policy implications in the prioritization and of maintenance of educational, recreational, and social activities with added MH supports in the face of future events.

How do new crises impact HIV risk behaviour - exploring HIV risk behaviour according to COVID-19-related orphanhood status in South Africa?

The COVID-19 pandemic resulted in high death rates globally, and over 10.5 million children lost a parent or primary caregiver. Because HIV-related orphanhood has been associated with elevated HIV risk, we sought to examine HIV risk in children affected by COVID-19 orphanhood. Four hundred and twenty-one children and adolescents were interviewed, measuring seven HIV risk behaviours: condom use, age-disparate sex, transactional sex, multiple partners, sex associated with drugs/alcohol, mental health and social risks. Approximately 50% (211/421) experienced orphanhood due to COVID-19, 4.8% (20/421) reported living in an HIV-affected household, and 48.2% (203/421) did not know the HIV status of their household. The mean age of the sample was 12.7 years (SD:2.30), of whom 1.2% (5/421) were living with HIV. Eighty percent (337/421) reported at least one HIV risk behaviour. HIV sexual risk behaviours were more common among children living in HIV-affected households compared to those not living in HIV-affected households and those with unknown household status (35.0% vs. 13.6% vs.10.8%, X2 = 9.25, p = 0.01). Children living in HIV-affected households had poorer mental health and elevated substance use (70.0% vs. 48.5%, X2 = 6.21, p = 0.05; 35.0% vs. 19.9%, X2 = 4.02, p = 0.1306, respectively). HIV-affected households may require specific interventions to support the health and well-being of children and adolescents.

2-Year-olds' free play during the COVID-19 pandemic

Free play is a natural activity in toddlerhood, depending on environmental conditions like available objects and the social environment. The COVID-19 pandemic and its consequences for parents' mental health held the potential to change toddlers' play environment. This cross-sectional study investigated 2-year-olds' (N = 97) free play with objects, and aspects of caregiver mental well-being in three cohorts during the pandemic in Germany. Caregivers reported their positive mental health (PMH), threat perception, perception of current family situation from negative to positive, and workload. We categorized toddlers' behavior in free play sessions in their homes with a fixed set of objects through behavioral coding. Play behavior did not differ between cohorts and did not correlate with caregivers' positive mental health, threat perception, and perception of family situation. A MANOVA revealed a significant main effect of cohort on PMH, threat perception and perception of family situation, qualified by two discriminant functions. Full sample analyses revealed that toddlers of caregivers perceiving a workload increase compared to the time before the pandemic showed less pretend play, and less functional and nonfunctional play. The results provide insights into 2-year-olds' play behavior during a global pandemic and highlight the role of caregiver availability for children's play.

Mental Health Impact of Pandemics and Other Public Health Emergencies in Children

Pediatric health care providers can provide universal support to children and families to mitigate potential risk factors to adjustment while fostering protective factors to promote resiliency in children and families. They can educate caregivers about ways to enhance recovery of their children by modifying expectations and addressing the special emotional and social needs of their children. Most public health emergencies evolve through stages across an extended time period, often taxing the personal resources of health care providers. This underscores the need for pediatric health care providers to integrate self-care strategies in their personal and professional practice routines.

Commentary: Health anxiety in youth during 'COVID' - some thoughts prompted by Rask et al. (2024)

Researchers continue to count the short- and longer-term mental health costs for children and adolescents of the COVID-19 pandemic and the associated exceptional restrictions imposed by governments on their lives in an attempt to control the pandemic and its impacts. Despite being at low risk of serious physical illness from COVID-19 themselves, some studies have reported a decline in the mental health of many young people during the pandemic. Some have suggested that this could even create a risk for long-term morbidity. In this commentary, we reflect on the excellent article by Rask and colleagues on paediatric health anxiety and consider key research gaps for the field in general and for the specific challenges and questions posed by the COVID-19 pandemic and its legacy.

Association between Family Functioning, Child Emotional and Behavioral Problems, and Parental Stress during the COVID-19 Pandemic in Thailand

The COVID-19 pandemic has had a huge impact on people of all ages, especially children. This is a cross-sectional study in Thailand to explore the emotional and behavioral problems of school-aged children and associated factors during the lockdown. An online survey was conducted with 942 parents of school-age children. Strengths and Difficulties Questionnaire (SDQ) scores showed that total difficulties and all subscale difficulties (hyperactivity, conduct problems, peer problems, and emotional problems) were increased, whereas prosocial behaviors were decreased in the pandemic period. The factors significantly associated with higher parental stress were higher emotional and peer problems after the COVID-19 outbreak, high family difficulty, and sleep problems. Sleep problems were associated with all children's difficulties, except prosocial behavior. High score in family difficulty subscale was associated with increased emotional problems, whereas poor family communication was associated with increased hyperactivity. Appetite change was negatively associated with parental stress and some children's difficulties. Higher household income, family time, physical activities, and recreational activities were associated with a decreased level of some difficulties and family functioning problems, but positively with an increase in the prosocial behavior of children. Additionally, higher screen time was associated with a higher level of hyperactivity, conduct problems, and poor family communication. This study demonstrated that Thai children were at high risk of developing mental health problems during the pandemic lockdown. We suggest that intervention to promote physical activities and reduce screen time is needed. Moreover, efficient monetary policy is urgently required. The limitations here include a recall bias with no baseline to compare and a potential selection bias due to parental selection and a webpage announcement.

Mental health and lifestyle behavior changes during COVID-19 among families living in poverty: A descriptive phenomenological study

PROBLEM

Families living in poverty may be particularly vulnerable to the deleterious effects of the coronavirus disease (COVID-19). The current study focuses on caregivers of preschoolers aged 3-5 years old who lived in poverty to explore how COVID-19 affected mental health and lifestyle behaviors and what coping strategies were helpful for dealing with challenges induced by COVID-19.

METHODS

A qualitative study was conducted using individual semi-structured interviews with 17 caregivers.

FINDINGS

Both caregivers and preschoolers experienced high levels of stress, anxiety, and depression and reported unhealthy eating habits and excessive screen time. Physical activity increased in preschoolers, but declined among caregivers during COVID-19. Caregivers' coping strategies included taking short walks, seeking professional and social support, and praying; avoidant caregiver coping strategies including eating when stressed and increased screen time.

CONCLUSIONS

Future interventions are warranted to empower caregivers who live in poverty with the skills needed to maintain optimal physical and mental health, as well as assisting them to cope with challenges that may continue post-COVID-19.

Using the Whole School, Whole Community, Whole Child Model to Support Mental Health in Schools

The COVID-19 pandemic increased already high rates of student mental health concerns and further underscored inequities and disparities in access to services and care. As schools continue to address the effects of the pandemic, they must prioritize student mental health and well-being. In this commentary, using feedback from the Maryland School Health Council, we present the connection between mental health in school and the Whole School, Whole Community, Whole Child (WSCC) model, a school health model commonly employed by schools and school districts. In doing so, we aim to highlight how school districts can use this model to address child mental health needs across a multi-tiered system of support.

Socio-emotional adjustment throughout the COVID-19 pandemic: A longitudinal study of elementary school-aged children from low-income neighbourhoods

Children's socio-emotional adjustment during the COVID-19 pandemic could depend on their pre-pandemic risk of heightened socio-emotional distress and available resources. In a sample of elementary school-aged children from low-income neighbourhoods in Germany, we examined children's socio-emotional adjustment throughout two pandemic-related school closing periods of 5 months each and explored possible determinants of their adjustment. On three occasions before and after school closing, home-room teachers reported on the distress of 365 children (Mage  = 8.45, 53% female) and provided information on their family backgrounds and internal resources. We studied child pre-pandemic risk of low socio-emotional adjustment based on low basic care by families and group membership (i.e., recently arrived refugee, deprived Roma family). We studied child resources regarding families' home learning support during school closings and selected internal resources of the children (German reading skills, academic ability). Results showed that children's distress did not increase throughout the school closings. Instead, their distress remained at constant levels or even decreased. On pre-pandemic risk, only low basic care was linked to higher levels of distress and worse trajectories. On child resources, home learning support, academic ability, and German reading skills were inconsistently linked to less distress and better trajectories depending on the school closing period. Our findings suggest better-than-expected socio-emotional adjustment of children from low-income neighbourhoods during the COVID-19 pandemic.

Supporting Emotionally Exhausted Community Mental Health Therapists in Appropriately Adapting EBPs for Children and Adolescents

Evidence-based practices (EBPs) are often adapted during community implementation to improve EBP fit for clients and the service context. Augmenting EBPs with additional dosing and content may improve fit. However, reducing EBP content can reduce EBP effectiveness. Using multilevel regression models, this study examined whether supportive program climate and program-furnished EBP-specific implementation strategies (e.g., materials, ongoing training, in-house experts) are associated with augmenting and reducing adaptations, and whether therapist emotional exhaustion moderated these associations. Data were collected from surveys completed by 439 therapists from 102 programs 9 years after a system-driven EBP implementation initiative. Supportive program climate was associated with more augmenting adaptations. Emotional exhaustion was a significant moderator. When organizations used more EBP-specific implementation strategies, more emotionally exhausted therapists reduced EBPs less and less emotionally exhausted therapists augmented EBPs more. Findings provide guidance on how organizations can support appropriate EBP adaptations in spite of therapist emotional exhaustion.

Associations between pre-pandemic authoritative parenting, pandemic stressors, and children's depression and anxiety at the initial stage of the COVID-19 pandemic

Large-scale changes due to the Novel Coronavirus (COVID-19) pandemic negatively affected children's mental health. Prior research suggests that children's mental health problems during the pandemic may have been concurrently attenuated by an authoritative parenting style and exacerbated by family stress. However, there is a gap in the literature investigating these mechanisms and whether pre-pandemic authoritative parenting had a lasting positive influence on children's mental health while they were exposed to pandemic-related family stressors. The current study begins to fill this gap by investigating these unique relationships in a sample of 106 4-8 year old children (51% female). Before the pandemic, caregivers completed questionnaires on their parenting style and their children's depression and anxiety symptoms. Shortly after the onset of COVID-19's stay-at-home mandate, parents answered questionnaires about their children's depression and anxiety symptoms and pandemic-related family stressors. Child depression and anxiety symptom severity increased. Higher levels of pandemic-related family stress were associated with increases only in child anxiety scores. Further, greater endorsement of a pre-pandemic authoritative parenting style was associated with smaller changes only in child depression scores. Study findings elucidate unique and complex associations between young children's anxiety and depression symptoms severity and pre-pandemic parenting and pandemic-related family stressors.

Pre-pandemic support for shared reading buffers adverse parenting impacts: an RCT in Brazil

BACKGROUND

To examine whether (1) a parent-child reading program (Universidade do Bebê [UBB]), conducted in Brazil pre-pandemic can support parenting and parent-child reading 6 months into the pandemic, (2) cognitive stimulation at pandemic onset mediates effects of UBB on these outcomes, and (3) UBB pre-pandemic buffers associations between COVID-19-related distress and parenting/parent-child reading 6 months into the pandemic.

METHODS

400 women, either pregnant or with children 0-24 months, were randomized to UBB (n = 200) or control groups. UBB consisted of monthly parent workshops focusing on parent-child reading and a book-lending library. Assessments pre-pandemic (June-2019) and at pandemic onset (April-2020) included cognitive stimulation. Assessments 6 months into the pandemic (October-2020) included COVID-19 exposure/impact/distress, as well as parenting and parent-child reading.

RESULTS

133 families (n = 69 UBB) contributed data 6 months into the pandemic. Participation in UBB pre-pandemic was associated with parent-child reading but not parenting 6 months into the pandemic. Indirect effects of UBB through cognitive stimulation at pandemic onset were observed for both outcomes. Increased COVID-19-related distress was significantly associated with reduced parenting/parent-child reading 6 months into the pandemic in the control group only.

CONCLUSION

Promotion of cognitive stimulation pre-pandemic may have reduced risk for effects of the pandemic on parenting/parent-child reading.

CLINICAL TRIAL REGISTRATION

The trial has been registered with the Brazilian Clinical Trials Registry RBR-29RZDH on 05/28/2018.

IMPACT

This is the first study showing sustained impacts of a reading aloud intervention beginning in pregnancy and early infancy implemented pre-pandemic. Findings suggest that participation in a reading-aloud intervention buffered associations between COVID-19 distress and parenting/parent-child reading 6 months into the pandemic. Novel empirical evidence suggests that promotion of cognitive stimulation prior to the pandemic may buffer its impacts on parenting and parent-child book reading following onset in low- and middle-income countries. Findings provide important new support for implementation of parent-child reading aloud programs and likely have implications for early childhood development beyond the COVID-19 pandemic for disasters generally.

Changes in Depression and Anxiety Among Children and Adolescents From Before to During the COVID-19 Pandemic: A Systematic Review and Meta-analysis

Importance

There is a growing body of high-quality cohort-based research that has examined changes in child and adolescent mental health during the COVID-19 pandemic vs before the pandemic. Some studies have found that child and adolescent depression and anxiety symptoms have increased, while others have found these symptoms to have remained stable or decreased.

Objective

To synthesize the available longitudinal cohort-based research evidence to estimate the direction and magnitude of changes in depression and anxiety symptoms in children and adolescents assessed before and during the pandemic.

Data Sources

Medline, Embase, and PsycInfo were searched for studies published between January 1, 2020, and May 17, 2022.

Study Selection

Included studies reported on depression and/or anxiety symptoms, had cohort data comparing prepandemic to pandemic estimates, included a sample of children and/or adolescents younger than 19 years, and were published in English in a peer-reviewed journal.

Data Extraction and Synthesis

In total, 53 longitudinal cohort studies from 12 countries with 87 study estimates representing 40 807 children and adolescents were included.

Main Outcomes and Measures

Standardized mean changes (SMC) in depression and anxiety symptoms from before to during the pandemic.

Results

The analysis included 40 807 children and adolescents represented in pre-COVID-19 studies and 33 682 represented in during-COVID-19 studies. There was good evidence of an increase in depression symptoms (SMC, 0.26; 95% CI, 0.19 to 0.33). Changes in depression symptoms were most conclusive for study estimates among female individuals (SMC, 0.32; 95% CI, 0.21 to 0.42), study estimates with mid to high income (SMC, 0.35; 95% CI, 0.07 to 0.63), and study estimates sourced from North America (SMC, 0.25; 95% CI, 0.15 to 0.36) and Europe (SMC, 0.35; 95% CI, 0.17 to 0.53). There was strong evidence that anxiety symptoms increased slightly during the pandemic (SMC, 0.10; 95% CI, 0.04 to 0.16), and there was some evidence of an increase in study estimates with mid to high income.

Conclusions

This systematic review and meta-analysis of longitudinal studies including children and adolescents found an increase in depression symptoms during the COVID-19 pandemic, particularly among female individuals and those from relatively higher-income backgrounds.

Trajectories of child mental health, physical activity and screen-time during the COVID-19 pandemic considering different family situations: results from a longitudinal birth cohort

BACKGROUND

Many authors have described a significant mental health burden on children and adolescents during the COVID-19 pandemic, possibly moderated by social disparities. This analysis explores whether pre-pandemic family circumstances might be related to different aspects of child health during the pandemic.

METHODS

We analyzed trajectories of health-related outcomes in children aged 5 to 9 years (T7 to T11) using the Ulm SPATZ Health study, a population based birth cohort study (baseline 04/2012-05/2013) conducted in the South of Germany. Outcomes were children's mental health, quality of life, and lifestyle, such as screen time and physical activity. We conducted descriptive statistics of maternal and child characteristics before and throughout the pandemic. We defined three different groups of pre-pandemic family situations and used adjusted mixed models to estimate differences in means associated with the time during the pandemic vs. before the pandemic in (a) all children and in (b) children belonging to specific pre-pandemic family situations.

RESULTS

We analyzed data from n = 588 children from whom at least one questionnaire was completed between T7 and T11. When not considering the pre-pandemic family situation, adjusted mixed models showed statistically significant lower mean scores of health-related quality of life among girls during vs. before the COVID-19 pandemic (difference in means (b): - 3.9 (95% confidence interval (CI): - 6.4, - 1.4). There were no substantial differences in mental health, screen time, or physical activity in boys or girls. When considering pre-pandemic family situations, boys with mothers having symptoms of depression or anxiety showed a substantial loss of health-related quality of life on the subscale of friends (b: - 10.5 (95% CI: - 19.7, - 1.4)). Among girls in this group, 60% of the 15 assessed outcomes were negatively associated with a remarkable loss in health-related quality of life (e.g., KINDL-physical well-being difference in means: - 12.2 (95% CI: - 18.9, - 5.4)). Furthermore, a substantial increase in screen time was found (+ 2.9 h (95% CI: 0.3, 5.6)).

CONCLUSION

Our results suggest that the health (and behavior) of primary school-aged children is possibly impacted by the COVID-19 pandemic, with adverse consequences differing by gender and very likely by the pre-pandemic family situation. Especially in girls having a mother with depression or anxiety symptoms, the adverse consequences of the pandemic on mental health seem to be aggregated. Boys showed fewer adverse trajectories, and it needs to be further assessed which factors exactly are behind the (socio-economic) factors, such as maternal working habits and limited living space, when analyzing the effect of the pandemic on children's health.

Child and Maternal Mental Health Before and During the COVID-19 Pandemic: Longitudinal Social Inequalities in a Brazilian Birth Cohort

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has caused major stress for families and children, particularly in the context of prolonged school closures. Few longitudinal studies are available on young children's mental health, including data both before and during the pandemic. This study examined experiences that might increase risk for mental health problems among caregivers and young children during the COVID-19 pandemic and inequalities driven by pre-pandemic disadvantage.

METHOD

This prospective, population-based birth cohort study in Pelotas, Brazil, analyzed 2,083 children and caregivers with data from before the pandemic in 2019, when children were 4 years old, and again in 2020, when schools were closed for a long period during the pandemic. Child conduct problems, emotional problems, and hyperactivity-inattention problems were assessed using the Strengths and Difficulties Questionnaire. Family financial hardship, relationship difficulties, caregiver mental health, parenting practices, and child fears and isolation were considered as potential risk factors.

RESULTS

Across the whole population, the only significant increase in mental health problems from before to during the pandemic was found for maternal depression. However, poorer families were at far greater risk of experiencing serious financial problems, food shortages, increased conflict in adult relationships, parenting problems, and child worries about food availability during the pandemic. In turn, these difficulties were associated with increases in multiple mental health problems for both caregivers and children. Increased child mental health problems were most strongly associated with concurrent maternal anxiety (β > 0.20, p < .001, for each of child conduct, emotional, and hyperactivity problems), maternal depression (β = 0.26, p < .001, for child emotional problems), partner criticism (β = 0.21, p < .001, for child conduct problems), and harsh parenting (β > 0.20, p < .001, for both child conduct and hyperactivity problems). Child worry about COVID-19 was associated with increased emotional problems (β = 0.14, p < .001), but children's isolation was not associated with their mental health.

CONCLUSION

Overall, the impact of the COVID-19 pandemic on mental health is a mixed picture, but for families in poverty, marked material and interpersonal difficulties were associated with increases in mental health problems among children and caregivers.

Restricted and repetitive behaviors and their developmental and demographic correlates in 4-8-year-old children: A transdiagnostic approach

Background: Restricted and repetitive behaviors (RRBs) are a broad class of behaviors characterized by frequent action repetition and intense preference for sameness. Research has predominantly focused on RRBs in diagnosed clinical groups, particularly in autism spectrum disorder and genetic disorders. Using a transdiagnostic approach, the current study examined RRBs in a diverse sample of children in relation to developmental and demographic correlates (age, language, non-verbal ability, child anxiety, sex, and socioeconomic status). Separate analyses examined two RRB subtypes; repetitive sensory and motor behaviors (RSMB) and insistence on sameness (IS). Method: Children (N = 260, age 4-8 years, 174 male, 86 female) in mainstream schools identified by teachers as having behavioral, emotional, and/or cognitive difficulties, were assessed using the Repetitive Behavior Questionnaire-2 (RBQ-2), the British Picture Vocabulary Scale (BPVS), Lucid Ability Scale, the Welsh Index of Multiple Deprivation (WIMD) and the Screen for Child Anxiety Related Emotional Disorders (SCARED). Recruitment excluded diagnosed clinical conditions. The Strengths and Difficulties Questionnaire (SDQ) was used to assess children's difficulties. Results: RRB scores were of high frequency and the scores for the IS were higher than for RSMB. The severity of anxiety symptoms and male sex were significantly associated with both RRB subtypes, and younger age and SES scores were associated with IS. Elevated RRB total and subtype scores were significantly related to SDQ scores for emotion, conduct, hyperactivity, and peer-relations. Discussion: The study provides the first evidence of RRBs in a diverse sample of young children with emerging difficulties in behavior, cognition, and/or emotion. The results contribute to proposals about psychological development in RRB and indicate that RRBs are best represented on a continuum of severity found across children in the early school years. The results support previous findings of a relation between RRB and anxiety reported in clinical samples and importantly, they indicate that it is time to move beyond the study of categorically defined groups and consider correlates of RRBs that include broad indices of mental health and well-being.

COVID-19 Policies, Pandemic Disruptions, and Changes in Child Mental Health and Sleep in the United States

IMPORTANCE

The adverse effects of COVID-19 containment policies disrupting child mental health and sleep have been debated. However, few current estimates correct biases of these potential effects.

OBJECTIVES

To determine whether financial and school disruptions related to COVID-19 containment policies and unemployment rates were separately associated with perceived stress, sadness, positive affect, COVID-19-related worry, and sleep.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was based on the Adolescent Brain Cognitive Development Study COVID-19 Rapid Response Release and used data collected 5 times between May and December 2020. Indexes of state-level COVID-19 policies (restrictive, supportive) and county-level unemployment rates were used to plausibly address confounding biases through 2-stage limited information maximum likelihood instrumental variables analyses. Data from 6030 US children aged 10 to 13 years were included. Data analysis was conducted from May 2021 to January 2023.

EXPOSURES

Policy-induced financial disruptions (lost wages or work due to COVID-19 economic impact); policy-induced school disruptions (switches to online or partial in-person schooling).

MAIN OUTCOMES AND MEASURES

Perceived stress scale, National Institutes of Health (NIH)-Toolbox sadness, NIH-Toolbox positive affect, COVID-19-related worry, and sleep (latency, inertia, duration).

RESULTS

In this study, 6030 children were included in the mental health sample (weighted median [IQR] age, 13 [12-13] years; 2947 [48.9%] females, 273 [4.5%] Asian children, 461 [7.6%] Black children, 1167 [19.4%] Hispanic children, 3783 [62.7%] White children, 347 [5.7%] children of other or multiracial ethnicity). After imputing missing data, experiencing financial disruption was associated with a 205.2% [95% CI, 52.9%-509.0%] increase in stress, a 112.1% [95% CI, 22.2%-268.1%] increase in sadness, 32.9% [95% CI, 3.5%-53.4%] decrease in positive affect, and a 73.9 [95% CI, 13.2-134.7] percentage-point increase in moderate-to-extreme COVID-19-related worry. There was no association between school disruption and mental health. Neither school disruption nor financial disruption were associated with sleep.

CONCLUSIONS AND RELEVANCE

To our knowledge, this study presents the first bias-corrected estimates linking COVID-19 policy-related financial disruptions with child mental health outcomes. School disruptions did not affect indices of children's mental health. These findings suggest public policy should consider the economic impact on families due to pandemic containment measures, in part to protect child mental health until vaccines and antiviral drugs become available.

The Impact of the COVID-19 Pandemic on Children/Youth With Special Health Care Needs: A School Nurse's Perspective

School nurses repeatedly have been stretched to the limits over the past few years with the COVID-19 pandemic-managing not only routine daily care of students but also juggling those unique needs of children and youth with special health care needs, especially for those who also lost a parent/caregiver from COVID-19. This article provides background demographic information on how the COVID-19 pandemic affected these children, along with a specific case report of a middle school student with attention deficit hyperactivity disorder who also experienced the loss of a parent from COVID-19. Specific practical suggestions are discussed on how school nurses proactively and collaboratively can assist these students whose lives were permanently changed by the life-changing event of losing a parent/caregiver from COVID-19.

COVID-19 Stress, Religious Affiliation, and Mental Health Outcomes Among Adolescents

PURPOSE

To examine the relationship between religious affiliation, stressors due to the COVID-19 pandemic, and mental health challenges in a representative sample of adolescents.

METHODS

The sample was composed of 71,001 Utah adolescents who participated in a survey by the Utah Department of Health in 2021. Data are representative of all Utah adolescents in grades 6, 8, 10, and 12. Bootstrapped mediation was used to test indirect effects of religious affiliation on mental health challenges through COVID-19 stressors.

RESULTS

Religious affiliation was related to significantly lower rates of teen mental health challenges as measured by suicidal thoughts, suicide attempts, and depression. For religiously affiliated adolescents, the rate of considering and attempting suicide was nearly half of that of unaffiliated adolescents. In mediation analyses, affiliation was indirectly related to mental health challenges (suicide ideation, suicide attempt, and depression) through stressors from COVID-19, including affiliated adolescents experiencing the following: less anxiety, fewer family fights, fewer school difficulties, and fewer skipped meals. However, affiliation was positively related to becoming sick with COVID-19 (or having COVID-19 symptoms), which was related to more suicidal thoughts.

CONCLUSIONS

Findings suggest that adolescent religious affiliation may be a promotive factor that decreases mental health challenges through a reduction in COVID-19-related stressors, except religious individuals may be more likely to become sick. To increase positive mental health outcomes among adolescents during pandemic times, consistent and clear policies that facilitate religious connections that also align with good physical health measures will be critical.

'Everything turned upside down': A thematic analysis of adolescents' experiences of everyday life during COVID-19 restrictions

BACKGROUND

At the beginning of the COVID-19 pandemic, people were encouraged to practice social distancing, and schools and leisure venues closed.

AIMS

We aimed to explore the everyday experiences of Norwegian adolescents during COVID-19 restrictions, when in-person contact with peers was severely limited.

METHODS

A total of 622 high-school students (16-18 years of age) replied to an online survey containing open-ended questions about the changes they experienced in everyday life during the first three months of the pandemic.

RESULTS

Reflexive thematic analysis resulted in four themes: (a) 'Everyday life turned upside down - everything is on hold'; (b) 'Alone with my thoughts - new concerns'; (c) 'A loss of social life - a fear of wasting important time'; and (d) 'Gratitude - new perspectives in life'. The results are discussed according to mental-health concerns and psychological developmental challenges during adolescence, such as social exploration of roles with peers, autonomy and identity formation during a crisis.

CONCLUSIONS

The results underline individual variations and positive experiences among adolescents during the COVID-19 pandemic, despite social restrictions. Still, the lack of in-person contact with friends is related to an increased experience of loneliness and mental-health concerns for many adolescents.

A mixed-method study on adolescents' well-being during the COVID-19 syndemic emergency

In this study, we set out to investigate adolescents' levels of perceived well-being and to map how they went about caring for their well-being during the COVID-19 syndemic. Participants were 229 Italian adolescent high school students (48.9% males, mean age = 16.64). The research design was based on an exploratory, parallel, mixed-method approach. A multi-method, student-centered, computer-assisted, semi-structured online interview was used as the data gathering tool, including both a standardized quantitative questionnaire on perceived well-being and an open-ended question about how adolescents were taking charge of their well-being during the COVID-19 health emergency. Main findings reveal general low levels of perceived well-being during the syndemic, especially in girls and in older adolescents. Higher levels of well-being are associated with more affiliative strategies (we-ness/togetherness) whereas low levels of well-being are linked with more individualistic strategies (I-ness/separatedness) in facing the health emergency. These findings identify access to social support as a strategy for coping with situational stress and raise reflection on the importance of balancing the need for physical distancing to protect from infection, and the need for social closeness to maintain good mental health.

Impacts of health care service changes implemented due to COVID-19 on children and young people with long-term disability: A mapping review

AIM

To identify the research on childhood disability service adaptations and their impact on children and young people with long-term disability during the COVID-19 pandemic.

METHOD

A mapping review was undertaken. We searched the World Health Organization Global COVID-19 database using the search terms 'children', 'chronic/disabling conditions', and 'services/therapies'. Eligible papers reported service changes for children (0-19 years) with long-term disability in any geographical or clinical setting between 1st January 2020 and 26th January 2022. Papers were charted across the effective practice and organization of care taxonomy of health system interventions and were narratively synthesized; an interactive map was produced.

RESULTS

Reduction of face-to-face care and usual provision had a huge impact on children and families. Adoption of telehealth provided continuity for the care and management of some conditions. There was limited evidence of changes to mental health services, transitions of care, social care, or child-reported satisfaction or acceptability of service changes.

INTERPRETATION

The long-term impacts of service change during the pandemic need full evaluation. However, widespread disruption seems to have had a profound impact on child and carer health and well-being. Service recovery needs to be specific to the individual needs of children with a disability and their families. This should be done through coproduction to ensure that service changes meet needs and are accessible and equitable.

Reformed child and adolescent mental health services in a devolved healthcare system: a mixed-methods case study of an implementation site

Background

Efforts are being made to reform and reconceptualise children and young people's (CYP) mental health services. This is in response to a rapid increase in mental health difficulties in this population, and the shortcomings of current service provision. The present study seeks to comprehensively evaluate the local implementation of the THRIVE Framework for System Change in Greater Manchester, UK (GM i-THRIVE) from 2018 to 2021. The framework was designed to change the way mental health is perceived, and subsequently how support is allocated. The current study focusses on the implementation of the framework's principles into CYP mental health support in the region.

Methods

The study comprised three methodological components, beginning with examination of the GM i-THRIVE implementation plan and self-assessment questionnaire measure using the Quality Implementation Tool. This was to provide a wider backdrop of implementation method adequacy to the rest of the study's findings. Subsequently, evaluation measures completed by professionals across Greater Manchester were examined to establish implementation progress, before corroborating key items from this measure with thematically analysed interview data from six CYP (13-22 years) who recently received mental health support in the region. Levels of agreement between staff and CYP were examined.

Results

GM i-THRIVE's implementation plan and self-assessment measure were respectively deemed a strong guiding foundation, and a suitable way of evaluating implementation progress. Every principle within the self-assessment measure demonstrated closer alignment with the THRIVE Framework as time progressed. Two themes were developed from the qualitative interview data, each overarching four subthemes: (1) Qualities of the service: information and decision sharing; communication and continuity; needs-based support; compassion and trust, and (2) The mental health journey: beginnings; endings; waiting; satisfaction with support. A good level of agreement between CYP testimony and staff progress reports was found.

Conclusions

Findings suggested that the experiences of the CYP in the sample, who were interviewed in the spring to summer period of 2022, were overwhelmingly positive. The rich insights into mental health support offered by the young participants lead us to recommend continued qualitative research with service-users as GM i-THRIVE's embedding period continues, with focus on representing a wide range of experiences in future research samples. Methodological limitations were explored, including the extent to which true cross-references could be made between professional and CYP accounts.

On return to school: disorder symptoms, stress at home and evaluations of school COVID-19 measures

Background: Social restrictions during the COVID-19 pandemic had a major impact on the mental health of children. Yet, analyses on the mental health of younger children in the later course of the pandemic are scarce. The present study assessed 8- to 11-year-olds' internalising disorder symptoms during the last three weeks, from the third week of February through to the first week of March, of the 2021 national lockdown.Method: One hundred and forty-five pupils, including a subset of keyworkers' children who had face-toface schooling, completed the validated Revised Child Anxiety and Depression scales, items on COVID-related stress at home, and evaluations of home-learning and school's measures for reopening.Results: Symptoms increased with age in months and/or number of siblings. Girls reported more symptoms and home stress than boys did. Pupils who had face-to-face schooling were more satisfied with school measures and less satisfied with home learning compared with those who only had home learning. Hierarchical regression analyses corroborated the contributions of sociodemographic characteristics and found that home stress and school measures evaluations were associated most with major depression, generalised anxiety, and social phobia.Conclusion: Findings can contribute to mental health practice by promoting school communications and family and educator awareness of stressors, vulnerabilities and symptoms to boost pupils' readiness for school returns.

COVID-19: Implications for Nursing and Health Care in the United States

PURPOSE

COVID-19 and other recent infectious disease outbreaks have highlighted the urgency of robust, resilient health systems. We may now have the opportunity to reform the flawed health care system that made COVID-19 far more damaging in the United States (U.S.) than necessary.

DESIGN AND METHODS

Guided by the World Health Organization (WHO) Health System Building Blocks framework (WHO, 2007) and the socio-ecological model (e.g., McLeroy et al., 1988), we identified challenges in and strengths of the U.S.' handling of the pandemic, lessons learned, and policy implications for more resilient future health care delivery in the U.S. Using the aforementioned frameworks, we identified crucial, intertwined domains that have influenced and been influenced by health care delivery in the U.S. during the COVID-19 pandemic through a review and analysis of the COVID-19 literature and the collective expertise of a panel of research and clinical experts. An iterative process using a modified Delphi technique was used to reach consensus.

FINDINGS

Four critically important, inter-related domains needing improvement individually, interpersonally, within communities, and for critical public policy reform were identified: Social determinants of health, mental health, communication, and the nursing workforce.

CONCLUSIONS

The four domains identified in this analysis demonstrate the challenges generated or intensified by the COVID-19 pandemic, their dynamic interconnectedness, and the critical importance of health equity to resilient health systems, an effective pandemic response, and better health for all.

CLINICAL RELEVANCE

The novel coronavirus is unlikely to be the last pandemic in the U.S. and globally. To control COVID-19 and prevent unnecessary suffering and social and economic damage from future pandemics, the U.S. will need to improve its capacity to protect the public's health. Complex problems require multi-level solutions across critical domains. The COVID-19 pandemic has underscored four interrelated domains that reveal and compound deep underlying problems in the socioeconomic structure and health care system of the U.S. In so doing, however, the pandemic illuminates the way toward reforms that could improve our ability not only to cope with likely future epidemics but also to better serve the health care needs of the entire population. This article highlights the pressing need for multi-level individual, interpersonal, community, and public policy reforms to improve clinical care and public health outcomes in the current COVID-19 pandemic and future pandemics, and offers recommendations to achieve these aims.

The Effects of Financial Stress and Household Socio-Economic Deprivation on the Malnutrition Statuses of Children under Five during the COVID-19 Lockdown in a Marginalized Region of South Punjab, Pakistan

The lockdown after the COVID-19 pandemic not only caused public health crises and income stress but also put millions at risk of food insecurity and malnutrition across the globe, especially in low and middle-income countries [LMICs]. This study evaluated the effects of financial stress and household socio-economic deprivation on the nutritional status of 1551 children under the age of five during COVID-19 in Pakistan. A self-administered questionnaire was used between November 2020 and April 2021 to collect information on age, height, children's weight, and socio-economic status from 1152 rural households from underdeveloped regions in Punjab, Pakistan. With the help of the proportionate simple random sampling method, this study employed a model (binary logistic regression) to calculate the likelihood of malnourishment. The findings showed that the stunting, underweight, and wasting prevalence rates during COVID-19 were 58.86%, 41.89%, and 8.11%, respectively, in the Bahawalpur region. According to the binary logistic regression analysis, among the household deprivation status (HDS) categories, the risks of childhood malnutrition were lesser in HDS-2 (OR = 0.05, 95% CI: 0. 005-0.879) and HDS-3 (OR = 0.04, 95% CI: 0.008-0.193). Similar to this, within the financial stress index (FSI) categories, the children in homes with medium financial stress had reduced odds of malnutrition (OR = 0.10, 95% CI: 0.018-0.567), and the children in households with low financial stress had reduced risks of malnutrition (OR = 0.006, 95% CI: 0.005-0.061). The proposed research found that stunting and underweight increased by 17.26% and 12.29% during the COVID-19 lockdown in the Bahawalpur region. Additionally, financial stress and socio-economic deprivation strongly affected children's nutritional statuses during the COVID-19 lockdown in the Bahawalpur region of Southern Punjab.

COVID-19-related financial strain and adolescent mental health

Background

The COVID-19 pandemic and associated responses have induced a host of crises worldwide, including an economic recession and a global mental health crisis. The specific effects of recession on youth mental health are understudied. We aimed to examine the mechanisms by which pandemic-related financial strain may affect mental health in a diverse sample of American adolescents.

Methods

We analyzed data from the Adolescent Brain Cognitive Development Study (ABCD Study®), a large, longitudinal study of diverse US adolescents which collected data before and during the pandemic (N = 9,720, mean age 12.9 years, 18.2% Black). Linear mixed-effects models tested associations of financial strain (parent-reported household wage loss and youth-reported financial stress) with depressive symptomatology over time, covarying for multiple confounders including pre-pandemic socioeconomic status and psychopathology, and pandemic-related environmental factors. Longitudinal mediation analyses examined potential mechanisms leading from wage loss to youth mental health.

Findings

Financial strain was highly prevalent, especially among low-income participants, with >70% of the total sample reporting lost wages. Both wage loss and subjective financial stress were associated with depressive symptomatology over time (Estimate = 0.04, P = 0.014; Estimate = 0.17, P < 0.001; respectively). The association between financial stress and depressive symptomatology was robust to the addition of multiple environmental confounders (Estimate = 0.16, P < 0.001). Both family-level (family conflict) and individual-level (financial stress) factors mediated the relationship between wage loss and depressive symptomatology.

Interpretation

The financial effects of COVID-19 (and worldwide responses to it) have taken a significant toll on youth mental health. In families that lost wages, youth-reported financial stress and familial factors mediated the relationship between wage loss and mental health over time. Findings highlight financial stress as a key driver of youth mental health burden and identify familial factors as critical targets for intervention to mitigate mental health risks in periods of economic crises.

Funding

This study was supported by the National Institute of Mental Health [grant numbers K23MH120437 (RB), R01MH117014 (TMM)]; the Lifespan Brain Institute of Children's Hospital of Philadelphia and Penn Medicine, University of Pennsylvania.

Mood and Behaviors of Adolescents With Depression in a Longitudinal Study Before and During the COVID-19 Pandemic

OBJECTIVE

To investigate whether, compared to pre-pandemic levels, depressive and anxiety symptoms in adolescents with depression increased during the pandemic.

METHOD

We used data from National Institute of Mental Health Characterization and Treatment of Depression (NIMH CAT-D) cohort, a longitudinal case-control study that started pre-pandemic. Most of the participants are from the states of Maryland and Virginia in the United States. We compared depressive symptoms (1,820 measurements; 519 measurements pre-pandemic and 1,302 during the pandemic) and anxiety symptoms (1,800 measurements; 508 measurements pre-pandemic and 1,292 ratings during the pandemic) of 166 adolescents (109 girls, 96 adolescents with depression) before and during the pandemic. Data were collected during yearly clinical visits, interim 4-month follow-up visits, inpatient stays, and weekly outpatient sessions, with additional data collection during the pandemic. Pre-pandemic, healthy volunteers (HVs) had a median of 1 depressive and anxiety rating (range, 1-3), and adolescents with depression had a median of 2 ratings (anxiety rating range, 1-25; depressive rating range, 1-26). During the pandemic, HVs had a median of 8 anxiety ratings and 9 depressive ratings (range, 1-13), and adolescents with depression had a median of 7 anxiety and depressive ratings (range, 1-29). We also analyzed adolescent- and parent-reported behaviors in the CoRonavIruS Health Impact Survey (CRISIS), totaling 920 self-reported measures for 164 adolescents (112 girls, 92 adolescents with depression). HVs had a median of 7 surveys (range, 1-8), and adolescents with depression had a median of 5 surveys (range, 1-8).

RESULTS

Pre-pandemic, adolescents with depression had a mean depressive score of 11.16 (95% CI = 10.10, 12.22) and HVs had a mean depressive score of 1.76 (95% CI = 0.40, 3.13), a difference of 9.40 points (95% CI = 7.78, 11.01). During the pandemic, this difference decreased by 22.6% (2.05 points, 95% CI = 0.71, 3.40, p = .003) due to 0.89 points decrease in severity of scores in adolescents with depression (95% CI = 0.08, 1.70, p = .032) and 1.16 points increase in HVs' depressive symptoms (95% CI = 0.10, 2.23, p = .032). Compared to their pre-pandemic levels, adolescents with depression reported overall lower anxiety symptoms during the pandemic. Parent-on-child reports also were consistent with these results.

CONCLUSION

Contrary to our hypothesis, we found that both depressive and anxiety symptoms were lower for adolescents with depression during the pandemic compared to before. In contrast, the depression scores for the HVs were higher during the pandemic relative to their pre-pandemic ratings; these scores remained much lower than those of adolescents with depression.

CLINICAL TRIAL REGISTRATION INFORMATION

Characterization and Treatment of Adolescent Depression; https://clinicaltrials.gov/; NCT03388606.

Financial stress during COVID-19: implications for parenting behaviour and child well-being

BACKGROUND

Family financial stress and parenting behaviours are each associated with child behaviours. We sought to explore the association between parent financial stress and child socioemotional and behavioural difficulties during the COVID-19 pandemic and examine parenting behaviour, including overreactive and lax parenting approaches, as a potential mediator to this relationship.

METHODS

Cross-sectional sample of parent and child data pairings in Ontario, Canada between April and November of 2020. Linear models were used to describe the relationships between financial worry, child Strengths and Difficulties Questionnaire (SDQ) total difficulties and parenting behaviours measured by the Parenting Scale 8-item (PS-8), which includes measures of both overreactive and lax parenting tendencies. Formal mediation testing was performed to assess the potential mediating role of parenting behaviour.

RESULTS

528 parent and child pairs were enrolled from largely European ancestry (78%), female (93%) and varied household income levels. Analysis revealed increased financial worry during the COVID-19 pandemic was significantly associated with increased child SDQ total difficulties scores (β=0.23, SE=0.10, p=0.03). This relationship was mediated by reported parenting behaviour, independent of parent education, household income, parent age, parent sex, parent anxiety and child sex (total effect: β=0.69, p=0.02, average causal mediation effects: β=0.50, p=0.02, average direct effects: β=0.19, p=0.08).

CONCLUSION

Financial stress during the COVID-19 pandemic was associated with poorer child social and emotional well-being. Parenting behaviours measured by the PS-8 significantly mediated these effects. This work supports the importance of policies aimed to alleviate family financial stresses and highlights the potential impact such policies have on child well-being.

Determinants of adolescents’ Health-Related Quality of Life and psychological distress during the COVID-19 pandemic

Background

We examined the determinants of adolescents’ Health-Related Quality of Life (HRQoL) and psychological distress (self-reported and parent-reported) during the COVID-19 pandemic, using a random sample of the population of Geneva, Switzerland.

Methods

Data was drawn from participants aged 14–17 years, who participated with their families to a serosurvey conducted in November and December 2020. Adolescents’ HRQoL was evaluated using the validated adolescent-reported KIDSCREEN-10 and parent-reported KINDL^® scales. Psychological distress was assessed with self-reported sadness and loneliness, and using the KINDL^® emotional well-being scale. Using generalized estimating equations, we examined the role of socio-demographic, family and behavioural characteristics in influencing adolescents’ mental health status and wellbeing.

Results

Among 240 adolescents, 11% had a low HRQoL, 35% reported sadness and 23% reported loneliness. Based on parents’ perception, 12% of the adolescents had a low HRQoL and 16% a low emotional well-being. Being a girl (aOR = 3.20; 95%CI: 1.67–6.16), increased time on social media (aOR = 2.07; 95%CI: 1.08–3.97), parents’ average to poor mood (aOR = 2.62; 95%CI: 1.10–6.23) and average to poor household financial situation (aOR = 2.31; IC95%: 1.01–6.10) were associated with an increased risk of sadness. Mismatches between adolescents’ and their parents’ perception of HRQoL were more likely for girls (aOR = 2.88; 95%CI: 1.54–5.41) and in households with lower family well-being (aOR = 0.91; 95%CI: 0.86–0.96).

Conclusions

A meaningful proportion of adolescents experienced low well-being during the second wave of COVID-19, and average well-being was lower than pre-pandemic estimates. Adolescents living in underprivileged or distressed families seemed particularly affected. Monitoring is necessary to evaluate the long-term effects of the pandemic on adolescents.

School-based screening for childhood anxiety problems and intervention delivery: a codesign approach

OBJECTIVES

A very small proportion of children with anxiety problems receive evidence-based treatment. Barriers to access include difficulties with problem identification, concerns about stigma and a lack of clarity about how to access specialist services and their limited availability. A school-based programme that integrates screening to identify those children who are most likely to be experiencing anxiety problems with the offer of intervention has the potential to overcome many of these barriers. This article is a process-based account of how we used codesign to develop a primary school-based screening and intervention programme for child anxiety problems.

DESIGN

Codesign.

SETTING

UK primary schools.

PARTICIPANTS

Data were collected from year 4 children (aged 8-9 years), parents, school staff and mental health practitioners.

RESULTS

We report how the developed programme was experienced and perceived by a range of users, including parents, children, school staff and mental health practitioners, as well as how the programme was adapted following user feedback.

CONCLUSIONS

We reflect on the mitigation techniques we employed, the lessons learnt from the codesign process and give recommendations that may inform the development and implementation of future school-based screening and intervention programmes.

Impact of COVID-19-related Stress on Preschool Children's Internalizing and Externalizing Problem Behaviors: The Indirect Effect of Mother's Depression and Parenting Behavior

The COVID-19 pandemic is affecting families and children worldwide. Experiencing the pandemic leads to stress in families resulting from fear of infection and social isolation derived from social distancing. For families raising preschoolers, the prolonged closure of childcare centers puts additional childcare burden on family members, especially mothers. Due to the limited research exploring the impact of COVID-19 on preschool children's problem behaviors, this study examines the association between stress due to COVID-19 and preschool children's internalizing and externalizing problem behaviors related to mother's depression and parenting behavior. The study sample included data collected from 316 South Korean mothers raising preschool-aged children aged 3 to 5. The study findings suggest that mother's COVID-19 stress was indirectly associated with preschool children's internalizing and externalizing problem behaviors resulting from the mother's depression and parenting behaviors, although the direct effect of COVID-19 stress on preschool children's outcomes was not statistically significant. Increase in mother's COVID-19 stress was associated with increase in depression, and sequentially decreased positive parenting behaviors, which in turn resulted in preschool children's internalizing and externalizing problem behaviors. The study findings highlight the need to focus on enhancing mental health of mothers and preschool children's adjustment by implementing supportive interventions to reduce the adverse impacts of the prolonged COVID-19 pandemic.

Longitudinal impact of psychosocial status on children's mental health in the context of COVID-19 pandemic restrictions

Emerging research suggests that the prevalence of child and adolescent mental health problems has increased considerably during the COVID-19 crisis. However, there have been few longitudinal studies on children's mental health issues according to their social determinants in this context, especially in Europe. Our aim was to investigate the association between family socioeconomic status (SES) and children' mental health during the period of school closure due to COVID-19. Longitudinal data came from 4575 children aged 8-9 years old in 2020 and participating in the ELFE population-based birth cohort that focuses on children's health, development and socialization. Parents completed the Strengths and Difficulties Questionnaire (SDQ) when children were (a) 5 years of age and (b) 9 years of age, which corresponded to the period of school closure due to the COVID-19 pandemic in France. We retrieved data from the ELFE cohort collected on children from birth to age 5 years (birth, 1 year, 2 years, 3,5 years and 5 years). Socioeconomic status (SES) was measured based on information obtained when the child was 5 years old. Data were analyzed using multinomial logistic regression models. Children's elevated levels of symptoms of Attention-deficit/Hyperactivity disorder (ADHD) during the period of school closure were significantly associated with prior low family SES (aOR 1.26, 95% CI 1.08-1.48). Children's elevated symptoms of hyperactivity/inattention and of emotional symptoms were associated with decline in income during the COVID crisis (respectively, aOR 1.38, 95% CI 1.16-1.63 and aOR 1.23, 95% CI 1.01-1.51). Moreover, when testing interactions, a low prior SES was significantly associated with a higher risk of emotional symptoms aOR 1.54 (1.07-2.21), only for children whose families experienced a decline in income, while gender, parental separation and prior mental health difficulties were not associated. This study underlines the impact of the financial crisis related to the COVID-19 epidemic on children's mental health. Both pre-existing family SES before lockdown and more proximal financial difficulties during the COVID crisis were negatively associated with children's psychological difficulties during the period of school closure. The pandemic appears to exacerbate mental health problems in deprived children whose families suffer from financial difficulties.

Understanding de novo onset of anxiety during COVID-19: Pre-pandemic socio-emotional functioning in vulnerable children

Background

There is a need to understand and mitigate the psychological impacts of the COVID-19 pandemic for children known to be vulnerable. Data from prior to the pandemic are required to provide robust assessments of the socio-emotional impacts of COVID-19 and identify those who are more vulnerable.

Method

This study capitalises on an ongoing UK study of primary school children (4-8 years) identified prior to the pandemic as "at risk" for mental health problems by teachers. We collected mental health and social-emotional functioning data prior to the pandemic (Time 1) and re-assessed this cohort (N = 143) via researcher-led videocalls during lockdown (Time 2, summer 2020) and post-lockdown, 12 months later (Time 3; summer 2021).

Results

Mental health problems, particularly clinically significant anxiety, increased from 34% to 43% during lockdown and to 48% post-lockdown. Parental mental health difficulties (anxiety and depression) were prevalent during lockdown (40%) but had decreased 1 year later (20%). Children who developed clinically significant anxiety during the pandemic had impaired socio-emotional functioning at Time 1 (i.e., impaired emotion recognition, low self-esteem and social problems) and a high proportion (44%) had no contact with any peers during lockdown, which may have contributed to their anxiety, especially their school anxiety.

Conclusion

The pandemic appears to have exacerbated anxiety in already vulnerable children. A profile of socio-emotional problems identified a group of children who developed significant anxieties during the pandemic. These socio-emotional processes can be targeted for intervention to mitigate the negative mental health consequences of the pandemic and contribute to resilience in children.

Mental health of children with and without special healthcare needs and of their caregivers during COVID-19: a cross-sectional study

OBJECTIVE

To describe mental health outcomes and measures of pandemic burden of children with and without special healthcare needs, and their caregivers following the second wave of the COVID-19 pandemic in Germany.

DESIGN

This is the second of a sequential series of cross-sectional online surveys conducted among caregivers of children ≤18 years since the onset of the COVID-19 pandemic, administrated between 2 April 2021 and 31 July 2021.

MAIN OUTCOME MEASURES

Child and parental mental health were assessed using the Strengths and Difficulties Questionnaire and WHO-5 Well-being index. Children with Special Healthcare Needs (CSHCN) were identified using the CSHCN-Screener. Descriptive statistics, linear and hierarchical logistic regression modelling assessed associations between parent-reported child mental health problems and measures of pandemic burden, disease complexity, caregiver mental well-being and socioeconomic status.

RESULTS

521 participants were included in the final sample. There was a high prevalence of parent-reported mental health problems in n=302 (66.7%) children, particularly in CSHCN. Among caregivers, n=372 (72.5%) screened positive for depression. Logistic regression modelling showed a strong association of child mental health problems and disease complexity, parental mental well-being, increase in family conflict and inadequate social support.

CONCLUSIONS

Our study identifies CSHCN as a particularly vulnerable group in terms of mental health outcomes. Psychosocial factors were important predictors of parent-reported child mental health problems. Policy measures should consider the importance of social support systems for vulnerable children and their families, and aim to provide accessible mental health support for caregivers.

Minding Mental Health: Clinicians’ Engagement with Youth Suicide Prevention

Suicidal ideation and deaths among children and adolescents have seen an unprecedented rise over the last ten years, recently further exacerbated by the COVID-19 pandemic. This research explores mental health professionals’ approaches to delivering suicide prevention treatment services. Using insights from Giddens’ structuration theory, the study examines licensed mental health professionals’ (1) reflections on suicide prevention trainings for those in their profession, (2) appraisals of available treatment options, and (3) assessments of postvention services provided to professionals who encounter a client suicide. Additional attention was given to the structural impacts of the COVID-19 pandemic on intervention services. Data were collected through qualitative interviews with youth mental health clinicians in the state of Texas. Results underscore the interplay between structural influences and practitioner innovations in the delivery of these essential services to a vulnerable population. This study underscores the agency of mental health professionals in navigating the demands of a difficult profession.

Association between violence and mental distress, self-harm and suicidal ideation and attempts among young people in Malawi

BACKGROUND

Mental health problems ranging from depression to more severe acts such as self-harm or suicidal behaviours are a serious problem among adolescents and young adults. Exposure to violence during the life of young people can increase mental health issues for youth. This study examines the relationship between exposure to violence and mental health issues among youth using a nationally representative study in Malawi.

METHODS

We analysed data from the nationally representative Violence Against Children Survey from Malawi (2013) to quantify the association between exposures to violence (physical, sexual and emotional) and their relationship with mental distress, self-harm behaviours and suicidal ideation and attempts among youth aged 13-24 years. We evaluated the association of exposures to violence against children with reported mental health conditions among women and men. We used ordinal logistic regression models with appropriate survey weights to assess exposures to violence and the three outcomes of interest.

RESULTS

Children and youth aged 13-24 years exposed to violence in childhood reported higher levels of adverse mental health effects, including mental distress, self-harm behaviours and suicidal ideation and attempts. The odds of reporting these outcomes increased as the number of violence types increased.

CONCLUSIONS

Understanding the risks based on different combinations of exposures to violence in Malawi can help identify populations at higher risk and optimise violence prevention strategies.

Intersections between COVID-19 and socio-economic mental health stressors in the lives of South African adolescent girls and young women

BACKGROUND

In contexts where poverty and mental health stressors already interact to negatively impact the most vulnerable populations, COVID-19 is likely to have worsened these impacts. Before the COVID-19 pandemic, adolescent girls and young women (AGYW) in South Africa already faced intersecting mental health stressors and vulnerabilities. It is critical to understand how additional challenges brought on by COVID-19 have intersected with existing vulnerabilities and mental health risks AGYW faced, particularly given the intersections between psychological distress and increased risk behaviours that impact sexual and reproductive health. We aimed to examine socio-economic and mental health impacts of COVID-19 on South African AGYW in order to understand how additional challenges brought on by COVID-19 have intersected with existing challenges, compounding AGYW vulnerabilities.

METHODS

Using qualitative and quantitative methods, framed by the syndemic theory, we examined the intersections between mental health and the COVID-19 epidemic amongst AGYW in six districts of South Africa characterised by high rates of HIV, teenage pregnancy and socio-economic hardship. Between November 2020 and March 2021 we conducted a cross-sectional telephone survey with 515 AGYW, and in-depth interviews with 50 AGYW, aged 15 to 24 years.

RESULTS

Our findings reveal how COVID-19 restrictions led to increased experiences of stress and anxiety. Poor mental health was compounded by strained family relationships, increased fear of domestic violence, household unemployment, economic stress and food insecurity. Respondents described feelings of boredom, frustration, isolation, loneliness, fear and hopelessness. However, despite the multitude of challenges, some AGYW articulated emotional resilience, describing ways in which they coped and retained hope.

CONCLUSION

Various psycho-social risk factors already disproportionally affect the mental health of AGYW in these communities; the COVID-19 pandemic intersects with these pre-existing social and environmental factors. Understanding strategies AGYW have used to positively cope with the uncertainty of COVID-19 amongst an array of pre-existing mental health stressors, is key in informing efforts to respond to their needs. Multisectoral interventions are needed to address the drivers of poor mental health among AGYW, and bolster healthy coping mechanisms; interventions seeking to mitigate the mental health impacts on this vulnerable population need to be responsive to the unpredictable pandemic environment.

Lifestyle changes, mental health, and health-related quality of life in children aged 6-7 years before and during the COVID-19 pandemic in South Germany

BACKGROUND

The measures against the COVID-19 pandemic are challenging for children and parents, and detrimental effects on child health are suggested especially from lock-down measures and school closings.

METHODS

We conducted a cross-sectional analysis using a population based longitudinal (birth-) cohort study (SPATZ study) conducted in the South of Germany. Data included all 6 or 7 year old children for whom a questionnaire was completed during first grade of school. Consequently, we were able to analyze children being in first grade before the first lockdown in Germany (≤ 15th March 2020), as well as children being in first grade during the pandemic (> 15th March 2020). We conducted descriptive statistics and estimated the associations between the two time periods, before and during the pandemic, and various outcomes of child health using multivariable adjusted linear or logistic regression modeling. The analysis was stratified by gender.

RESULTS

Results among n = 362 children aged six or seven years showed substantially lower mean scores of health-related quality of life (difference in means: - 5.5, 95% confidence interval (CI) - 9.0, - 2.0), and higher mean scores in total emotional and behavioral difficulties (difference in means: 2.0, 95% CI 0.2, 3.8) in girls during vs. before the COVID-19 pandemic using multivariable linear regression modeling. In addition, weekly screen-time was increased in boys by 3.5 h (95% CI 0.6, 6.4). We did not find substantial differences in sleep quality, physical activity, and time spent with books, neither in boys nor in girls, however, the limited sample size has to be considered.

CONCLUSION

Child health (and behavior) of first grade school children is possibly impacted by the COVID-19 pandemic with adverse consequences possibly differing by gender.

Adoptive parents' finances and employment status: a 5-year longitudinal study

We investigated risk and facilitating factors related to families' change in finances and employment over 5 years following adoption of a child from local authority care in a prospective, longitudinal study of children placed for adoption between 2014 and 2015 (N = 96). Parents completed questionnaires at approximately 5, 21, 36, 48 and 60 months post-placement. We used time series analysis to examine the impact of child (e.g. pre-placement experiences, mental health), family structure (e.g. number of siblings, parent relationship status), and parent (e.g. mental health) factors on change in household income and parent employment status after adoption. We also examined the tendency for parents to comment on employment and finances and the emotional valence of their comments to gauge their concern about their circumstances. Children's mental health problems were associated with primary caregivers reducing their time spent in employment and parents' tendency to comment on their financial and work circumstances. Children who experienced more moves in care were more likely to have a primary caregiver not in full-time work, as were children with higher prosocial behaviour scores. Being in full-time work was associated with parents' symptoms of anxiety. We also detected associations between structural features of the family and changes in income and employment. This study represents one of the first empirical investigations of factors associated with the socioeconomic features of adoptive families' lives and informs ongoing discussion regarding the support needs of families and the timing, nature, and delivery of post-adoption professional services.

Change in Japanese children's 24-hour movement guidelines and mental health during the COVID-19 pandemic

Specialized guidelines are required for the health behaviors of vulnerable populations such as children. This is especially true during the COVID-19 pandemic, wherein major lifestyle changes have occurred, especially among young children. The present study aims to use longitudinal data to understand changes in the physical activity, screen time, sleep, and mental health of preschoolers in Japan during the COVID-19 pandemic, compared to pre-pandemic period. Subjective and objective measures were used to assess the variables of interest longitudinally. It was found that physical activity, adherence to WHO-recommended screen time, and prosocial behaviors decreased significantly. On the other hand, sedentary time and hyperactivity increased. Our results are consistent with findings from other countries. The implications with respect to outdoor playtime, screen-time in the context of online learning during the pandemic, and the effects of parents' mental health on preschool-aged children are discussed.

COVID-19 and mental health in children and adolescents: a diagnostic panel to map psycho-social consequences in the pandemic context

Since the beginning of the COVID-19 pandemic, much research has been done on the psycho-social consequences, especially for children, adolescents and families. In the long run, there is a large set of quantitative data available. However, these still seem to be not well understood. Theoretical classifications of the evidence also diagnostic tools still seem to be open. This paper elaborates a possible systematisation based on theoretical models of systemic self-organisation theories. This leads to a model for a comprehensive psycho-social child-in-environment diagnostic to map potential problem areas. Such a theoretical framing should enable both: a deeper understanding of the impact of pandemics on young people and hypotheses for intervention strategies in the context of pandemic management as well as in the context of diagnostic-systemic interventions in psycho-social working settings. In the coming months and years, it will be essential to be able to understand and describe psychosocial disabilities that have developed in the context of the pandemic in a differentiated way in order to establish targeted interventions.

Children's Psychological Reactions to the COVID-19 Pandemic

PURPOSE OF REVIEW

This paper reviews the literature on the psychological effects of the COVID-19 pandemic on children and the reactions of vulnerable children.

RECENT FINDINGS

Research reveals increases in clinically significant depression, suicidal ideation and behavior, and some anxiety symptoms. Substance use studies suggest an inadvertent decrease in substance use in some youth though findings are inconsistent across substances and for males and females. Children with pre-existing emotional and behavioral problems are especially vulnerable though some children appear to improve in the context of public health measures which have decreased the stresses associated with school and socialization. In addition, children with pre-existing problems are likely to have established resources and relationships that may protect them relative to other children. COVID-19 has had a major effect on the mental health of children around the world, but findings should be considered preliminary until more rigorous research has been conducted.

Childhood Antisocial Behavior: A Neurodevelopmental Problem

Early-onset disruptive, aggressive, and antisocial behavior is persistent, can become increasingly serious as children grow older, and is difficult to change. In 2007, our group proposed a theoretical model highlighting the interplay between neurobiological deficits and cognitive and emotional functioning as mediators of the link between genetic influences and early social adversity, on the one hand, and antisocial behavioral problems in childhood, on the other. In this article, we review the post-2007 evidence relevant to this model. We discuss research on genetics/epigenetics, stress/arousal regulation, and emotion and executive functioning in support of the argument that antisocial children, especially those who persist in engaging in antisocial behavior as they grow older, have a range of neuropsychological characteristics that are important in explaining individual differences in the severity and persistence of antisocial behavior. Current clinical practice tends not to acknowledge these individual neuropsychological risks factors or to target them for intervention. We argue that aggressive and disruptive behavior in childhood should be regarded as a neurodevelopmental problem and that intervening at the level of mediating neuropsychological processes represents a promising way forward in tackling these serious behavioral problems. Expected final online publication date for the Annual Review of Psychology, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Challenges for Child Mental Health Raised by School Closure and Home Confinement During the COVID-19 Pandemic

PURPOSE OF REVIEW

The closure of schools during the COVID-19 pandemic has interrupted the education of children worldwide. This paper reviews the psychological effects of this action on children and the impact on school-based services.

RECENT FINDINGS

Emerging epidemiologic findings have generated an intense debate about the need for, and potential benefit of, school closure in the context of COVID-19. International research reveals reactions in children that are not typically considered in the disaster literature as well as those that arise in other disasters. School closure also has curtailed the delivery of mental health services commonly offered in schools. The debate about school closure will likely persist depending on local disease conditions and school readiness. Moreover, school closure is a possibility in future epidemics and pandemics and other disasters. The benefit of school closure must be balanced against the risk to children's education and psychosocial development.

Impact of the COVID-19 pandemic on child and adolescent mental health services

The COVID-19 pandemic and government lockdown restrictions have had an impact on children and young people worldwide. In this editorial, we explore how and why referrals to UK children and adolescent mental health services (CAMHS) have changed during the pandemic and summarise the emerging data on the potential reasons behind this.