The long shadow of the COVID-19 pandemic on children and adolescents’ mental health
In May 2023, the World Health organisation announced the end of the COVID-19 pandemic (1), which killed nearly 7 million persons worldwide since 2020 (2). One of the well-described consequences of the pandemic and of the sanitary crisis which resulted from it was a rapid and durable deterioration in the mental health of children and adolescents: in particular, a notable increase in levels of anxiety and depression (3). While this increase was highest during the course of 2020, it appears that contrary to what has been observed in adults (4), there has been no major improvement in the psychological health of young people since 2022. What is more, there is evidence of increases in self-harm and suicidal attempts (5), that is clinically-significant mental health problems that require medical attention. While the deterioration in youths’ mental health during the pandemic, when fear of illness and death due to COVID-19 made the headlines, schools were closed, sports and leisure activities were curtailed and social relations were limited, is understandable (6), what could explain the persistence of what appears to be a mental health crisis among young people? Several articles in this issue of European Child and Adolescent Psychiatry shed light upon some of the mechanisms that may be at play.
First, the study conducted by Calvano et al (7), shows an increase in levels of verbal, physical and sexual abuse towards children during the course of the COVID-19 pandemic, as well as a worsening of parental mental health. Child maltreatment and abuse are among the best described risk factors of children’s poor mental and physical health over the long-term, and the increase in the prevalence of violence among parents and toward children could have lasting effects (8). Second, the study conducted by Rapport et al. shows that children’s mental health additionally fluctuated with the prevalence of COVID-19 infection rates (9). Clearly, COVID-19 infection rates were a source of stress in and of themselves and were additionally related to the stringency of protective measures implemented, as well as decreased parental mental health in part due to a worsening in employment and income (10, 11). Several reports highlighted the relationship between parental levels of stress, anxiety and depression as well as their fluctuations and children’s mental health (12-15). It may be that in some families the COVID-19 pandemic precipitated the occurrence of parental symptoms of anxiety and depression, which in turn had a negative impact on parent-child interactions – possibly during critical periods of development - and therefore exert long-term consequences on youth well-being (16). Third, the COVID-19 appears to have had an impact on social behaviours that may have consequences on children’s and adolescents’ psychological difficulties – in particular an increase in the levels of screen use (17) and a decrease in social leisure activities which, as shown by the study conducted by Timonen et al in this month’s issue of ECAP are an important sources of positive mental health and appear to mediate the relationship between early signs of psychological distress and later psychiatric morbidity (18).
Overall, these studies highlight negative changes in multiple risk factors of children’s and adolescents’ psychological well-being in the context of the COVID-19 pandemic, some of which persist over time which could explain relatively stable rates of young people’s levels of depression, anxiety and self-harm. One of the issues that seems unresolved at this time is the extent to which the deterioration in youth mental health is a lasting phenomenon and whether it will predict a rise in the number of cases of psychiatric disorders in the future. Since the COVID-19 pandemic, the world has provided children and adolescents which much reason to worry - the Russia-Ukraine war, an economic shock and massive increases in economic and energy prices exerting pressure on family budgets, unresolved climate change, and now the war between Israel and the Hamas. In parallel, exposure to known risk factors of stress, anxiety and depression such as violence in the context of family or school, as well as school pressure, do not appear to have receded (19). Finally, child and adolescent mental health care systems are experiencing a serious shortage of professionals and underfunding across several European countries, making access to care more difficult for a substantial fraction of children in need of psychological and psychiatric treatment (20). Almost two years after the end of the COVID-19 pandemic, the global sanitary crisis casts a long shadow on children’s and adolescents’ mental health and all efforts should be made to implement actions that may help address the needs of those who require psychological attention, from broad-ranging, population-wide, psychosocial support, through psychological care all the way to psychiatric treatment whenever necessary.
References
1. World Health Organization. Statement on the fifteenth meeting of the IHR (2005) Emergency Committee on the COVID-19 pandemic. 2023. [https://www.who.int/news/item/05-05-2023-statement-on-the-fifteenth-mee…]
2. World Health Organization. WHO Coronavirus (COVID-19) Dashboard 2023. [https://covid19.who.int/]
3. Miao R, Liu C, Zhang J, Jin H. Impact of the COVID-19 pandemic on the mental health of children and adolescents: A systematic review and meta-analysis of longitudinal studies. Journal of Affective Disorders. 2023;340:914-22.
4. Sun Y, Wu Y, Fan S, Dal Santo T, Li L, Jiang X, et al. Comparison of mental health symptoms before and during the COVID-19 pandemic: evidence from a systematic review and meta-analysis of 134 cohorts. British Medical Journal. 2023;380:e074224.
5. Madigan S, Korczak DJ, Vaillancourt T, Racine N, Hopkins WG, Pador P, et al. Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis. Lancet Psychiatry. 2023;10(5):342-51.
6. Viner R, Russell S, Saulle R, Croker H, Stansfield C, Packer J, et al. School closures during social lockdown and mental health, health behaviors, and well-being among children and adolescents during the first COVID-19 wave: a systematic review. JAMA Pediatrics. 2022;176(4):400-9.
7. Calvano C, Engelke L, Holl-Etten AK, Rennenberg B, Sibylle M. Almost 2 years into the COVID-19 pandemic: an update on parental stress, parental mental health, and the occurrence of child maltreatment. European Child and Adolescent Psychiatry. 2023.
8. Li M, D'Arcy C, Meng X. Maltreatment in childhood substantially increases the risk of adult depression and anxiety in prospective cohort studies: systematic review, meta-analysis, and proportional attributable fractions. Psychological Medicine. 2016;46(4):717-30.
9. Rappaport L, Mactavish A, Mastronardi C, Babb K, Menna R, Amstadter A, et al. Monthly correlates of longitudinal child mental health during the COVID-19 pandemic according to children and caregivers. European Child and Adolescent Psychiatry. 2023.
10. Hajek A, Neumann-Böhme S, Sabat I, Torbica A, Schreyögg J, Barros PP, et al. Depression and anxiety in later COVID-19 waves across Europe: New evidence from the European COvid Survey (ECOS). Psychiatry Research. 2022;317:114902.
11. Hecker I, El Aarbaoui T, Wallez S, Andersen AJ, Ayuso-Mateos JL, Bryant R, et al. Impact of work arrangements during the COVID-19 pandemic on mental health in France. SSM Population Health. 2022;20:101285.
12. Moulin F, El-Aarbaoui T, Bustamante JJH, Héron M, Mary-Krause M, Rouquette A, et al. Risk and protective factors related to children's symptoms of emotional difficulties and hyperactivity/inattention during the COVID-19-related lockdown in France: results from a community sample. European Child and Adolescent Psychiatry. 2022;31(7):1-12.
13. Monnier M, Moulin F, Thierry X, Vandentorren S, Côté S, Barbosa S, et al. Children's mental and behavioral health, schooling, and socioeconomic characteristics during school closure in France due to COVID-19: the SAPRIS project. Scientific Reports. 2021;11(1):22373.
14. Wolf K, Schmitz J. Scoping review: longitudinal effects of the COVID-19 pandemic on child and adolescent mental health. European Child and Adolescent Psychiatry. 2023:1-56.
15. Fischer K, Tieskens JM, Luijten MAJ, Zijlmans J, van Oers HA, de Groot R, et al. Internalizing problems before and during the COVID-19 pandemic in independent samples of Dutch children and adolescents with and without pre-existing mental health problems. European Child and Adolescent Psychiatry. 2023;32(10):1873-83.
16. Thomson KC, Jenkins E, Gill R, Hastings KG, Richardson CG, Gagné Petteni M, et al. Parent psychological distress and parent-child relationships two years into the COVID-19 pandemic: Results from a Canadian cross-sectional study. PLoS One. 2023;18(10):e0292670.
17. Shoshani A, Kor A. The longitudinal impact of the COVID-19 pandemic on adolescents' internalizing symptoms, substance use, and digital media use. European Child and Adolescent Psychiatry. 2023.
18. Timonen J, Niemela S, Hakko H, Alokokkare A, Rasanen S. Social leisure time activities as a mediating link between self-reported psychological symptoms in adolescence and psychiatric morbidity by young adulthood: the Northern Finland 1986 Birth Cohort study. European Child and Adolescent Psychiatry. 2023.
19. Boer M, Cosma A, Twenge JM, Inchley J, Jeriček Klanšček H, Stevens G. National-level schoolwork pressure, family Structure, Internet use, and obesity as drivers of time trends in adolescent psychological complaints between 2002 and 2018. Journal of Youth and Adolescence. 2023;52(10):2061-77.
20. Ball WP, Black C, Gordon S, Ostrovska B, Paranjothy S, Rasalam A, et al. Inequalities in children's mental health care: analysis of routinely collected data on prescribing and referrals to secondary care. BMC Psychiatry. 2023;23(1):22.