Coronavirus (COVID-19): impact on children, young people and families - evidence summary July 2020

Learning from past pandemics and natural disasters

Pandemic-related research findings

Many of the issues identified in COVID-19 surveys and emerging research echo those documented in historical pandemic literature. This suggests that some children and young people (in particular) and families in Scotland may be at heightened risk of adverse effects of the pandemic on their health and wellbeing.

• A systematic review^[6] on the psychological impacts of quarantine in adults suggest that the psychological impact of quarantine is wide-ranging, substantial, and can be long lasting. There seems to be a fairly consistent pattern across studies and emerging COVID-19 evidence that parents, especially women, are more vulnerable to stress and anxiety – particularly those with young children.
• Research on risk factors for health and mental wellbeing of children during quarantine include prolonged duration, fears of infection, frustration and boredom, inadequate information, lack of in-person contact with classmates, friends, and teachers, lack of personal space at home, and family financial loss^[7].
• Research from China^[8] earlier in the year suggested that the impact of prolonged school closure and home confinement may include social isolation, lengthened screen time, frustration and boredom, weight gain, and disrupted sleep cycles.
• There is emerging (international) evidence^[9] that, as anticipated, some adverse childhood experiences (ACEs) are increasing during the current pandemic such as domestic abuse and parental mental health problems and substance abuse. Risk factors for ACEs can include race/ethnicity (though more so in the US than here), socioeconomic factors and social isolation – all known risk factors for negative impacts of this pandemic. Previous evidence suggests that child abuse tends to increase during times of recession. A recent study from the Kaiser Family Foundation highlighted an increase in risk for parental mental health and substance use problems as a result of school closures, social isolation, and job loss and income insecurity. Some of the children impacted by these experiences during the pandemic may also have limited access to sources of resilience and support which further increases their risk.

Young people, isolation and mental health risks

Emerging literature on the impact of COVID-19 suggests that adolescents' mental health may be particularly vulnerable during and after this pandemic, but further research is needed.

A systematic review on 'The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19' was published in June^[10]. The review draws on more than 60 peer-reviewed studies covering isolation, loneliness, and mental health for children and young people aged between 4 and 21.

• Only one study was conducted in an infectious diseases context; its findings suggest that quarantine disease control measures can lead to an increase in mental health problems and potential post-traumatic stress in children^[8].
• The review surmises that children and adolescents may be vulnerable to depression and anxiety during and after lockdown, and that this may increase as lockdown continues. That said, it also notes that it is difficult to predict the effect that COVID-19 will have on the mental health of children and young people, given the global nature of social isolation in this context (and usage of social media) which is arguably different from individual subjective experiences of isolation described in previous research.
• Young people who are lonely might be as much as three time more likely to develop depression in the future, and the impact of loneliness could last for up to nine years.
• There was some evidence that it's the duration of loneliness as opposed to the intensity of loneliness which seems to have the biggest impact on depression rates in young people. This suggests that the easing of lockdown measures should take full account of young people's need for social connection at the earliest opportunity.
• Mental health services should be prepared for an increase in mental health problems.

These concerns are echoed in another recent paper in The Lancet Child and Adolescent Health^[11] that considers how physical distancing may have a disproportionate effect on adolescents for whom peer interaction is a vital aspect of healthy development. The paper explores how social deprivation in adolescence might have long-term consequences and considers how digital communication can enable social connection and might, therefore, mitigate the impact of physical distancing. The authors call for more information provided about the potential merits (and harms) of digital connection and for governments to address the digital divide.

Insights from disasters literature

COVID-19 shares some of the characteristics of a natural disaster: it affects the community simultaneously which impacts on the availability of health and other services; people have less support than would normally be available when they experience a traumatic event; the event occurs quickly and can be unpredictable and uncontrollable (although the latter is arguably less pronounced for COVID-19 compared to events such as earthquakes)^[12]. Evidence from previous disasters may therefore shed some light on potential impacts of the pandemic:

• Research on the mental health impacts of natural disasters and terrorist incidents on children suggests that they can suffer significant deterioration of their mental health and that these effects can persist over the longer-term^[13]. Symptoms vary depending on factors such as the nature and severity of disaster, the diagnostic criteria used, and cultural differences in understandings of trauma. Effective interventions include counselling, CBT, brief trauma/grief-focused psychotherapy, and play therapy which can be given individually and in groups^[14].
• It is not the case that young children are immune to the effects of disasters (e.g. because they can't remember them or are too young to understand). Studies of earthquakes, hurricanes and 9/11 in the US have reported PTSD and developmental delays in young children, particularly those from disadvantaged backgrounds^[15]. Children exposed to severe disaster-related stress in utero have also been shown to be more likely to be born with low birth-weight, have lower cortisol levels, lower IQ scores, language difficulties, and lower school achievement^[16]. This is consistent with wider biological evidence that stressful environments can affect pre-natal development and development after birth.
• Wider research has shown that the risk factors for PTSD in children who have experienced traumatic events (including in-utero exposure) include female gender, minority ethnicity and low socioeconomic status (SES), parent mental health problems, pre-existing mental health problems as well as the type, intensity, duration and the number of traumatic events^[17].
• Outcomes associated with PTSD in childhood include developmental delays, poorer physical health, mental health problems, suicide ideation and substance abuse; increased school absences, poor learning, memory and achievement; and impaired relationships with parents, siblings, peers and teachers^[18].

Example - A New Zealand study (2016)^[19] on children starting school in the years after a series of earthquakes in Christchurch found that behavioural problems and post-traumatic stress symptoms were significantly higher in children in the post-earthquake group than children in the control (pre-earthquake) group. The 300 children in the study (including those who were in utero at the time of the earthquake) were five times more likely to exhibit symptoms of PTSD than other New Zealand children. Eighty per cent had at least one symptom and a third exhibited at least six of 12 symptoms. About a third had eight or more behavioural problems^[20]. The study also found that children who were younger (<2) at the beginning of the earthquake period were significantly more likely to have higher behaviour problem and PTS scores than the pre-earthquake control group and older age groups in the post-earthquake groups. This suggests that very young children are more at risk of mental health impacts of significant natural disasters than older children^[9].

The question is whether the COVID-19 pandemic and associated disease control measures are equivalent to other natural (or otherwise) disasters and therefore pose the same level of risk to children's mental wellbeing. It will be crucial to track the impact of the pandemic on children and families in the short, medium and longer term, and to pay particular attention to those families and children with new or previous experience of adversity, trauma, disadvantage or discrimination.

Mitigating the impact of pandemics and disasters

Disasters and pandemic research^{[21],(22], (23],(24]} suggests that the following factors are important for protecting the wellbeing of children and young people:

Information and messaging

• Providing age-appropriate information and prioritising communication with children about COVID-19. Listening to what children believe about COVID-19 transmission; providing children with an accurate explanation that is meaningful to them will ensure that they do not feel unnecessarily frightened or guilty.

Parental advice and support

• Education and advice for parents to ensure that children are given age-appropriate, honest information at home.
• Good parenting skills are essential with an emphasis on fostering safe, stable and nurturing relationships between children and their caregivers, and maintaining close and open communication to enable early identification of issues.
• Social work and other services to provide a 'social safety net' to help parents cope in the absence of their usual support networks.

Service response and recovery

• Child and mental health services should take into account the uniqueness of each disaster/event as the actions required will vary depending on the context;
• The direct engagement of children and young people is key to minimise reporting bias by parents who may struggle recognising symptoms in their children;
• The review described above recommends that targeted efforts are made to mitigate loneliness in adolescents, and that mental health services should offer preventative support and early intervention.^[25]
• Joined up support services, ideally with a single point of contact (e.g. schools), to identify and screen those most vulnerable (using validated tools) for risk and mental health problems, and refer to relevant services.
• Recovery should take a holistic approach that includes social, school and family systems in order to achieve sustainable recovery. Attention should be given to teachers' distress, teacher–pupil relationships, and peer relationships in the school system, as well as to parents' distress, parent–child relationships, and the marital relationship in the family system.

Specialist support

• Specialist care is not usually required at early stages - instead widespread psychological first aid that focuses on psycho-education about normative reactions and coping strategies is recommended. Most children exposed to traumatic events develop fleeting psychological responses, which, although distressing, are normal. Mental health service responses should include different levels of interventions moving from universal/low-intensity interventions to specialist/ high-intensity ones [e.g. a trauma-informed approach].
• Some commentators recommend early and effective trauma screening for all children and trauma-focused cognitive-behavioural therapy for those that need it^[26].
• The provision of online evidence-based psychological services can help children and young people cope with issues such as health anxiety and family conflict.
• There is emerging evidence about the efficacy of trauma-focused cognitive–behavioural principles in early treatment for PTSD in trauma-exposed child. However, there are also concerns that certain types of early interventions (debriefing) may have harmful effects, presumably by promoting the consolidation of trauma memories.
• Other effective interventions include counselling, CBT, brief trauma/grief-focused psychotherapy, and play therapy which can be given individually and in groups.