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OFCOM’s 2020 report “Children and parents: media use and attitudes report highlights that half of 5–15-year-olds use social media sites or apps with that figure rising to 87% of 12–15-year-olds.  The most popular being Instagram, Snapchat and Facebook.  The same report identified that 61% of children aged 5-15 had their own table and 55% had their own smartphone.

OFCOM also reports that 50% of 12–15-year-olds use Facebook compared to 20% of 8–11-year-olds.  Sites such as Instagram tend to be the most popular – 20% of 8–11-year-old use Instagram and 67% of 12–15-year-olds (Ofcom 2021)

It can be concluded that social media sites such as Facebook, Instagram and Tiktok are an accessible route to engage children. Research into how CAMHS (children and adolescence mental health services) are represented upon TikTok concluded that videos raising awareness of mental health symptoms and management had a high percentage of likes and views (Chadee and Evans 2021).  This would suggest that social media is a positive media in which to share mental health education and awareness

Vicky

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Main Objective – To improve access to mental health services for children.

Strengths

·         Dedicated mental health teams around the country

·         Both NHS and private providers

·         Expert teams in IT

Weakness

·         Long waiting lists

·         Out of area treatment might be offered

·         Long waits impact the child’s education, family life, wellbeing, physical health

Opportunities

·         Petition sent to CCG – shows support from local community to make changes

·         Local community is open to other ways of engaging – suggested social media which would indicate this is their preferred method.

Threats

·         Consequences of the children having to wait

·         CCG may face legal proceedings over waiting times

·         CQC involvement

·         Reputation of the CCG

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Mental health services have suffered under austerity – in 2010/11 there were 34000 beds allocated for mental health patients compared to just 18000 in the first quarter of 2018 (Galante, Humphreys and Molodynski 2019).  Referrals to mental health services are increasing and waiting times for assessment and treatment going up (Moldoynski, McLellan and Craig et al 2020).  The impact of the Covid pandemic has exacerbated mental health conditions with those who have ongoing mental health problems reporting a worsening of their condition (Molodynski, McLellan and Craig et al 2020).

The reliance upon using out of area services for mental health treatment has been increasing.  From the period of 2014 to 2016, the use of out of area services increased by 40% and with the annual cost rose from £108 million to £159 million (Molodynski, McLellan and Craig et al 2020).  The reason for the increase can be directly linked to the reduction in mental health bed and the increased reliance upon private sector providers.  Interestingly, research highlights that those patients who have out of area treatment tend to remain in treatment for longer that those who are treated by their local NHS provider (Molodynski, McLellan and Craig et al 2020).

Vicky

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6 examples of how the NHS uses social media | Care Opinion

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I've been inspired by Dan Slee's great blog in which he gives examples of how social media is being used by the public sector to help to inform, discuss and promote their services. Do give it a read.

I thought it would be useful to pull together some of the best examples of how the NHS is using social media. I have broken up each example by how it uses social media. To explain this simply, let's use the analogy of a busy street in the middle of rush hour. The first set of examples show what happens when social media is used to broadcast, just like a person shouting for the passers-by to stop and do something. The second set aims to increase transparency; a shopkeeper asking a passer-by to come in and have a look around. And the final set (which, here at Patient Opinion, we value above all else), involving patients in the discussion, or asking shoppers to 'come sit down and chat'.
Social media as a broadcast tool
South Central Ambulance (SCAS) Social media as a tool t East and North Hertfordshire NHS Trust o increase transparency
SCAS wanted to reduce the misuse of its service. It employed an outside agency to create an incredibly powerful short film, which shows the problems caused by people who call for ambulances unnecessarily. It's a powerful film, which helps educate people on what are legitimate 999 ambulance calls. twitter and Facebook to generate discussion about this issue, which not only helped raise further awareness, but also helped people understand the issue further.
Using social media to involve patients/staff in the discussion NHS Flu Fighters
'Say yes to the test' campaign

The NHS launched its 'Say yes to the test' campaign, to promote Chlamydia testing and to raise awareness about the issue. Through its social media platform on Facebook, the campaign has currently reached over 60,000 people and is highlighting how influential social media has been for them. Facebook is helping to reach patients and is getting the message of 'Say yes to the test' out to those that matter most.

This trust chose to live tweet its annual general meeting for the first time, with great major success. The team uploaded not only tweets informing others on the event, but photos uploaded through Flickr. Check out this blog where they explain how and why it was so successful for them, and gives key tips and advice. Although it wasn't all sunshine and roses, as the staff involved admitted how stressful the process was, overall the experience seems to have been a positive one that demonstrates how live streaming can help people share content quickly and effectively.
NHS Smokefree
This HIV and sexual health centre in Soho decided to hold a twitter afternoon, attempting to highlight how having a sexual health check should be a normal part of people's lives and not something to be ashamed of. The health centre decided to follow patients through the various stages of its visit to find out what happens on a typical visit to a sexual health clinic. What a brilliant way to involve members of the public on the great work that that it does!

NHS Employers needed a bit of help to make sure that front line staff get flu jabs. The Flu Fighters campaign used social media to help. Through twitter and Facebook, it engaged NHS trusts and staff across the country, getting them talking about whether staff were getting the vaccination, and if not, why not.

It wasn't all smooth sailing, as "there is most definitely a fear factor around communication/customer engagement teams using Twitter and Facebook in the NHS". But by giving it a go, they were able to get over that 'fear factor' and really make social media an effective tool for changing behaviour.

NHS Smokefree has had great success with using social media as a support tool for people who are giving up smoking. With over 45,000 fans on facebook, it's certainly got a strong national take-up, but it's also working well locally. In Sheffield and Stoke, NHS Smokefree groups are providing support and resources that are region specific and locally appropriate.

And the most creative blog of the day goes to NHS Bradford, for their sexual health poems! A way of engaging patients and shedding light on a particularly taboo subject. They have been promoting sexual health testing by uniting services and spreading the word through using the #NHSvday hashtag on twitter.

From investigating the purposes behind the use of social media in the NHS, I discovered that each purpose has both its benefits and its flaws. As mentioned above, social media can be used as a platform to broadcast, inform and notify patients; basically a form of advertising, that involves no real form of interaction between service and service and service user. This method, if successful, can help to raise awareness of an issue, but it doesn't seem a very social use, as it doesn't bring in the views of others. Secondly, social media can help to increase transparency and openness within the NHS, by allowing patients to delve deeper into the organisation. The problem that arises from this is whether or not the service encourages the public to give a view on what they have been shown. What is the purpose of transparency? Finally, the involving patients approach acts as a forum for interaction and improvement, which seemingly has very few problems, except whether or not the service likes what the public have to say, if that criticism is taken on board. So, on the face of it, each method is of value and importance and with social media continuing to expand into new routes, I hope that the NHS remain to utilize the ever-essential tool that is social media

*Credit goes to the brilliant NHSSM, who heavily influenced this blog - check out their site, and follow their twitter debates each Wednesday at 8pm on #nhssm.

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6 examples of how the NHS uses social media

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I've been inspired by Dan Slee's great blog in which he gives examples of how social media is being used by the public sector to help to inform, discuss and promote their services. Do give it a read. I thought it would be useful to pull together some of the best examples of how the NHS is using social media.

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Children and young people's emotional wellbeing and mental health – facts and figures | Local Government Association

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Children and young people’s emotional wellbeing and mental health – facts and figures

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A collection of facts and figures regarding children and young people’s emotional health and wellbeing, access to services and government investment. They are correct as of January 2022.

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-Online surveys (link on original referral letter)
-Option of paper survey

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-Only 'bridging the gap'
-Understanding of limitations

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-Who would evaluate, when and how often?

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Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations - PMC (nih.gov)

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Abstract

Background

COVID-19 pandemic and lockdown has brought about a sense of fear and anxiety around the globe. This phenomenon has led to short term as well as long term psychosocial and mental health implications for children and adolescents. The quality and magnitude of impact on minors is determined by many vulnerability factors like developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection or fear of infection.

Aims

This paper is aimed at narratively reviewing various articles related to mental-health aspects of children and adolescents impacted by COVID-19 pandemic and enforcement of nationwide or regional lockdowns to prevent further spread of infection.

Methodology

We conducted a review and collected articles and advisories on mental health aspects of children and adolescents during the COVID-19 pandemic. We selected articles and thematically organized them. We put up their major findings under the thematic areas of impact on young children, school and college going students, children and adolescents with mental health challenges, economically underprivileged children, impact due to quarantine and separation from parents and the advisories of international organizations. We have also provided recommendations to the above.

Conclusion

There is a pressing need for planning longitudinal and developmental studies, and implementing evidence based elaborative plan of action to cater to the psycho social and mental health needs of the vulnerable children and adolescents during pandemic as well as post pandemic. There is a need to ameliorate children and adolescents' access to mental health support services geared towards providing measures for developing healthy coping mechanisms during the current crisis. For this innovative child and adolescent mental health policies policies with direct and digital collaborative networks of psychiatrists, psychologists, paediatricians, and community volunteers are deemed necessary.

Keywords: COVID-19, Lockdown, Mental health, Children, Adolescents

1. Introduction

There are more than 2.2 billion children in the world who constitute approximately 28% of the world's population. Those aged between 10 to 19 years make up 16 % of the world's population ( UNICEF, 2019). COVID-19 has impacted the lives of people around the world including children and adolescents in an unprecedented manner. Throughout the world, an essential modus of prevention from COVID- 19 infection has been isolation and social distancing strategies to protect from the risk of infection ( Shen et al., 2020). On these grounds, since January, 2020, various countries started implementing regional and national containment measures or lockdowns. In this backdrop one of the principal measures taken during lockdown has been closure of schools, educational institutes and activity areas. These inexorable circumstances which are beyond normal experience, lead to stress, anxiety and a feeling of helplessness in all.

It has been indicated that compared to adults, this pandemic may continue to have increased long term adverse consequences on children and adolescents ( Shen et al., 2020). The nature and extent of impact on this age group depend on many vulnerability factors such as the developmental age, current educational status, having special needs, pre-existing mental health condition, being economically under privileged and child/ parent being quarantined due to infection or fear of infection. The following sections discuss about findings of studies on mental-health aspects of children and adolescents impacted by COVID-19 pandemic and lockdowns being implemented at national or regional levels to prevent further spread of infection.

2. Material and methods

We searched the electronic data bases of MEDLINE through PubMed, Cochrane Library, Science-direct and Google Scholar databases, from January,2020 till June,2020. We carried out the search with the following methods like, MeSH or free text terms and Boolean operators were employed for PubMed; COVID-19 and Children [All Fields] OR (Children and COVID-19 effects [Terms] OR & Psychological effects of COVID-19 on children &Quot;[All Fields] OR (&Quot; COVID effects on children &Quot;[All Fields] AND &quot; &Quot;[All Fields]) OR effects on Children of COVID-19 &quot; Psychological effects of COVID, Children &quot;[All Fields]) OR (&quot;COVID-19 and children &quot;[MeSH Terms] OR &quot; Psychological effects of COVID-19, Children &quot;[All Fields]. This search strategy and terms were modified for other databases as appropriate. The searches were done by five independent reviewers. A manual search was also conducted of the references of the related articles to gather information about the relevant studies. Initial PubMed search with the term with " COVID-19 in children" showed only 12 results. Among these, only four articles were related to "Psychological effects of COVID in children". Therefore in order to make the review more comprehensive and informative, we also included studies that reported the effect on older children and impact of COVID1-19 on their lives. This was done keeping in mind the varied terminologies used to describe the phenomenon of 'Children and COVID-19". After using the above strategy, our search showed 112 results. Only articles in English language peer reviewed journals were included. Grey literature such as conference proceedings were not included due to possibility of insufficient information. We included case studies and review articles and Advisories by the WHO (World Health Organization), APA (American Psychiatric Association) and NHS (National Health Services) and Government of India Ministry of Health. Based on these inclusion criteria we included 22 articles. Three independent authors participated in study selection and all authors reached a consensus on the studies to be included. Being a narrative review, we did not attempt computation of effect sizes or do a risk of bias assessment for included papers.

The studies included were categorized under eight headings divided in various thematic sections and discussed with studies and reports found. The data is qualitatively analysed and reported in the paper. A summary of the papers included in this narrative review is presented in Table 1 .

Table 1

Sl.

Thematic area

Author and Year

Articles

Findings

Conclusions

1

School closures during COVID-19

Viner, R.M et al. (2020).

School closure and management practices during coronavirus outbreaks including COVID-19: A rapid systematic review
Lancet Child Adolescent Health

This systematic review included 16 articles on Closure of schools in China and its impact on transmission on COVID-19.
Studies using modelling method showed that closing the schools in itself contributes to 2-4% additional prevention of deaths due to COVID-19, which is quite less than using other methods of social distancing.

For academic social and psychological reasons, Policy makers need to consider combinations of social distancing measures which are less disrupting if restrictive social distancing policies are needed for long periods.

2

Mental health effects of School Closures

Lee, J. (2020)

Mental health effects of school closures during COVID-19. Lancet Child & Adolescent Health.

School routines are crucial for young people with mental health challenges as schools help them to cope and structure their behavior.
Children with special education needs are at high risk.
Also since the pandemic and lockdown has caused economic distress, there are indications of increased abuse towards children.

Since the pandemic is ongoing it is crucial to provide psycho social support to the minors who are highly vulnerable and are exposed to various economic and social stressors.

3

Mental health considerations for children quarantined

Liu.J.,Bao Y.,Huang X.,&Lu Lin.(2020).

Mental health considerations for children quarantined because of COVID-19. Short review

A large number of children have been quarantined in addition to the adult population.
Quarantine policies have been developed keeping in mind the impact of quarantine on mental health aspects of children

Paediatric health care workers need to focus on the emerging mental health issues of children. Recommendations should be made for early identification of mental health issues and appropriate referrals and management.

4

Impact on Young People with Mental Health Needs

The mental health charity Young Minds, 2020

Coronavirus: Impact on Young People with Mental Health Needs: 2020. Survey

Survey of 2111 individuals [age<=25 years] with history of mental health conditions in UK. The current pandemic and lockdown worsened their condition. About 26% of then were unable to access the mental health services. Since support groups and 'face to face services' were stopped.
Certain activities and routines were important coping mechanisms. Support by tele or online services was found challenging by some youth.

It was recommended that maintenance of social contact with families and friends by tele services or social platforms would help to reduce stress. However, excessive social media use should be under check.

5
Stress in students due to postponement of exams
Ng Kang chug, 5 April 2020

Coronavirus: stress over university entrance exams has skyrocketed amid Hong Kong school closures, study finds. (survey) South China morning post

The March poll, which interviewed 757 students before the first postponement of the Diploma of Secondary Education (DSE) exam - showed that over 20 per cent reported that the level of stress faced by them was maximum (10 / 10). The students reported feeling 'helpless' in this condition.

Authorities to be more transparent in their negotiations and to allow candidates sufficient notice to prepare emotionally as well. Students to be timely provided counselling.

6

Behavioral and Emotional Disorders in Children

Jiao, W. Y., Wang, L. N., Liu, J., Fang, S. F., Jiao, F. Y., Pettoello-Mantovani, M., & Somekh, E. (2020)

Behavioral and Emotional Disorders in Children during the COVID-19 Epidemic. The Journal of Paediatrics. Commentory

A collaborative working group of China-EPA-UNEPSA found
clinginess, difficulty in attention, and being irritable as commonest psychological conditions shown by all minors. Media entertainment was largely successfully used by families as a means to relieve their children's distress.

The measures suggested to the parents and their families were to increase communication with minors, playing collaborative games, encouraging physical activity, and music therapy . Moreover, parents need to focus on sleep problems and nightmares in children, and forbid augmented sleep during the daytime

7

Associations of social distancing with Mental and Social Health in adolescent.

Oosterhoff.B,et al (2020)
Adolescents' Motivations to Engage in Social Distancing during the COVID-19 Pandemic: Associations with Mental and Social Health.
98.1% respondent adolescents shared that they engaged in at least some method of maintaining social distancing. they found that different motivations for social distancing were related with the symptoms of anxiety and depression and feeling of burdensomeness and belongingness.

Among youth it is found that social distancing is viewed primarily as a social responsibility and is followed more sincerely if it is motivated by prosocial reasons to prevent others from getting sick, hence prosocial motivation for this cause should be encouraged.

8

Children and adolescents with eating disorders

David.C et al (2020).

Caring for children and adolescents with eating disorders in the current COVID-19 pandemic: A Singapore perspective. Journal of Adolescent Health.

Services for paediatric disorders related to eating habits care had made major adaptations in terms of the service delivery. This was done in response to the changing psychological and social requirements of the needs of people in Singapore during containment phase. Partnerships were established with school counselling and community services. They showed that "Coronaphobia" effected the patients' visits and increased existing health anxiety in some people.

The experience of the study provides suggestions to deal with stress and provide support for children and adolescents with eating disorders
in the present during periods of crisis.

9

Diagnosis, treatment, and prevention COVID 19 infection in children

Shen K, Yang Y, Wang T, Zhao D, Jiang Y, Jin R, et al.

Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts' consensus statement. World J Pediatr 2020.

An expert committee was called to gather consensus and standardize COVID 19 prevention and management in children. It was found that psychological counselling improves rate of recovery. If children have complaint of mood swings, fear or psychological disorder timely psychological management is warranted.

Methods of promotion of healthy and balanced diet, maintaining oral health, physical exercise, proper rest, avoidance of fatigue, and enhancing immunity are prescribed measures to preventi infection, and improving mental health

2.1. Impact on young children

Stress starts showing its adverse effect on a child even before he or she is born. During stress, parents particularly pregnant mothers are in a psychologically vulnerable state to experience anxiety and depression which is biologically linked to the wellbeing of the foetus ( Biaggi et al., 2016; Kinsella and Monk, 2009). In young children and adolescents the pandemic and lockdown have a greater impact on emotional and social development compared to that in the grown-ups. In one of the preliminary studies during the on-going pandemic, it was found younger children (3-6years old) were more likely to manifest symptoms of clinginess and the fear of family members being infected than older children (6-18 years old). Whereas, the older children were more likely to experience inattention and were persistently inquiring regarding COVID-19. Although, severe psychological conditions of increased irritability, inattention and clinging behaviour were revealed by all children irrespective of their age groups ( Viner et al., 2020a). Based on the questionnaires completed by the parents, findings reveal that children felt uncertain, fearful and isolated during current times. It was also shown that children experienced disturbed sleep, nightmares, poor appetite, agitation, inattention and separation related anxiety ( Jiao et al., 2020).

2.2. Impact on school and college going students

Globally, the pre-lockdown learning of children and adolescents predominantly involved one-to-one interaction with their mentors and peer groups. Unfortunately, the nationwide closures of schools and colleges have negatively impacted over 91% of the world's student population ( Lee, 2020). The home confinement of children and adolescents is associated with uncertainty and anxiety which is attributable to disruption in their education, physical activities and opportunities for socialization ( Jiao et al., 2020). Absence of structured setting of the school for a long duration result in disruption in routine, boredom and lack of innovative ideas for engaging in various academic and extracurricular activities. Some children have expressed lower levels of affect for not being able to play outdoors, not meeting friends and not engaging in the in-person school activities ( Lee, 2020; Liu et al., 2020; Zhai and Du, 2020). These children have become more clingy, attention seeking and more dependent on their parents due to the long term shift in their routine. It is presumed that children might resist going to school after the lockdown gets over and may face difficulty in establishing rapport with their mentors after the schools reopen. Consequently, the constraint of movement imposed on them can have a long term negative effect on their overall psychological wellbeing ( Lee, 2020).

A study found that older adolescents and youth are anxious regarding cancellation of examinations, exchange programs and academic events ( Lee, 2020). Current studies related to COVID-19 demonstrate that school shut downs in isolation prevent about 2-4% additional deaths which is quite less if compared to usage of other measures of social distancing. Moreover, they suggest to the policy makers that other less disrupting social distancing strategies should be followed by schools if social distancing is recommended for a long duration ( Lee, 2020; Sahu, 2020; Viner et al., 2020a). However, in current circumstances, it is controversial whether complete closure of school and colleges is warranted for a prolonged period.

It has been reported that panic buying in times of distress indicate an instinctual survival behaviour ( Arafat et al., 2020). In present pandemic era there has been a rise in the hoarding behaviour among the teenagers ( Oosterhoff et al., 2020a). It is also found that among youth social distancing is viewed primarily as a social responsibility and it is followed more sincerely if motivated by prosocial reasons to prevent others from getting sick (Oosterhoff et al., 2020a). Further, due to prolonged confinement at home children's increased use of internet and social media predisposes them to use internet compulsively, access objectionable content and also increases their vulnerability for getting bullied or abused ( Cooper, 2020; UNICEF, 2020b). Worst of all, during lockdown when schools, when legal and preventative services do not functioning fully, children are rarely in a position to report violence, abuse and harm if they themselves have abusive homes.

2.3. Impact on children and adolescents having special needs

There are about 1 in every 6 children within the age group of 2-8 years who have some or the other neurodevelopmental, behavioural or emotional difficulty ( CDC, 2019). These children with special needs [autism, attention deficit hyperactivity disorder, cerebral palsy, learning disability, developmental delays and other behavioural and emotional difficulties] encounter challenges during the current pandemic and lockdown ( CDC, 2019). They have intolerance for uncertainty and there is an aggravation in the symptoms due to the enforced restrictions and unfriendly environment which does not correspond with their regular routine. Also, they face difficulties in following instructions, understanding the complexity of the pandemic situation and doing their own work independently. With the closure of special schools and day care centres these children lack access to resource material, peer group interactions and opportunities of learning and developing important social and behavioural skills in due time may lead to regression to the past behavior as they lose anchor in life, as a result of this their symptoms could relapse ( Lee, 2020). These conditions also trigger outburst of temper tantrums, and conflict between parents and adolescents. Although prior to the pandemic, these children had been facing difficulties even while attending special schools, but in due course they had learnt to develop a schedule to adhere to for most of the time of the day ( APA, 2020; Cortese et al., 2020; UNICEF, 2020a). To cater to these challenges, it is difficult for parents to handle the challenged children and adolescents on their own, as they lack professional expertise and they mostly relied on schools and therapists to help them out ( Dalton et al., 2020).

Since every disorder is different, every child has different needs to be met. The children with autism find it very difficult to adapt to the changing environment. They become agitated and exasperated when anything is rearranged or shifted from its existing setup. They might show an increase in their behavioral problems and acts of self-harm. It is a huge challenge for parents to handle autistic children due to lockdown. The suspension of speech therapy and occupational therapy sessions could have a negative impact on their skill development and the achievement of the next milestone, as it is difficult for them to learn through online sessions ( UNICEF, 2020a). The children with Attention Deficit Hyperactivity Disorder (ADHD), struggle to make meaning of what is going around them from the cues they get from their caregivers. It is difficult for them to remain confined to a place and not to touch things, which might infect them. Due to being confined to one place the chances of their hyperactivity increases along with heightened impulses and it becomes difficult for the caregivers to engage these children in meaningful activities ( Cortese et al., 2020).

Obsessive compulsive disorder (OCD) among the children and adolescents is estimated to be of 0.25%-4% among children and adolescents ( CDC, 2019). Children with OCD are suspected to be one of the most affected ones by this pandemic. Due to obsessions and compulsions related to contamination, hoarding, and somatic preoccupation, they are expected to experience heightened distress. Cleanliness is one key protective measure against the spread of COVID-19. According to United Nations' policy guidelines to fight the infection one has to be careful about washing their hands six times a day, and whenever they touch anything ( APA, 2020; United Nations, 2020). The lockdown, which has made the healthy population distressed about possessing enough food and prevention related resources like masks and sanitizers, has made it worse for people with hoarding disorder ( APA, 2020; Mukherjee et al., 2020)

2.4. Impact of lockdown on underprivileged children

Social inequality has been associated with the risk of developing mental health challenges. The pandemic and lockdown world has experienced global economic turn-down which has directly worsened the pre-existing social inequality. In developing countries, with the imposed lockdown, the underprivileged children face acute deprivation of nutrition and overall protection. The prolonged period of stress could have a long term negative impact on their development. For instance, in India, which has the largest child population in the world with 472 million children, the lockdown has significantly impacted 40 million children from poor families. These include children working on farms, fields in rural areas, children of migrants and street children ( Dalton et al., 2020; Rosenthal et al., 2020). An increasing number of poor and street children now have no source of income, making them a high risk population to face abuse and mental health issues with greater vulnerability and exposure to unfavorable economic, social and environmental circumstances ( Birla, 2019).

A home represents a source of security and safety in most families. However, for the poor and the underprivileged it is just the opposite. With the restriction of movement due to lockdown, these children have increased risk of being exploited and become victims of violence and abuse ( Cooper, 2020; United Nations, 2020). The Deputy Director of 'CHILDLINE 1098' India, announced that India saw a 50 per cent increase in the calls received on helpline for children since the lockdown began ( PTI, 2020). This increase in rate is alarming and has made an increasing number of child victims in their own homes.

During the time of lockdown an increasing number of poor families have no source of daily wages which lead to frustration and feelings of helplessness. By the reason of displacement, the frustration and family conflict may manifest itself in the form of violence towards children. This can make the child more vulnerable to depression, anxiety and suicide ( Jiao et al., 2020; Petito et al., 2020; Solantaus et al., 2020) School closure coupled with economic adversity may force children and adolescents into child labour. Likewise, children without parents or guardians are more prone to exploitation ( United Nations, 2020).

In order to cover up the loss of education during lockdown, many schools have offered distance learning or online courses to students. However, this opportunity is not available to underprivileged children as a result of which they face a lack of stimulation and have no access to online resource material to study. A study pointed out that in underprivileged families, in comparison to boys, girls have decreased access to gadgets, this may diminish their involvement in digital platforms of education ( McQuillan and Neill, 2009). Due to this gender inequality, increasing number of girls are prone to bear the consequences of school dropouts once the lockdown is lifted ( Cooper, 2020; PTI, 2020).

2.5. Impact due to quarantine and separation from parents

COVID-19 infection is expressed differently in children and adolescents. Yet the incidents of infection in the minors have been reported worldwide, which result in children being quarantined. Moreover, in many cases a single parent or both the parents are infected and quarantined. In either condition children are separated from their parents. Many countries have laid down strict quarantine policies as a measure to fight COVID-19 pandemic. Such as in China several adults, adolescents and children have been put in complete isolation to control the spread of infection. Although quarantining measures are for the benefit of the community at large, its psychological effects cannot be ignored ( Liu et al., 2020). The children who are in isolation require special attention as these children might be at risk of developing mental health problems due to grief caused by of parental separation. As during the formative years of life, the role of parents is very crucial, any disruption in the form of isolation from parents can have long term effects of perceived attachment of the child. It is found that separation from the primary caregivers can make a child more vulnerable and can pose a threat to a child's mental health ( Cooper, 2020; Jiao et al., 2020; Liu et al., 2020). The children may develop feelings of sadness, anxiety, fear of death, fear of parents' death and fear of being isolated in the hospital which may have a very detrimental effect on their psychological development ( APA, 2020; CDC, 2019; Dalton et al., 2020). Children have emotionally pent up feelings of distress which may turn inwards into emotional fear or outwards towards acting out behavior ( Liu et al., 2020). They might feel separated or alone as they have limited knowledge and level of maturity to understand the implications of the current pandemic situation in their limited world.

2.6. Advisories of international organizations

With the objective of universal prevention and mental health promotion, the International organizations and advisory bodies have issued various guidelines taking into account the mental health needs of children during the COVID-19. They have suggested parents to interact constructively with the children by communicating with them about the current pandemic, according to their maturity level and their ability to comprehend the crisis. Parents should plan their children's tasks one at a time, involve them in various home activities, educate them about following hygiene habits and social distancing, engage in indoor play and creative activities. In addition to these activities, adolescents are advised to be involved in household chores and understand their social responsibilities ( WHO, 2020b). Interventions supervised by adults can help them in understanding their concerns. The activities of children and adolescents should include more structure in home schooling activities. Children should be encouraged to socialize with their friends and classmates through digital forums under adult supervision ( WHO, 2020a).

The advisory committees have also provided guidelines for managing children with special needs and neurodevelopmental disorders ( UNICEF, 2020a, 2020b; WHO, 2020a). The children prone to risk for trauma and heightened anxiety. The children need early identification prompt management involving the parents and experts to prevent long term mental health morbidity.

2.7. Recommendations

It is imperative to plan strategies to enhance children and adolescent's access to mental health services during and after the current crisis. For this direct and digital collaborative network of various stakeholders is required. Recommendations for ensuring mental well-being of children and adolescents during the COVID-19 pandemic and lockdown and the role of parents, teachers, pediatricians, community volunteers, the health system and policy makers are being discussed. In addition a brief summary of the roles is given in Table 2 .

Table 2

S. no.

Target Group/Support System

Primary Roles

1
Young Children

2
School going children and adolescents

3
Children with special needs

4
Underprivileged/vulnerable children

5
Quarantined parents/children

2.8. Role of Parents

In the times of paramount stress and uncertainty, a secure family environment which the parents can provide is a strong protective factor ( Schofield et al., 2013). There is evidence to show that parental practices and coping measures affect the children's post disaster mental health ( Cobham et al., 2016). Parents need to respond to the needs of their children based on the developmental phase of the child is being discussed below:

2.12. Role of pediatricians

During a child's formative years when their personalities are shaped, parents are in regular touch with pediatricians, as parents reach out to their local pediatricians whenever they encounter health/ behavioral complaints associated with their children. Parents expect answers from them as they trust them. Hence a pediatrician's role is paramount in promoting mental health, developing resilience, recognizing mental health problems, and coordinate with the mental health care providers when it comes to mental health care of children. In the backdrop of COVID 19 specific roles of pediatricians are enlisted below:

2.15. Critical appraisal of the studies included

The studies included in the review were collected after setting criteria to have a comprehensive view of the global vision in managing the crisis of children in the COVID-19 pandemic. The majority of the studies included in the review were based on online self-reports( Bhat et al., 2020; Jiao et al., 2020; Oosterhoff et al., 2020b). The adults and older children were the respondents of the study( Lee, 2020; Liu et al., 2020; Viner et al., 2020b; Wang et al., 2020). The studies are mainly carried out in the developed nations and the East Asian countries. Studies have reported the concerns may not be generalizable throughout the globe. There are variations in the number of samples as well, thus they make it difficult to generalize the findings of their study alone.

The cross sectional studies are useful in understanding the immediate or short term impact apparent at a certain point of time. However the limitations of these cross sectional studies are that these studies cannot conclude about the long term impact of COVID-19, given that certain pre-existing vulnerabilities, high risk factors and stressors could be multiple, ongoing or recurrent and also the manner through which they work may vary. Consequently, there is a pressing need for carrying out longitudinal and developmental studies to be able to apprehend multiple layers of dynamic determinants playing role during this time of global crisis ( Holmes et al., 2020).The literature suggests the need for evidence based elaborative strategies and plan of action to cater to the mental health needs of children and adolescents during the period of pandemic ( Wade et al., 2020).

3. Limitations

The review articles for this review have been selected during the time of global lockdown, where the issues and challenges were new and the global crisis was at peak times. In our review, we were unable to track the measures of management targeted towards the children. The strategies reported in the studies were isolated to geopolitical conditions. The recommendations provided in this review can be modified to suit the needs of the places according to their local resources and geopolitical scenarios. Due to strict selection criteria and the short period of data collection and the only use of electronic databases for our research, there is a possibility of missing studies relevant to the care of children and adolescents.

4. Conclusion

Although the rate of COVID-19 infection among young children and adolescents is low, the stress confronted by them poses their condition as highly vulnerable. Many cross-sectional studies have been conducted to analyze the impact of COVID-19 and lock down on children and youth. The results of these studies show that the nature and extent of this impact depend on several vulnerability factors such as the developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection /fear of infection. Studies show that young children show more clinginess, disturbed sleep, nightmares, poor appetite, inattentiveness, and significant separation problems.

The containment measures like school and activity centers closures for long periods together expose the children and youth to the debilitating effects on educational, psychological, and developmental attainment as they experience loneliness, anxiety, and uncertainty. Compulsive use of internet gaming and social media puts them at higher risk. Children and adolescents with mental health conditions are not used to variation in the environment. Hence there could be an exacerbation in symptoms and behavioral problems.

The children who receive training, therapy, and other treatments are at high risk of being derailed from therapy and special educations. Economically underprivileged children are particularly prone to exploitation and abuse. Children quarantined are at high risk for developing higher risk for mental health-related challenges.

There is a need to ameliorate children and adolescent's access to mental health services by using both face to face as well as digital platforms. For this collaborative network of parents, psychiatrists, psychologists, pediatricians, community volunteers, and NGOs are required. There is a need for 'tele mental health compatibility' and be accessible to the public at large. This would be crucial to prevent during and post-pandemic mental challenges in the most vulnerable and underprivileged section of the society. The focal point of the health care system and policymaking should be prevention, promotion, and interventions corresponding to the public mental health system to meet the mental health needs of the population at large by taking the regional contextual parameters into account.

Disclosure of prior presentation of study data

This paper has not been submitted in full or part in any conference and is not being considered for publication elsewhere.

Financial disclosure

This is a completely researcher initiated study without any external funding whatsoever.

CRediT authorship contribution statement

Shweta Singh: Writing - review & editing, Software, Validation, Supervision, Data curation, Writing - original draft, Conceptualization, Methodology. Deblina Roy: Validation, Visualization, Investigation, Data curation, Writing - original draft, Software. Krittika Sinha: Visualization, Investigation, Data curation, Writing - original draft. Sheeba Parveen: Visualization, Investigation. Ginni Sharma: Visualization, Investigation, Data curation, Writing - original draft. Gunjan Joshi: Visualization, Investigation, Data curation, Writing - original draft.

Declaration of Competing Interest

There is no known conflict of interest.The authors whose names are listed below certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants, participation in spakers' bureaus arrangements, consultancies, memberships, stock ownerships, or other equity interest, or expert testimony and patent licencing arangements) or non financial interests such as ( personal or professional relationships, affiliations, knowledge or beliefs)in the subject matter or materials discussed in this manuscript. All the authors confirm that, all of them has contributed in the conception of design; analysis, interpretation of data; drafting the article; critically revisiting the article for important intellectual inputs; and approval of the final version. This paper has not been submitted elsewhere or is under review at another journal or publishing venue. The authors have no affiliation with any organization, with a direct or indirect financial interest in the subject matter discussed in the manuscript.

Acknowldegment

We would like to Acknowldge the efforts of Mrs. Meenakshi Seth and Mr. Prakhar Bhanu, who were involved in improving the language of the manuscript. Additionally the authors are gratefull to the CORONA Warriers i.e. the Health Care Workers for their selfless and tremendous service to the mankind.

Footnotes

☆ This paper is aimed at reviewing articles related to mental-health aspects of children and adolescents impacted by COVID-19 pandemic and lockdowns. There is a need to carry out longitudinal and developmental studies and plan strategies to enhance children's and adolescent's access to mental health services during and after the current crisis. For this direct and digital collaborative network of psychiatrists, psychologists, pediatricians, and community volunteers are of vital importance.

Supplementary material associated with this article can be found, in the online version, at doi: 10.1016/j.psychres.2020.113429.

Appendix. Supplementary materials

References

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Articles from Psychiatry Research are provided here courtesy of Elsevier

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Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations

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COVID-19 pandemic and lockdown has brought about a sense of fear and anxiety around the globe. This phenomenon has led to short term as well as long term psychosocial and mental health implications for children and adolescents. The quality and magnitude ...

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Impacts of lockdown on the mental health of children and young people | Mental Health Foundation

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Read the executive summary of this report here.

Introduction

One of the most significant public health measures implemented during the COVID-19 pandemic has been extended periods of 'lockdown' where whole populations have been advised to remain in their households other than to collect necessary supplies, to care for others, or to exercise.

There are increasing calls to understand the impacts of this lockdown, and of subsequent school closures, on the mental health and wellbeing of children and young people during the COVID-19 pandemic ¹⁻⁵. As lockdown measures begin to ease, we require an understanding of what children and young people have been experiencing during the lockdown period1 as well as how children and young people can be best supported to resume to normal life, or the 'new normal', over the coming months and years. This understanding can inform responses to recovery implemented at the policy level and by those working directly with children and young people. Such responses are beginning to be formalised in other countries. For example, the New Zealand Government have published a national psychosocial and wellbeing recovery framework with a focus on prevention and early intervention upheld through the principles of collectivity, empowerment, community solutions, assets-focus, and support for community and specialist services.

In this evidence overview, we consider empirical studies of the impacts of lockdown of both COVID-19, and of similar previous health-related disasters, to identify important considerations about the mental health and wellbeing impacts of lockdown, both positive and negative, on children and young people. By similar health-related disasters in the past, we refer to previous pandemics, epidemics, and other health disasters. Given that much of the literature in this space is not focused specifically on the mental health and wellbeing of children and young people1 , we consider the empirical evidence of impacts across three areas:

1. The individual: Direct impacts on children and young people's mental health and wellbeing

2. The interpersonal/family: Impacts within the family context

3. The school: Impacts within the context of education

Based on our findings, we consider policy and practice recommendations that can help to inform solutions and responses to the challenges facing children and young people, their families, and those who work with these groups. As a result, this overview is focussed predominantly on the problem. This is an emerging situation evidence of effective interventions are limited. As such, we hope that by broadly contextualising some of the mental health impacts and challenges for children and young people, that decision-makers have more informed scope to develop effective programmes and interventions to support children and young people going forward.

Approach to reviewing literature

This evidence overview used the following structured approach to identify key pieces of empirical literature to include. The focus was on empirical research and therefore we include both primary research articles and articles analysing secondary data or conducting systematic/ rapid reviews of empirical literature.

To begin with we focussed on a wide set of events which could be considered similar to COVID-19. Initially, this included pandemics, epidemics, health disasters, natural disasters, and conflict zones. The hits on this wide search were large, so we decided to focus on health-related disasters more narrowly. Indicative search terms relating to health-related disasters include: pandemic OR endemic OR covid OR coronavirus OR SARS OR MERS OR H1N1 OR ebola OR health NEAR/2 [N1] disaster OR outbreak OR isolate* OR quarantine OR social distanc* OR home confin*. Searches were then refined to focus on mental health and wellbeing impacts and children and young people. This overview includes only articles printed in English. Searches were undertaken in the Web of Science and PsychInfo databases. Thereafter, the reference lists of relevant articles were reviewed to identify additional relevant articles. In the overview of evidence, we also consulted available findings from several large-scale surveys of the mental health impacts of COVID-19 that relate to the potential impacts of lockdown. The surveys include but are not limited to: Mental Health in the Pandemic i , Lockdown Lowdown ii, Co-SPACE iii & Co-SPYCE studies, Office for National Statistics routine survey of 16+ iv, and the Carers Trust Survey of Young carers v.

Key findings

The individual: direct impacts on children and young people's mental health and wellbeing

The direct impact of lockdown on the mental health and wellbeing of children and young people yields mixed findings. Findings center on the mental health and wellbeing impacts of lockdown and the factors affecting mental health and wellbeing.
Mental health and wellbeing impacts of lockdown for children and young people
In some cases, where quarantine was not at the population level, e.g. only required for those with contact with infected persons, one study on the impacts in the context of the H1N1 influenza found no immediate negative psychological effect of quarantine for undergraduate students ⁷ . However, in the case of the SARS epidemic, stress scores for Post-Traumatic Stress Disorder (PTSD) were reported by parents to be 4 times higher in children quarantined than those not quarantined ⁸, ⁹: in this case, criteria for PTSD was met by 30% of quarantined children. A study from India, during the COVID-19 pandemic, yields similar results 10 and further studies conducted in China find that young people report increased depressive symptoms and anxiety symptoms ¹¹ and can experience negative psychological consequences as a result of the COVID-19 pandemic ¹².

Qualitative evidence indicates a number of reasons for these findings including the perceived threat of the virus, confusion, disruption, and isolation imposed by this type of health-related crisis8. Other studies have found that levels of distress were higher in young adults as a potential consequence of increased consumption of social media for example 13,14. Emerging evidence from the COVID-19 pandemic in the UK suggests similar trends that young people, in particular teenagers, in the UK are feeling more anxious than they did before the outbreak, a trend which is up to 10% higher for black and mixed race participants ¹⁵. Further evidence of the mental health and wellbeing impacts of this kind of quarantine related to both the fear of stigma and the stigma experienced by those young people who had been quarantined and returned to college 16 which this study identifies as a risk factor for maintaining social support mechanisms with friends, classmates, or roommates post-quarantine.

Young carers are one group whose mental health has been negatively impacted by the lockdown restrictions. A survey of nearly 1000 young carers in the UK found that over half of young carers have felt overwhelmed and stressed and have, as a result, suffered worsened mental health during the a. The individual: direct impacts on children and young people's mental health and wellbeing 7 lockdown period ¹⁷. Around a third of those surveyed said they struggled to get emotional support with some respondents saying they had increased their alcohol intake as a result of the stresses they were feeling, and were struggling to take care of themselves. The survey identified that young carers require more practical support in coping with day to day life, but also more access to peer support, either online or in-person.
Factors affecting the mental health and wellbeing of children and young people Loneliness
Loneliness is considered as a key risk factor of lockdown for the mental health and wellbeing of children and young people. A rapid review of the links between loneliness and mental health highlights the potential for increases in children and young people experiencing loneliness to link to mental health problems in children and young people ¹⁸. However, it is important to note that experiences of loneliness involve some form of social comparison, and in the UK case, the shared experience of lockdown might mitigate the negative impacts of loneliness to some extent18. Yet, emerging evidence of the impact of the COVID-19 pandemic suggests that, despite the shared experience of lockdown, children and young people are experiencing loneliness. Emerging evidence suggests that, amongst the general population in the UK, the proportion of adults experiencing loneliness is highest amongst young adults aged 18-24 ¹⁹, with another survey identifying that 50% of 16-24 year-olds have experienced 'lockdown loneliness' ²⁰. This could, as the literature suggests, be a consequence of the loss of peer group support during this important developmental stages where peer interaction is important for brain development, self-concept construction, and ultimately mental health and wellbeing 18,21. #
Worries about school and the future
Emerging evidence from the COVID-19 pandemic also suggests several other factors influencing the mental health and wellbeing of children and young people including: worries and concerns around their education (all ages), missing school (all ages), transitions and being away from school (primary school age), academic pressures (secondary school age), their career (young adults), and uncertainties about the future more generally (young adults) 19,22,23. Similarly, in the case of children and young people currently in contact with youth justice systems, it has similarly been reported that lack of contact with others, boredom, not being able to attend school, financial worries and general uncertainty about the future are key factors impacting mental health and wellbeing ²⁴.
Supporting mental health and wellbeing
One study has found that a majority of participating parents report that their children are keeping in regular contact with family and friends via video-chat and are getting regular physical exercise ²⁵, factors that can support the mental health and wellbeing of children and young people ²¹. However, this was not the case with pre-school age children in one survey, where parents had concerns about their children's lack of communication with others outside the household ²⁶.

The interpersonal/family: impacts within the family context/on parents and carers

An important consideration about the impact of quarantine is the impact on both the relational family contexts in which children and young people are isolating, and the impacts on the mental health and wellbeing of parents/ caregivers more generally. This is particularly important to consider given the wide range of literature evidencing the long-term health and wellbeing impacts of traumatic events that occur during childhood ²⁷. Such traumatic events include but are not limited to the experience of or witnessing violence, abuse, and neglect in the household, substance abuse, mental health problems, and parental separation and, overall, a lack of sense of safety, stability and bonding within the household ²⁸.
Mental health and wellbeing impacts of lockdown on parents/carers
For a variety of reasons, quarantine can be traumatising for some parents8. In a study on post-traumatic stress disorder in health-related disasters, criteria for PTSD was met in 25% of isolated or quarantined parents ⁸. The same study found links between PTSD criteria in adults and their children having PTSD symptoms ⁸. Duration of quarantine and consequent lack of social and physical contact with friends/family and the outside world has been shown to be associated with increased PTSD symptoms29. Similarly, it has been shown that social isolation and associated loneliness have a negative impact on mental health outcomes for adults ³⁰. Other factors that have been shown to have an impact on stressors and wellbeing9 include the duration of quarantine, fear of infection, frustration and boredom, inadequate supplies and information (guidelines, rationale for actions, and level of risk), loss of work or working more than usual ³¹, or COVID-19 related stressful life events e.g. bereavement/having an acquaintance infected 14,31,32. The links between experience of COVID-19 related stressful life events and increased stress were shown to be the case in one study regardless of previous mental illness or childhood trauma ³¹.

The psychological impacts are particularly important to consider in cases where parents are front-line workers 4 with much evidence showing that those working in health care in particular, experience negative psychological consequences during health emergencies 33,34. Moreover, in the case of healthcare workers, quarantine has been associated with distress, exhaustion, detachment, anxiety, and PTSD symptoms over time ⁹, all of which will impact upon the home environment. Worryingly, the same study identified that alcohol abuse and dependency, and avoidance behaviours were positively associated with workers having been quarantined 9 , all of which have been shown to have negative effects on the mental health and wellbeing of children in such households ²⁸. One UK-based study has found that children (aged 13-24) of key workers have experienced greater levels of COVID-19 anxiety and trauma and also report more somatic symptoms ¹⁵.
Factors affecting mental health and wellbeing in the context of the family Groups disproportionately affected by lockdown
There is mixed evidence of the factors associated with pre-quarantine predictors of impact on mental health and wellbeing. Some factors associated with negative effects on the mental health and wellbeing of adults include those that are younger 9,13,31,35, female 9,13,14,31,32,33,35,36, with a history of psychiatric illness or chronic illness/ poor health (diagnosed or selfreported) 14,31,32,33,35,36, and single parent adolescents ¹ . There is mixed evidence on the impact of education level as a predictor of impact of lockdown on mental health 9,13,36. Post-quarantine stressors can include: finances9, ³⁷ and stigma for healthcare workers ⁹ . At a broader level, Harkins has identified that there are several groups who have experienced, and are still experiencing, disproportionate vulnerability to the 'lockdown' public health measures ³². These groups include: disadvantaged communities, people with disabilities, BAME groups, people experiencing homelessness, those affected by violence, older people, and frontline health and care staff ³². Particular note should also be given to the increases in both calls and referrals to domestic abuse charities 38,39, with the mental health impacts this has for the victim, and to the children and young people witnessing or experiencing such abuse, being of primary concern as we emerge from lockdown.
Worries about financial security, homelife, and the future
Emerging evidence from the COVID-19 pandemic suggests that in general, many adults are feeling anxious or worried about the future. In particular, adults who are unemployed have reported not coping as well19 with a quarter of this group feeling hopeless with primary concerns around financial security ¹⁹. Parents who are working have also reported difficulties in balancing the needs of their child with the demands of working ²³. Moreover, parents with children with special educational needs/ neurodevelopmental disorders have reported that they were experiencing higher levels of stress and require more support to cope with changes in their children's behaviour ²³. One study has reported that difficulties in relationships and conflict within the family home are problematic for children and young people, particularly those with experience of the youth justice system ²⁴.

The school: Impacts within the context of education

Lockdown related school closures has been one of the most significant public health measures across the world. For children and young people in the UK , this has been the first extended closure of schools in recent history and as such, its impact on their mental health and wellbeing is important to consider, particularly given the already contentious nature of the effectiveness of school closures on disease containment1,40 and the fact that school is often the first place that children and young people can and do seek support for their mental health and wellbeing ⁴.
Worries about education
An extended period of school closures will no doubt impact curriculum delivery over the coming years and as such, school is an emerging source of distress and worry for children and young people 17,19,41. In particular, young adults are experiencing concerns about their education being interrupted and their future career opportunities ¹⁹. Young carers have also reported concerns about their education, with half of those surveyed in one study reporting that their education has suffered as a result of increased caring responsibilities and associated stresses ¹⁷. With respect to returning to school, children and young people have reported having worries over losing the enjoyable aspects of school and the impact of social distancing on friendships. In particular, one surveyreports that primary aged children worry about being away from home and transitioning between schools, whereas secondary aged children worry about increased academic pressures as well as catching COVID-19 ⁴². Moreover, a case study of a group of quarantined students during the SARS outbreak found that the students experienced stigma upon returning to their studies due to their contact with infection ¹⁶, a factor which is important to consider should we experience more localised lockdown measures during future outbreaks of COVID-19.
Factors affecting the delivery of education Disadvantage and engagement with curriculum
In terms of the delivery of education during lockdown, there has been concern over the exclusion of children without digital access, physical space, and other resources to support their learning ⁴³. Emerging evidence from England suggests that there has been a substantial deficit in curriculum coverage across schools, that just over half of parents are engaged with their children's home learning, and that less than half of pupils had returned their last piece of work at the time the survey was undertaken 43. In this particular survey, teachers expressed concern over the engagement of the most disadvantaged pupils with the analysis finding that the level of disadvantage of the school being influential on pupil engagement ⁴³. Variability in engagement with the curriculum will potentially have differing effects on both the development and mental health of pupils returning to school43. Moreover, those receiving free school meals may have experienced increasing food insecurity, although recent policy changes reflect governments' commitment to continuing such funding over the summer break this year ⁴⁴.
School responses
In previous outbreaks, there has been variability in school responses to public health measures. In one study, despite highly consistent evidence of duty of care, schools varied in extent to which information was shared openly and transparently; in how responsive school decision-makers were to the changing situation ⁴⁵. In this study, schools had reservations about the need for closures/quarantine, including a lack of understanding about the rationale for this action ⁴⁵. The study concludes that there needs to be high levels of trust between schools, public officials, and governments. School closures worked where there were high levels of trust between key players. The findings here highlight the importance of schools as agents of public health and the significance of their role in response to such crises ⁴⁵. This variability in response may have implications for parents and children. For example, there may be parental concerns about going back to school ²³, particularly worries around the child being upset and not understanding social distancing measures and so increasing their chances of catching/transmitting COVID-19. In this survey, these findings were particularly relevant in cases where children has special educational needs/ neurodevelopmental disorders, or for parents with lower incomes ²³.

Policy and practice implications for suppor ting children and young people

The overview of evidence presented here highlights some of the needs children and young people may have going forward, as lockdown measures begin to ease, and children return to school. Echoing earlier calls ¹, there seem to be several areas where attention is required, highlighting the need for a multi-disciplinary and multi-sectoral responses going forward3. Given the emerging nature of the COVID-19 pandemic, evidence for effective support mechanisms for children and young people is lacking. Nevertheless, we use the findings presented here, on the evidence of the problem, to highlight several areas for consideration for those developing programmes, interventions, and support for children and young people going forward.

a. Supporting the mental health and wellbeing of children and young people
Validating experiences
Many children and young people have likely experienced loneliness during lockdown and in particular, been affected by lack of physical contact with their friends, families and peers, and the boredom and frustration associated with a loss of all the activities they have been used to taking part in. Moreover, many children and young people have experienced worries and distress about their education and returning to school. It therefore seems important to facilitate support for children and young people that allows them to talk through some of these shared experiences and in turn, validating their experience of lockdown, whilst simultaneously informing them of what is being done to ensure their return to school and education is impacted as little as possible. For example, in one post-quarantine study of young students, students benefited from sense of connection developed with group and validating their experiences with peers, and through gaining reliable information to ease early anxieties ¹⁶. Success factors associated with this particular case of group work included a combination of psychoeducational, interpersonal, and effective elements introduced in a phased, structured approach over 5 weeks ¹⁶.
Continued communication about COVID-19
It is important that there is continued provision of clear information about COVID-1946, the rationale and guidelines for both public health measures and for supporting mental health and wellbeing for children and young people, in terms which are accessible for these groups. It is recommended that such communication continues for the foreseeable, beyond the easing of lockdown measures and return to school. Young Scot for example have provided access to a 'jargon buster' webpage on their website which communicates information about coronavirus in accessible ways: https://young.scot/ get-informed/national/coronavirusjargonbuster and provides information on the ways in which coronavirus is directly impacting children and young people.

b. Identifying and supporting vulnerable groups of children and young people

This overview has also identified that those children and young people living in families where the experience of lockdown may have been particularly difficult and challenging may require additional support to deal with the mental health and wellbeing impacts of lockdown. For example, the findings from several of the studies presented suggest that families that are young, have parents with a long-term physical or mental health conditions, have low household incomes/unemployment, or those that have experienced a COVID-19 related stressful life experience may have had particularly difficult experiences of lockdown. These are groups that may require additional support in making sense of and coping with their experiences of lockdown, particularly within the context of family support.

One study included in this overview highlights that those working with vulnerable groups should adopt a traumainformed approach to understanding the impacts of lockdown on such groups during health-related crises ⁸ in order to understand the different biopsychosocial reactions to the pandemic. The authors here suggest utilising a traumatic stress framework to organising response to provide appropriate evidence-informed care to vulnerable groups. From a policy perspective it will be important to continue to support vulnerable groups as we move out of lockdown. For example, informing policy through a trauma-informed perspective will be an important part of adequately supporting vulnerable families to begin shifting out of lockdown, especially in cases where the experience of lockdown has been particularly difficult. Similarly, some have highlighted the value of community responses to recovery ³² whereby policy should: incorporate the views and insights of community members, particularly the most vulnerable; policy should work with communities to identify and develop responses that are innovative and flexible to local circumstances and to build social cohesion; and should endorse community-based support to enhance mental health and wellbeing.

c. Returning to school
Clear communication about returning to school
This overview has identified evidence that both parents and children and young people are experiencing worry and distress about the return to school, both in terms of the process of returning to school safely and the impact on their educational experience, curriculum delivery and future prospects. Therefore, providing clear information and communication to both parents and children about the return to school will be important. This will include ensuring clarity over processes for returning to school safely, what the school-day will look like, and curriculum delivery. Evidence from experiences during the H1N1 pandemic suggest that clear communication and support from government (national and local) in facilitating the safe re-opening of schools is important. The study highlights that trust between schools and government officials will be central to enabling a safe re-opening of schools in a consistent way for all children and young people ⁴⁵. Young people have also expressed worries about how lockdown will affect their educational and career prospects. It is therefore also important to ensure that schools are providing support and reassurance to children and young people on how schools will support them to continue to sit exams and apply for further education/higher education/jobs.
Supporting those who have struggled to engage with the curriculum during lockdown
Additional guidance and support at the policy level will help schools support those children and young people for whom lockdown has been particularly challenging in terms of engagement with virtual learning, including those with no access to digital technologies and physical space to do school work, or those children and young people with special educational needs.

Research implications

There are many studies emerging of the impact of COVID-19 on the mental health and wellbeing of the population. We can also learn from similar events in the past, but evidence in such cases should be interpreted with caution given the differences between events and subsequent localised policy response. Based on the findings of this study, there is a need to understand the mental health and wellbeing impacts for children and young people, and particularly those in vulnerable groups and for whom lockdown has been particularly challenging.

The long-term effects for these groups will also require attention. In the case of education, research should continue to track the impacts of this extended period of lockdown on the delivery of the curriculum and of the process of returning to school. This learning is important for future outbreaks, but also in terms of coping with subsequent periods of lockdown should they be required in the case of a second wave of COVID-19. Moreover, as support is developed for children and young people and their families, careful attention should be paid to the evaluation of the effectiveness of such support, particularly for those groups mentioned above, for whom experiences of lockdown may have been particularly difficult.

Limitations

There are several limitations of this overview of evidence:

Whilst a structured approach to searching the literature was adopted, this was not a systematic search and as such, some relevant literature may have been omitted. Nevertheless, by searching the reference lists of identified studies, we hope that this overview provides a good coverage of empirical literature.

In terms of articles included in this review, there was no assessment of the quality of empirical studies. Moreover, the findings of different studies cannot be compared due to differences in methodology and measurement tools. This means that findings presented should be interpreted with caution.

The use of survey data is useful to contextualise academic research. However, it should be noted that included survey data are from a number of surveys, using different methodologies, and sampling strategies which are not necessarily representative of whole populations.

The findings and recommendations of this overview should be interpreted given differences of past pandemics and differences in international policy responses. Direct comparisons between events and policy responses is therefore not possible. For example, findings from the SARS epidemic should be interpreted considering a particularly high mortality rate when infected with SARS. Moreover, in past events the definition of 'quarantine'⁴⁷ may refer to individualised instances of isolation, rather than the population level lockdown experienced in the UK during the COVID-19 pandemic.

As this is an emerging phenomenon, and even though research on the impacts of COVID-19 is developing at great pace, there is still much to learn about this phenomenon, particularly its long-term impacts. These longerterm impacts should be the primary focus of researchers going forward.

Conclusions

This overview sought to provide an overview of evidence on the mental health and wellbeing impacts of lockdown for children and young people during both the COVID-19 pandemic and during similar events in the past.

Whilst studies yielded mixed findings, the findings presented here reflect not only evidence on the direct impacts to the mental health and wellbeing of children and young people but also Impacts of lockdown on the mental health and wellbeing of children and young people 16 how the challenges in the context of families and education can influence their mental health and wellbeing. As a result, it is recommended that policymakers and those working with children and young people develop and support multidisciplinary and multisectoral responses that ease the anxieties and worries of this group more broadly, but also identify and support those for whom lockdown will have been most challenging.

i. https://www.mentalhealth.org.uk/our-work/research/coronavirus-mental-hea...

ii. https://www.youthlinkscotland.org/news/april-2020/survey-reveals-96-of-y...

iii. https://emergingminds.org.uk/co-space-study-news/

iv. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/... coronavirusandthesocialimpactsongreatbritain/previousReleases

v. https://carers.org/what-we-do/our-survey-on-the-impact-of-coronavirus-on...

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Impacts of lockdown on the mental health of children and young people

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Read the executive summary of this report here. One of the most significant public health measures implemented during the COVID-19 pandemic has been extended periods of 'lockdown' where whole populations have been advised to remain in their households other than to collect necessary supplies, to care for others, or to exercise.

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-Natalie

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-Introduce group therapy sessions online(limit to 4 families). This could be facilitated by final year students under supervision(important to have universities on board and could be part of a module or a competency to be achieved or signed of).
-create a section for school's pastoral team with activities/ideas to use to support these children. Early intervention is crucial (Mindfulness, CBT resources, talk and draw sessions).
-Consider our diverse community in order to be inclusive( sign language, pictures, translate to other languages spoken in the community).
-database of vetted parents who are willing to support other families with their own experiences-(buddy system)
Patience

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Impact on young people - data from GOV.UK

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Impact on young people - data from GOV.UK

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https://www.gov.uk/government/publications/covid-19-mental-health-and-wellbeing-surveillance-report/7-children-and-young-people

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This chapter is part of the COVID-19: mental health and wellbeing surveillance report. The report is about population mental health and wellbeing in England during the COVID-19 pandemic. It includes up to date information to inform policy, planning and commissioning in health and social care. It is designed to assist stakeholders at national and local level, in both government and non-government sectors.

The report is regularly updated with the most recent information available. It currently reflects information up to week 30 of 2020. The report follows a standard structure, to enable regular and easy use. This is chapter 7: Children and young people.

This section presents emerging findings from UK studies on the mental health (MH) and well-being of children and young people ( CYP) in relation to the coronavirus (COVID-19) pandemic and includes published studies found up to 10 July. For this report CYP is considered to be those aged 4 to 19, however some reporting for young adults has been drawn upon where findings include 16 to19 year olds.

Findings presented below need to be considered as indicative and not conclusive evidence of impacts at this stage (due to non-representative sampling, a lack of peer review, and other methodological constraints). Nevertheless, they provide us with an indication of the experiences of children and young people in the current period and the groups at greater risk of impacts on their mental health. Details of the method of searching and compiling evidence can be found in the Methodology document.

This version is based on emerging data found by a combination of rapid and informal searching.

Important gaps in publicly available findings so far include:

measures of mental health in younger children

changes in children's mental health against a recent pre-COVID-19 baseline

representative evidence on the experiences and mental health of children and young people from particular sub-groups, such as those living in areas of deprivation or with protected equalities characteristics

access to or change in protective factors

experiences of important pandemic related risk such as the experience of illness, bereavement or multiple parental stresses

1. Important findings so far

There is growing indicative evidence that coronavirus (COVID-19) and associated interventions, such as social distancing and stay at home guidance including school closures, have likely had an adverse effect on the mental health and wellbeing of children and young people ( CYP).

Loneliness has been a challenge for some CYP, although some have reported benefits for their mental health.

While many children and young people have retained some access to mental health support during this period, a lack of access to mental health support has been associated with worse mental health and wellbeing for some CYP.

There are indications that these experiences may vary by CYP characteristics.

1. There is mixed evidence on whether mental wellbeing varies by ethnicity during COVID-19. Some evidence suggests that young people from Black, Asian and Minority Ethnic ( BAME) backgrounds have experienced a higher rate of mental health and wellbeing concerns, though other studies have not found this to be the case.

2. Emerging evidence on young people with existing mental health conditions suggests that the pandemic has negatively affected the mental health and wellbeing of many of these young people, but there are no robust comparisons.

3. Parents have reported that CYP with Special Educational Needs and Disabilities ( SEN(D)) have been negatively affected by the pandemic, but measures of emotional and behavioural difficulties do not show a widening gap with their peers.

4. There is limited evidence available on the experiences of young people in low income areas - what evidence there is highlights the possible effects of their situation, for example having lower access to technology to communicate with friends, a protective factor in CYP wellbeing.

The latest evidence reviewed here suggests that vulnerable children and other CYP with challenging home environments, are more likely than others to have had experiences during the pandemic associated with a risk to mental health and wellbeing such as:

loneliness

disruption to access to support

difficult relationships within the home

parental stress or poor mental health

a lack of access to the outside or natural environment

2. COVID-19 impact on children and young people's mental health

Across multiple studies many young people report that coronavirus and lockdown have had a negative impact on their mental health and wellbeing. However, not all young people report a change in their mental health and some CYP report an improvement in their mental health. For example, the graph below from the COVID-19 Psychological Research Consortium (C19PRC) (a non-representative study of 2,000 13 to 24 year olds surveyed in April) shows that over half of 13 to 18 year olds felt no more anxious than prior to lock down.

Some of the same studies suggest that a majority of children and young people report that they are coping with changes due to the pandemic.

3. Suicidal thoughts and self-harm

As suicidal thoughts and self-harm are sensitive topics, most studies in CYP during the pandemic do not raise this subject with young people. However, there is emerging evidence in this area from other data sources. These do not offer a full and representative picture and would not ordinarily be routinely monitored, however in the absence of current official statistics for this period these can give an indication of the current situation. There is evidence of increased help seeking for suicidal thoughts from MeeTwo at the beginning of the lockdown cited by Inkster and others. and Kooth active user data from early July 2020 . 'Suicidal thoughts' accounted for 19% of all issues raised on the Kooth platform at this time, and the number of issues was 40% higher than the previous year. A review of likely child suicides in England during the COVID-19 pandemic raised a concerning signal that child suicide deaths may have increased during the first 56 days of lockdown, but that the risk remained low and the numbers were too small to reach definitive conclusions. Kooth user data showed increased proportions of CYP with self-harm related contact over several weeks compared to the same times last year . It is important to acknowledge the complex reasons underlying cases of likely suicide and self-harm, and there is no evidence of a simple link between the pandemic and the increased reporting of suicidal thoughts or self-harm related contact.

4. Reported symptoms of mental ill health

Data from C19PRC from April showed abnormal levels of anxiety were more common than depression; 64% of Young People ( YP), had high scores on an anxiety scale and 34% of YP scored in the abnormal range for depression. Previous reporting of the same study also found that 50% to 60% of CYP showed trauma-like symptoms related to COVID-19 with higher rates for females and older YP (aged 19 to 24). COVID-19 related trauma was examined using the Revised Child Impact Events Scale and relate to response to intrusive thoughts relating to experiences or concerns.

Analysis of mental health measures collected prior to and during the COVID-19 lockdown by the UK Household Longitudinal Study shows that for young adults' (aged 16 to 24) mental health had deteriorated more than any other adult age group. In April 2020, nearly half of 16 to 24 year olds self-reported symptoms which passed a threshold suggesting a possible 'common mental disorder', where they had been below this threshold previously. We do not have a pre COVID-19 baseline for this age group, however it is reported that 14% of all adults in the pre COVID-19 data had newly reported symptoms which showed them to be at or above this threshold. While reaching this threshold suggests a possible 'common mental disorder' it does not necessarily mean the individual has a clinically diagnosable mental health disorder. People self-reporting symptoms which pass this threshold may later report fewer symptoms if the causes of their distress are removed. There are also indications that the deterioration for young adults may be spread across a wider range of dimensions of psychological distress than for older adults.

In the Institute for Fiscal Studies (IFS) analysis (graph below) young women (aged 16 to 24) are shown to have reported the largest deterioration in mental health, whilst separate findings from C19PRC show higher anxiety reported by younger males, suggesting the pattern of impact is not yet clear.

5. Changes in reported symptoms over the period of lockdown

Findings on changes in the self-reported symptoms of mental ill health within the lockdown period are mixed, with some evidence of an increase in emotional difficulties, including anxiety and depression and some reports by young people themselves of there being no change in their emotional difficulties .

Few studies have so far specifically asked about behavioural issues. In a convenience sample Co-SPACE showed that parents of primary aged children reported a significant increase in behavioural difficulties over a one-month period in lockdown, but secondary school aged young people (non-representative sample of 1,000 young people), as well as parents of young people, reported no change in behavioural issues over the same time.

The same Co-SPACE survey showed that parents reported a significant increase in hyperactivity difficulties over a one month period in lockdown for both primary and secondary aged children, but secondary school aged young people themselves reported no change.

6. How mental health and wellbeing may vary by characteristics

6.1 Ethnicity

The emerging findings on outcomes associated with ethnic background are mixed and are complicated by the simultaneous increased profile of racism and anti-racism in the media and community. Some studies found no differences between White British CYP and those with other ethnicities . However, recent Kooth data on active users ( CYP aged 11 to 18. 42,000 active users between 1 March 2020 to 30 May 2020, of which 21% were from BAME backgrounds) suggest increased reporting of depression, anxiety, self-harm and suicidal thoughts amongst CYP from BAME backgrounds since lockdown and that the increase is higher than any among CYP from White ethnic background. The C19PRC study (a non-representative study of 2,000 CYP) found that Black and Mixed ethnic background respondents had higher levels of anxiety and depression compared to White and Asian respondents. On all other measures, similar scores were found across ethnic groups (well-being, somatic symptoms. COVID-19 Trauma, COVID-19 anxiety). It should be noted that there is also variation within CYP from the same ethnic background.

6.2 Special educational needs and disability

Children and young people with SEN(D), and existing mental health issues, and their parents, have reported that COVID-19 has negatively affected their mental health . Most studies do not compare their experiences with the wider population. Those that do, find evidence that children with SEN(D) have experienced poorer mental wellbeing during lockdown than other children . For example, in the Co-Space study, parents of children with SEN reported their children to have higher emotional and behavioural difficulties (as measured by parent completed Strengths and Difficulties questionnaire) than parents of children without SEN did. Parents of children with SEN(D) also reported that their children's levels of emotional difficulties had reduced over the course of a month in lockdown. The Co-Space study also found that children with Autistic Spectrum Disorders and their parents expressed more worry about catching COVID-19 than others, though they reported a reduction in emotional and conduct difficulties through the lockdown. No pre COVID-19 measures are available for comparison in this study.

6.3 Other characteristics

There is also emerging evidence on poorer mental wellbeing, including anxiety and loneliness, during the pandemic for vulnerable children and young people, such as children with experience of being in care, as well as children and young people in economically disadvantaged families or areas.

7.1 Access to existing support

Estimates of the proportion of young people with existing mental health issues who were not able to access their existing mental health or other support vary from around 25% to 80%. This range is likely to be due to the nature of support included by the question. Another study found 58% of young adults (including 16 - 19 year olds) reported some disruption to their mental health care. Children with pre-existing mental health conditions and those already receiving school or social services support appeared more likely to use specialist services for their COVID-19 related 'isolation and relationship' needs than other children who also had a need for COVID-19 related 'isolation and relationship' support.

There are reports of increasing use of online support options, although data is not scrutinised for differences in the characteristics of the CYP to whom the services have been made available.

7.2 Loneliness and social isolation

As seen in many studies, most young people reported increased levels of loneliness, in part attributed to not being able to see and socialise with friends. Experiences of loneliness appear to increase with age and young people themselves associate feelings of loneliness with feeling anxious. The proportion of young people with medium/high level of loneliness appears to have increased between end April and mid May. The Office for National Statistics ( ONS) reports that young adults (aged 16 to 29) are more likely than older adults to be concerned about the impact of the pandemic on their relationships, particularly friendships.

Although loneliness and social isolation have been a challenge for CYP, many can keep in touch with friends to some extent, for example through technology and social media . However, some of these studies and others also indicate a digital divide, with some young people, including those in 'low-income' areas, who report not having access to or not using devices to communicate with friends .

7.4 Home Environment

There is evidence that many CYP have experienced changes within their home environment, some of which could be either a risk to or protective of their mental health. There are indications of strains in some family relationships during the pandemic at the extreme cases including likely abuse within the home environment . Many CYP have, on the other hand, enjoyed more time with family or caregivers . There are indications that some CYP's parents may have had increased stress or experienced worse mental health . With the introduction of support bubbles for lone parents, many families have started using these for childcare. Most CYP have been able to spend time outside and/or in the natural environment, but for some CYP access to outside spaces is limited .

8. Weekly tracking data - children and young people

Data relating to people who live with children can be considered as a proxy for parents. Across most indicators of mental health and wellbeing examined, this group had similar figures to others. For loneliness and thoughts of self-harm and death, it was better than for comparison groups (data not shown). However, levels of anxiety, and stress related to COVID-19 and finance, appeared to be worse among parents - particularly at the start of lockdown.

9. Remote services - children and young people

Xenzone Kooth report relatively steady engagement with their service across the pandemic period. Key presenting issues continue to be anxiety and relationship issues.

The most recent data from Young Minds shows a continued trend of more parents seeking information and advice via email and online during the pandemic. They report that parents have been most likely to call about anxiety, anger, behaviour problems and self-harm.

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This chapter is part of the COVID-19: mental health and wellbeing surveillance report. The report is about population mental health and wellbeing in England during the COVID-19 pandemic. It includes up to date information to inform policy, planning and commissioning in health and social care.

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https://stpsupport.nice.org.uk/cyp-mental-health/index.html

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Future in Mind, the Children and Young People's Mental Health and Wellbeing Taskforce's report, estimates that half of mental health conditions in adult life start by the age of 14. Improving children and young people's mental health services is a priority across health, education and social care.

NHS Long Term Plan

Under the Long Term Plan, the NHS is making a new commitment that funding for children and young people's mental health services will grow faster than both overall NHS funding and total mental health spending. It aims to:

expand access to community-based mental health services to meet the needs of at least an additional 345,000 children and young people aged 0-25 years, to include support that is embedded in schools and colleges

create new services in selected areas for 6000 children and young people with complex needs

create a new approach to young adult mental health services for people aged 18-25, to support the transition to adulthood

boost investment in children and young people's eating disorder services to maintain delivery of the 95% standard beyond 2020/21 (95% of children and young people referred receiving NICE-approved treatment within 1 week if urgent, and within 4 weeks if routine or non-urgent).

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Children and young people's mental health

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How NICE resources can support local priorities

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Article on long waiting list for mental health support in children and young adults

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Article on long waiting list for mental health support in children and young adults

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https://www.bmj.com/content/375/bmj.n3053

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Children and young adults are waiting "far too long" for access to mental health services with too many placed in inpatient units far from home and facing inappropriate care, according to a new report by MPs.1

The Health and Social Care Committee warned that without urgent action mental health services for children and young adults risk "slipping backwards" as a result of the additional demand created by the pandemic and the scale of unmet need before it.

The committee said they are worried that a sufficient proportion of the additional funding from the health and social care levy has yet to be allocated to mental health and called on the government to demonstrate true parity between mental and physical health.

Jeremy Hunt, committee chair, said, "Partly because of the pandemic, we are seeing demand for mental health treatment pushing NHS services to breaking point. While ...

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Children and young adults are waiting far too long for mental health services, report warns

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Children and young adults are waiting "far too long" for access to mental health services with too many placed in inpatient units far from home and facing inappropriate care, according to a new report by MPs.1 The Health and Social Care Committee warned that without urgent action mental health services for children and young adults risk "slipping backwards" as a result of the additional demand created by the pandemic and the scale of unmet need before it.