Intended for healthcare professionals

Practice Practice Pointer

Mental health and wellbeing of children and adolescents during the covid-19 pandemic

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1730 (Published 24 August 2021) Cite this as: BMJ 2021;374:n1730

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  1. Elizabeth A Rider, general paediatrician and director, Boston Children’s Hospital/ Harvard Medical School Faculty Fellowships in Humanism & Professionalism, and Interprofessional Leadership1,
  2. Eman Ansari, pediatric emergency and critical care physician2,
  3. Pamela H Varrin, clinical psychologist and family support coordinator3,
  4. Joshua Sparrow, child psychiatrist and executive director, Brazelton Touchpoints Center4
  1. 1Department of Pediatrics, Harvard Medical School; and Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
  2. 2Department of Pediatrics, Harvard Medical School; and Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
  3. 3Mental Health Team, Cotting School, Lexington, MA, USA
  4. 4Department of Psychiatry, Harvard Medical School; and Brazelton Touchpoints Center, Division of Developmental Medicine, and Department of Psychiatry, Boston Children’s Hospital, Boston, MA, USA
  1. Correspondence to EA Rider elizabeth_rider{at}hms.harvard.edu; elizabeth.rider{at}childrens.harvard.edu

What you need to know

  • When assessing mental health and wellbeing, consider developmental stage, functional or behavioural manifestations, proximity to and severity of pandemic related hardships, and individual, family, and community strengths, supports, and protective factors

  • A child or adolescent may show no observable or reported symptoms of distress, or may show them at some later time

  • Primary care physicians’ roles include screening, outreach, identification, referral, ongoing monitoring or surveillance, support, and coordination with specialist clinicians

  • Encourage resilience in all patients, not just those presenting with mental health and wellbeing concerns

Many children and adolescents remain resilient over time and may recover rapidly after disasters such as a pandemic. However, their experiences and the burden of sustained, multiple stressors (including prior trauma, illness, attachment disruption, grief, isolation, closed borders, and home confinement)12345 may result in a range of challenges to their mental health and wellbeing, both short and long term.5

Given that half of mental health disorders (including depression, anxiety, post-traumatic stress disorder, and others) start by age 14, and three quarters by age 24,6 early recognition and treatment of the potential impacts of the covid-19 pandemic will help protect children’s and adolescents’ current and future mental health, development, learning, and wellbeing.78

The covid-19 pandemic, at the time of writing, affects an estimated 2.59 billion 0-19 year olds,9 with school closures in 193 countries that have affected more than 1.59 billion.10 This article—intended for generalists and others—covers common impacts and effects of the pandemic; assessment, including recognition of symptoms suggestive of mental health disorders; and management, including referral and mitigation of the potentially adverse impacts of the covid-19 pandemic.

Wellbeing is a person’s ability to recognise their own capacities, manage regular stresses of life, work productively, and contribute to their community.11 The authors advocate a trauma-informed approach, ie, remaining aware of physical and emotional traumas that children, adolescents, and families have experienced, and of the potential wide ranging repercussions of these traumas.1213141516 This includes understanding the severity and nature of events and their impact.

What does the evidence show?

At the time of writing, most research on covid-19 has focused on adults.17181920 Research on the mental health effects of the pandemic on children, adolescents, and their families is limited and in some instances contradictory.21222324 Many of the studies use life satisfaction and wellbeing assessments that are, in general, not intended to detect or predict diagnosable mental health disorders.

Most evidence specific to covid-19 depends on data that are limited because of self-selected/self-reporting participants, smaller sample sizes, virtual-only data collection, heterogeneous samples limiting data aggregation, and short term only outcomes.

The strongest evidence is not about the mental health effects of covid-19—that will emerge over the years to come—but for previously well established mental health disorders in children, for example, depression, anxiety, post-traumatic stress disorder, and for risk and protective factors for these disorders.

While longer term outcomes specific to covid-19 remain unknown, guidance can be extrapolated from previous large scale disasters, for example, the Indian Ocean earthquake/tsunami of 2004, the Nepal earthquakes in 2015, the Deepwater Horizon Gulf of Mexico oil spill in 2010, Hurricane Katrina in 2005, and disease outbreaks including the H1N1 influenza pandemic of 2009 and the Ebola epidemic of 2014.5252627282930

The advice in this article is based on a comprehensive evidence based literature search and analysis; guidelines and policy papers; consensus based guidance from national and international organisations; input from patients and parents; input from clinical, academic, and patient reviewers; and our own clinical experience.

Varying evidence

Some data are contradictory, at times reflecting divergent effects of the pandemic on younger children and adolescents, individual differences and contexts, and the impact of social determinants of health.

For example

  • Data from studies in multiple countries—including a longitudinal probability study that assessed youth in 2017 and 202031; a retrospective comparison of emergency department suicide risk screens comparing results from January-July 2019 with January-July 202032; a cross-sectional study of emergency department patients between January 2018 and January 202133; and a study of suspected suicide attempts between March 2020 and May 2021 compared with the same periods in 201934—all suggest increased frequency of mental health disruption and mental health disorders during the pandemic, and that prior mental health disorders can increase the risk of pandemic related or induced mental health trauma.22233135363738394041424344454647484950 However, a proportion of these data also shows that some children with prior and/or ongoing mental health disorders have had reduced symptoms during the pandemic.2231363947484950 This may be because of a pause on the demands of in-person schooling (peer interactions, sensory over-stimulation, etc)4751 as well as increased access to supportive parents who are forced to stay at home.

  • Systematic and narrative reviews and technical reports show screen time can support online learning and online connection with family, friends,52 and services,35 but lack of access to the internet or devices widens disparities.2353 Other technical reports, evidence reviews, systematic evidence mapping, and international investigations (Europol) report cyberbullying, cybercrime, privacy issues,3553545556 and screen fatigue.57

How do you assess mental health and wellbeing?

The following information is relevant to most consultations; ie, for children or adolescents attending expressly for mental health concerns, as well as those presenting with other symptoms. All children and families have experienced the pandemic in some way.

Start with a brief history of pre-pandemic physical and mental health and school functioning, and compare pandemic related findings with this baseline.

Include an interview with the child or adolescent, as well as the parent or adult caregiver whenever possible (see box 1 for prompts).585960

Box 1

Suggested prompts for children or adolescents, according to developmental stage

Young children (ages 3-5)

  • Did you hear about the virus that has been making some people sick? If the child does not respond or answers no, stop here, and ask parents

  • Did you know about anyone who got sick? What happened to them?

  • Do you think anyone else might get sick?

  • Did anyone in your family have to stay at home while this virus was making people sick? Who? What did you think about that?

Older children (ages 6-11) and adolescents

  • Did you know about anyone who got sick from the virus? What happened to them?

  • Do you think anyone else might get sick?

  • Did you hear about the vaccines? What do you think about that?

  • Did you or anyone in your family have to stay at home during this pandemic?

  • What was that like?

  • Did anyone in your family lose their job or have more trouble making money?

  • Did you get in touch with your friends when everyone had to stay at home? How did that go?

  • What was the worst part of this whole thing for you?

  • Were there any things you liked about it?

  • What do you think is going to happen after this pandemic?

RETURN TO TEXT

Keeping in mind developmental stages,5859 ask children about their understanding of the pandemic: Why did it happen? How have they responded? How has it affected them? What are their fears and worries? What helps them to feel safe? Validate their descriptions of any negative effects on their wellbeing and on friends, families, and activities.

What are their immediate needs (eg, food, shelter, safety, adult caregiver availability)? What is the current family constellation? What is the parent/family experience of and response to the pandemic (eg, job loss, new or exacerbated parental mental health challenges)? What supports currently exist (eg, family or social network; financial or material resources; access to healthcare and social supports; longstanding effective mechanisms for coping with adversity; spirituality/religious community)?

Consider what factors might be affecting mental health and wellbeing

Has the child or their family been exposed previously to trauma, separation, or loss, including adverse childhood experiences?71261 Is there a history of mental health disorder? Prior school performance challenges? What coping capacities has the child previously used? Is the child readily able to accept adult help?

Inquire about experiences related to covid-19, eg, deaths, serious illness, separations, hunger, safety, financial hardships, parental unemployment, food and housing security, school disruption, disrupted peer interactions, disrupted physical and extracurricular activities.

Grief after a death in the family is expected. However, grief complicated by disruption of traditional grieving rituals, multiple deaths, limited or no access to social or professional support, can increase the risk of mental health disorders. Inquire about parents’ grief or depressive symptoms (these may impact the child/adolescent).

Factors that can contribute to child or adolescent vulnerability during the covid-19 pandemic are summarised in fig 1 and table 1.

Fig 1
Fig 1

Factors contributing to child and adolescent vulnerability during the covid-19 pandemic

Table 1

Examples of factors contributing to child and adolescent vulnerability during the pandemic

View this table:

Ask about the effects of covid-19 related events or experiences

What have been the physical and emotional effects of the child’s or adolescent’s experiences of covid-19? Limited comprehension of pandemic related changes in routines and circumstances, frustration, and distress are often expressed through behaviour and can affect functioning in developmental domains such as sleeping, feeding or eating, behavioural control or regulation, mood, cognitive capacities (eg, attention, concentration, school performance), and family and peer relationships.

Common behavioural and functional responses to extraordinary circumstances, like the covid-19 pandemic, are summarised in table 2.

Table 2

Common child and adolescent behavioural and functional responses to adversities, by developmental stage585991

View this table:

Observe for and inquire about the severity and duration of distress associated with these functioning domains. These will depend, in part, on the proximity to pandemic related traumatic events and hardships, and to the severity of these events and hardships (eg, separations from/losses of primary caregivers),919596 as well as on developmental stage. The longer distress persists over time, the more likely it is to disrupt peer and family relationships and school performance.

Look for responses that might indicate a mental health disorder

The behavioural responses listed in table 2 fall on a continuum from developmentally expected and mildly distressing to severely disruptive to the child/adolescent and/or others. Severe disruption of one or more functional areas is more likely to indicate a mental health disorder than mild distress.

The length of time a behaviour has persisted might also indicate the presence of a mental health disorder—the DSM V, for example, specifies minimum duration of symptoms qualifying for diagnoses of disorders such as depressive and anxiety disorders, and trauma reactions.97 Generally, consider diagnosing a mental health disorder when responses occur for long enough to affect functioning.

Assessing distress

Distress associated with some areas of functioning may be subjective and may not be reported. A toddler, for example, may express distress through facial or verbal expressions of worry. More severe disruption in functioning may include relentless clinging to the caregiver, refusing to let the caregiver leave, loss of usual play behaviours when the caregiver is not present, etc.

Mildly distressing fears could be expressed by articulating fearfulness; whereas disruptive functioning might include panic attacks, or extreme avoidance of the sources of fear, eg, refusal to leave home when necessary.

Mild sleep disturbance in any age group may include occasionally taking longer to fall asleep and/or waking feeling fatigued. Disruption in sleep functioning, however, would include prolonged difficulty falling asleep on most nights, resulting in persistent daytime fatigue and related irritability.

Children/adolescents may also present to primary care or to the emergency department with medically unexplainable physical symptoms (eg, abdominal pain, headache) that are a manifestation of their distress, with or without clear signs or symptoms that are more commonly associated with mental health disorders (eg, depressed mood, loss of interest and pleasure in usual activities, low energy, anxiety, sleep disturbances, withdrawal/social isolation, suicidal ideation).

Severity of distress can also be determined by pervasiveness of symptoms across developmental domains (eg, more than one of the functional areas listed above), or across more than one self-regulatory capacity (eg, attention, frustration, tolerance, perseverance, impulse control, expressing emotions), or across more than one formal or informal learning capacity (eg, curiosity, exploration, motivation for learning, constructive risk taking in service of learning).

Many children and adolescents experiencing distress, whether reported or observable or not, may not develop symptoms of a mental health disorder, or may only develop them at some later time.9899

Screening

Simple, brief mental health screening (as recommended at regular intervals from infancy through adolescence by the American Academy of Pediatrics), including programmes that consider the whole family, may be used to help assess for emotional symptoms, behavioural functioning symptoms, and psychosocial symptoms100101 (box 2).

Box 2

Screening tools

  • Mental health screening can be used to detect emotional and behavioural functioning/psychosocial symptoms, and can help identify when referral for evaluation and treatment or other supports are needed100

  • Since 2016, the US Preventive Services Task Force has recommended screening for major depressive disorder for all adolescents aged 12-18,102 and notes that the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory are the screening tools used most often

  • The National Institute of Mental Health recommends suicide screening for all children ages 8 and above presenting to the emergency department, outpatient, and inpatient settings using the four-item brief screening questionnaire ASQ (Ask Suicide-screening Questions)103104

  • Recent studies comparing the PHQ-9A and the ASQ in 803 adolescents aged 12 and older in June 2019 to October 2020105 and 600 medical inpatients aged 10-21106 found the ASQ suicide risk screening identified patients not identified by other depression screening

  • A list of paediatric mental health screening tools, including global tools, can be downloaded from the American Academy of Pediatrics’ website.107 These and other tools100108 can help assess and identify children and adolescents who require referral for formal psychiatric evaluation109110111

RETURN TO TEXT

Box 3 includes signs that could suggest a mental health disorder.

Box 3

Behavioural responses and signs that could indicate a mental health disorder, and when to refer for specialist assessment

Consider referral for specialty care when these symptoms are present (as soon as possible, according to local protocol)58298:

  • Anxiety and/or depressive symptoms

  • Increased arousal, mood changes, irritability, withdrawal, emotional numbing, being overwhelmed

  • Physical symptoms such as fatigue, headaches, or stomach aches that cannot be medically explained

  • Disordered eating habits

  • Sleep disturbances, including unrestful sleep, trouble falling asleep, middle of the night waking

  • Traumatic grief

  • Symptoms of post-traumatic stress disorder—eg, that disrupt functioning and/or can create risk of harm to self or others

    • Nightmares

    • Re-experiencing the event/disaster

    • Intrusive thoughts—eg, that interfere with focus, concentration, attention

    • Increased arousal—eg, that may lead to aggressive behaviour

    • Hypervigilance—eg, that may lead to aggressive behaviour

    • Avoidance of activities, experiences, or places associated with the event or disaster and/or more general withdrawal

    • Emotional dysregulation or dissociation

These symptoms require referral for emergency/immediate mental health evaluation98:

  • Suicide attempt; suicidal ideation, intent or plan

  • First known self-cutting; repeat self-cutting if patient has no existing mental health clinician

  • Intense fear, anxiety, helplessness, panic or horror, especially if these disrupt basic areas of functioning such as sleep, eating, family and peer interactions, academic performance

  • Presence of dissociative symptoms such as detachment, depersonalisation, derealisation, eg, child may appear distant, aloof, confused, daydreaming

  • Extreme confusion or inability to make simple decisions

  • Uncontrollable and intense grief

  • Intrusive thoughts or severe cognitive impairment

  • Debilitating physical complaints suggestive of bodily symptoms in the absence of medical explanation

RETURN TO TEXT

How can you manage children’s and adolescents’ mental health and wellbeing?

Trauma informed management in primary care12 can help patients and families to access community supports, and, when indicated, to access mental health treatment and specialty care. In the face of the covid-19 pandemic, all children/adolescents/parents may benefit from resources and support to restore their resilience (“the ability to maintain or regain mental wellbeing, despite adversity”112). A smaller group requires additional support and guidance; and an even smaller number need specialist treatment.

We have adapted the stepwise, trauma informed management approach that is recommended by the Center for Pediatric Traumatic Stress113114 and others115116 to be applicable during the covid-19 pandemic (fig 2).

Fig 2
Fig 2

A stepwise model for management,* adapted from the Pediatric Preventative Psychosocial Health Model113114 and the Multi-tiered System of Support model.115116 See box 3 for symptoms requiring emergency/immediate mental health intervention

Support parents and caregivers and encourage consistency and sensitivity

Strong family relationships and positive interactions (in person, by phone, or online) are protective factors that can bolster resilience. Appreciate and reinforce parents’ efforts to be present and empathetic,59 to focus on the present, help their children to grow and continue learning, and model positive coping and stress reduction strategies63—eg, physical activity, regular use of safe green spaces, and pursuing social connections and routines (while adhering to physical distancing or mask use). These efforts can help reduce effects of the pandemic in children and adolescents such as hypervigilance, lack of trust in adults, self-regulation issues, and inappropriate social interactions, and can provide protection from developing a mental health disorder.115

Encourage open, age appropriate parent-child-family discussion about coping with the pandemic, including addressing concerns.3963 Cross sectional surveys and narrative reviews emphasise the importance of communication in mitigating symptoms of anxiety, depression, and stress.3964

Counsel parents in talking about illness or death—how to provide simple, clear information about family health problems, in calm and neutral tones, while avoiding minimisation of any serious health threats; and realistic reassurance (eg, “Your parents are doing everything they can to make sure you and they stay healthy”). Avoid false promises that may not be possible to keep and might later damage the child’s ability to trust (eg, “Don’t worry, you will be fine”). Box 4 offers advice about children or adolescents who have experienced the death of one or more caregivers or family members.

Box 4

Death of a family member

In the US, alone, at the time of writing, approximately 37 300 to 43 000 children and adolescents have experienced a parent’s death from covid-19.73 Globally, more than 1.5 million children under age 18 lost a parent, custodial grandparent, or secondary caregiver in the first 14 months of the pandemic.117 Here is some advice, based on clinical experience, for working with children or adolescents who have experienced the death of a caregiver or family member:

  • Ask adult caregivers and the child about family members, friends, teachers, and others who are providing emotional and material support and whether the child experiences these as helpful, comforting, and trustworthy

  • Consider referring for mental health evaluation if family and/or social supports are lacking

  • Confer with adult caregivers about, and monitor for, depression, behavioural changes, or disruptions in development and learning during the first six months, at regular intervals over the following 12-18 months, and as anniversaries of family members’ deaths approach

  • Assess for suicidality, for example, by asking questions about the child’s hope for the future. Refer for emergency mental health evaluation and treatment if any concerning findings are elicited

See the American Academy of Pediatrics’ report on Supporting the Grieving Child and Family for additional advice3

RETURN TO TEXT

Support parents,118 and acknowledge the understandable pandemic related stresses affecting all parents, as well as those specific to their situation. Offer information about referrals and available resources101—psychological, physical, social, spiritual, formal and informal—that support wellbeing. Acknowledge the variable capacity of communities and governments to make needed resources available, and empathise with the hardships that result from inadequate resources.2840778995112 Work with teachers and schools, public health professionals, and other community bodies to secure access to food, housing, physical and mental health services, and reliable childcare.

Encourage parental self-care, including creative outlets, supportive social interactions (with appropriate safety precautions), healthy nutrition, physical activities and exercise.94119 Consider discussion of mindfulness, spiritual practices, and cultural traditions for sense making and healing.119

Provide anticipatory guidance and suggested interventions to parents and caregivers, keeping in mind developmental stages (table 3).

Table 3

Practical guidance to share with parents and caregivers by developmental stage*

View this table:

Monitor the duration and severity of new symptoms

Many children and adolescents need only family, primary care, and/or community supports to cope and recover from pandemic induced distress, but some will develop behavioural or functional manifestations that might indicate ongoing distress.

Be aware of the difference between responses that are mild on the severity continuum and symptoms that could indicate a mental health disorder (box 3).

A minority of children and adolescents (ie, those with persistent, severe, or escalating distress and/or severe, prolonged disruption of functioning) need evaluation and treatment by a mental health specialist and more intensive psychosocial support (box 3, fig 2).

When to refer to specialist services

In accordance with local protocol and resources, refer as soon as possible after recognising symptoms that may suggest a mental health disorder—anxiety, separation anxiety (that may manifest as school refusal with return to school after long lockdowns), depression, and post-traumatic stress disorder are among the most frequently identified disorders during the covid-19 pandemic.35

Immediate specialist assessment is required for any suicide attempt, ideation, intent, or plan; first known or repeat self-cutting; intense fear, anxiety, helplessness, panic, or horror, especially if basic functioning is disrupted; dissociative symptoms; extreme confusion; uncontrollable or intense grief; intrusive thoughts; severe cognitive impairment; and debilitating physical complaints suggestive of bodily symptoms in the absence of medical explanation. See box 3 for more detailed referral criteria.

The American Academy of Pediatrics,120 Philippine Pediatric Society,121 American Academy of Child and Adolescent Psychiatry,122 and the American Psychiatric Association123 recommend routine and crisis telemedicine and teleconsultation, and the International Paediatric Association124 currently recommends these during the pandemic. Telepsychiatry is widely used and effective125; however, access is inequitable,120124125126 and it may not be effective for many young children who require interactive play therapies.

Offer ongoing mental health support for all children/adolescents

Follow child or adolescent mental health closely in primary care, in conjunction with parents, teachers and schools, public health professionals, and other community resources. Trauma, complications of grief, anniversaries of separations, deaths, and changes in the community can continue to affect some children and families for months, or even years.98

Might children and adolescents living through this pandemic present with mental health disorders in the future?

Data from previous pandemics and epidemics suggest that observable symptoms of mental health disorders may not show until well after the traumatic event98; and that post-traumatic stress, detachment, insomnia, and anger can be experienced up to three years after being quarantined.86 However, longitudinal studies after disasters in the US (Hurricanes Katrina and Gustav; Gulf oil spill) suggest an overall decrease in trauma distress symptoms over time, especially in younger children.29127 A follow-up study after the Boulder Creek Dam collapse also found that PTSD symptoms in children and adolescents decreased from 32% at two years after the disaster to 7% after 17 years.128

Education into practice

  • What covid-19 related mental health challenges do children and adolescents in your community face?

  • How do you distinguish between mild responses and symptoms that might indicate a mental health disorder at different developmental stages?

  • What community resources do you have that may be helpful for children and their families, eg, teachers, in-school services (where schools are open), early intervention programmes, and other community programmes?

How patients were involved in the creation of this article

Our parent coauthor (PV) has lived experience as the parent of a young adult with special healthcare needs. She teaches as “family faculty” (representing the voice of the parent/family) in workshops for healthcare professionals and is a clinical psychologist and family support coordinator at a school for students with special needs. She contributed to the material on school closings and reopening, and children with special needs.

Three parent contributors, one an autism/special needs teacher, reviewed a draft of the manuscript. Their insights are incorporated into the sections on school closures, children with disability and special needs, and green space activity. From patient reviewers, we added two new review studies, additional critical analyses of impacts, and additional suggested resources for parents.

Finally, four children, ages 6-18, were asked about their experiences with lockdown. They shared their worries about parents who are healthcare workers; finding supports (parents, siblings, friends, teachers); and getting outside. We incorporated these in tables 1, 2, and 3.

Search strategy

Our literature searches in PubMed and Web of Science began with the terms: “COVID-19” OR “Coronavirus” AND “children” OR “pediatric” OR “adolescent” OR “teen” OR “parent” OR “caregiver” AND “mental health” OR “psychological” OR “emotion” OR “psychiatry”. We used multiple combinations of keywords: pandemic, disasters, quarantine, lockdown, social isolation, physical/social distancing, school closures, school re-openings, anxiety, depression, PTSD, primary care, stress, child mental health, child development, behaviour, trauma-informed care, social determinants of health, families, telehealth, and others. We also searched for information from past epidemics/pandemics (eg, SARS, H1N1, MERS). We reviewed systematic, narrative, and rapid reviews and meta-analyses. Additional literature was found in the references of identified articles, and citation chaining of relevant articles in Google Scholar. The initial search occurred in May 2020 with frequently updated searches until July 2021. Given the importance of international experiences and findings in this rapidly developing pandemic, we included studies related to covid-19 and reports from various countries including Australia, Bangladesh, Brazil, Canada, China, Egypt, France, Germany, India, Italy, Nepal, Norway, Philippines, South Korea, Spain, UK, US, and others. Additional sources used for this paper are listed in the box “How this article was made.”

How this article was made

The authors of this article represent fields of primary care paediatrics, child psychiatry, paediatric emergency medicine and critical care, clinical psychology, and clinical social work.

Very little research evidence exists regarding mental health issues and wellbeing in children and adolescents during pandemics, including covid-19, SARS, and MERS. Although conclusive, evidence based guidelines for assessment and management of covid-19 related mental health effects in children and adolescents do not yet exist, we base our recommendations on

  • Evidence based literature including searches in PubMed and Web of Science

  • Guidelines, policy, and position papers from other pandemics and natural disasters from the American Academy of Pediatrics, National Institute for Health and Care Excellence, and the International Paediatric Association

  • Consensus based guidance from national and international health organisations, eg, World Health Organization, United Nations, Centers for Disease Control and Prevention, Unesco, Organisation for Economic Cooperation and Development

  • Limited early evidence on mental health related effects of covid-19 on children and adolescents

  • Well designed, longitudinal survey studies following parents and youth in the UK and US

  • Our own clinical experience

Potential areas for further research

  • School closure impacts—research findings are varied and conflicting.22 Challenges for future research will include unlinking the effects of school closures from other pandemic related life changes, and identifying individual, family, and community factors contributing to differential outcomes

  • Long term impacts of the pandemic on children’s and adolescents’ mental health and wellbeing, as well as the effectiveness of interventions administered during or after the pandemic for pandemic related effects. Challenges will include causal attribution of pandemic impacts versus non-pandemic related factors, especially given child and adolescent mental health declines observed prior to the pandemic

  • Outcomes and mitigating factors for children and adolescents who have experienced loss of a parent or carer because of covid-19

  • Community level and cultural factors affecting the pandemic’s effects on child or adolescent mental health

  • Possible positive effects on child or adolescent coping, resilience, wellbeing, and individual, family, community, and cultural factors contributing to positive effects

Resources for physicians and other professionals

General covid-19 resources

Management of mental health issues within primary care practice

Telepsychiatry

Impact of trauma: strategies for self-care and healing

Children and adolescents with special healthcare needs

Schools and covid-19

Resources for parents, families, caregivers, and children

General covid-19 resources

Children and adolescents with special healthcare needs

Books and videos for children

Footnotes

  • Acknowledgments: We thank Lauren Rozenvayn, Yuri Rozenvayn, and another anonymous parent reviewer for their helpful comments on earlier drafts. We also thank four children (ages 6-18) for sharing their experiences and perspectives on the covid-19 pandemic. We are grateful to the BMJ editorial team and reviewers for their helpful comments.

  • Funding: none

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

  • Contributorship statement: ER conceived the paper, consulted with EA, JS, and PV in developing areas of emphasis, and wrote the first draft. ER, JS, and EA performed literature searches, and all authors contributed additional content and reviewed drafts. ER provided the original tables 1, 2, and 3 and figs 1 and 2, JS provided boxes 1, 3, and 4, and all authors contributed. All authors revised the work for important intellectual content, approve the final submission, and agree to be accountable for all aspects of the work. ER is the guarantor.

  • Provenance and peer review: commissioned, based on an idea from the corresponding author; externally peer reviewed.

References

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