Mental health and wellbeing of children and adolescents during the covid-19 pandemicBMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1730 (Published 24 August 2021) Cite this as: BMJ 2021;374:n1730
- Elizabeth A Rider, general paediatrician and director, Boston Children’s Hospital/ Harvard Medical School Faculty Fellowships in Humanism & Professionalism, and Interprofessional Leadership1,
- Eman Ansari, pediatric emergency and critical care physician2,
- Pamela H Varrin, clinical psychologist and family support coordinator3,
- Joshua Sparrow, child psychiatrist and executive director, Brazelton Touchpoints Center4
- 1Department of Pediatrics, Harvard Medical School; and Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- 2Department of Pediatrics, Harvard Medical School; and Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
- 3Mental Health Team, Cotting School, Lexington, MA, USA
- 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
- Correspondence to EA Rider ;
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.
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.
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.
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?
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).
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.
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.
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).
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).
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
Box 3 includes signs that could suggest a mental health disorder.
Behavioural responses and signs that could indicate a mental health disorder, and when to refer for specialist assessment
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
Symptoms of post-traumatic stress disorder—eg, that disrupt functioning and/or can create risk of harm to self or others
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
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).
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.
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 advice3RETURN 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).
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.
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
American Psychological Association. APA covid-19 information and resources. 2021. https://www.apa.org/topics/covid-19/index
Boast A, Munro A, Goldstein H. An evidence summary of paediatric covid-19 literature. Don’t forget the bubbles. UK and Australia. 2021. https://doi.org/10.31440/DFTB.24063
Kassam-Adams N, Schneider S, Kazak AE, Center for Pediatric Traumatic Stress (CPTS). Addressing the psychological and emotional impact of the covid-19 pandemic for children, families, and healthcare staff. Health care toolbox. 2021. https://www.healthcaretoolbox.org/tools-and-resources/Covid19.html
American Academy of Child and Adolescent Psychiatry. Coronavirus/covid-19 resource library. 2021. https://www.aacap.org/coronavirus#clinicians
American Academy of Pediatrics. Mental health promotion and problem prevention: pediatric mental health minute series. 2020. https://services.aap.org/en/patient-care/mental-health-minute/mental-health-promotion-and-problem-prevention/
Schonfeld DJ, Demaria T, Committee on Psychosocial Aspects of Child and Family Health, Disaster Preparedness Advisory Council. Supporting the grieving child and family. Pediatrics 2016;138:e20162147. https://pediatrics.aappublications.org/content/138/3/e20162147
Management of mental health issues within primary care practice
National Institute of Mental Health. Ask Suicide-Screening Questions (ASQ) toolkit. https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/ (free download; available in many languages)
American Academy of Pediatrics. Mental health tools for paediatrics. Addressing mental health concerns in primary care: a clinician’s toolkit. Updated 2019. https://downloads.aap.org/AAP/PDF/Mental_Health_Tools_for_Pediatrics.pdf
Royal College of General Practitioners. Children and young people’s mental health. Mental health toolkit. https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/mental-health-toolkit.aspx
Oxford Precision Psychiatry Lab, Oxford Health Biomedical Research Centre. Telepsychiatry and digital technologies in child and adolescent psychiatry. Management of mental health issues within primary care practice. 2020. http://oxfordhealthbrc.nihr.ac.uk/wp-content/uploads/2020/10/5C.-COVID-and-MH_Digital_MH.pdf
Impact of trauma: strategies for self-care and healing
National Center on Parent Family and Community Engagement, Early Childhood Learning & Knowledge Center, US Department of Health and Human Services. Understanding trauma and healing in adults series. 2020. https://eclkc.ohs.acf.hhs.gov/mental-health/article/understanding-trauma-healing-adults
Early Childhood Learning and Knowledge Center:
Defining trauma: https://eclkc.ohs.acf.hhs.gov/publication/defining-trauma
Caring for ourselves as we care for others: https://eclkc.ohs.acf.hhs.gov/publication/caring-ourselves-we-care-others
Coping and healing: https://eclkc.ohs.acf.hhs.gov/publication/coping-healing
Children and adolescents with special healthcare needs
American Academy of Pediatrics. Caring for children and youth with special health care needs during the covid-19 pandemic. Interim guidance. 2021. https://services.aap.org/en/pages/2019-novel-coronavirus-Covid-19-infections/clinical-guidance/caring-for-children-and-youth-with-special-health-care-needs-during-the-Covid-19-pandemic/
Schools and covid-19
Halladay Goldman J, Danna L, Maze JW, Pickens IB, Ake III GS. National Center for Child Traumatic Stress. Trauma informed school strategies during covid-19. 2020. https://www.nctsn.org/resources/trauma-informed-school-strategies-during-covid-19
Unesco. Covid-19 education: from disruption to recovery. 2021. https://en.unesco.org/Covid19/educationresponse
Resources for parents, families, caregivers, and children
General covid-19 resources
National Center for School Crisis and Bereavement, Children’s Hospital Los Angeles covid-19 pandemic resources. 2020. https://www.schoolcrisiscenter.org/resources/Covid-19-pandemic-resources/
NHS Lothian, Scotland. Covid-19 resources. https://services.nhslothian.scot/camhs/Resources/Pages/ResourcePacks.aspx#Parents_and_Carers
Maudsley Charity, UK. Families Under Pressure. 2020. https://familiesunderpressure.maudsleycharity.org
American Academy of Pediatrics. Parenting in a pandemic: tips to keep the calm at home. 2020. https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Parenting-in-a-Pandemic.aspx
Emerging Minds Network: action for child mental health. UK research and innovation. Resources for families and supporters. 2021. https://emergingminds.org.uk/resources-for-families-supporters/
American Academy of Child and Adolescent Psychiatry. Resources for helping kids and parents cope amidst covid-19. 2020. https://www.aacap.org/AACAP/Families_and_Youth/Resource_Libraries/Covid-19/resources_helping_kids_parents_cope.aspx
American Academy of Pediatrics. Teens and covid-19: challenges and opportunities during the outbreak. 2020. https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Teens-and-COVID-19.aspx
Emerging Minds Network: Action for Child Mental Health 2021. UK research and innovation: top tips to support children and young people with their worries and anxiety.https://emergingminds.org.uk/supporting-children-and-young-people-with-worries-and-anxiety-coronavirus/
Children and adolescents with special healthcare needs
Family Voices. Coronavirus information and resources. 2021. https://familyvoices.org/Covid19/
CHILD-BRIGHT Network. Covid-19 resources for Canadian youth with disabilities, their families, and support teams. 2021. https://www.child-bright.ca/covid-19-resources
Kuo DZ, Coleman C. American Academy of Pediatrics. Covid-19: caring for children and youth with special health care needs. 2021. https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/COVID-19-Youth-with-Special-Health-Care-Needs.aspx
Books and videos for children
Free eBooks about covid-19. LibGuide for New York City School Library System. 2021. https://nycdoe.libguides.com/COVID-19ebooks/free (collection of free eBooks in multiple languages for children about coronavirus/covid-19)
Gomez AM. The Oyster and the Butterfly: The Corona Virus and Me (children’s book). 2020. https://www.anagomez.org/wp-content/uploads/dlm_uploads/2020/04/OysterandButterfly-EnglishV3.pdf (free download; translations into 20 additional languages are available here: https://www.anagomez.org/Covid-19-resources/)
Patuck H, Inter-Agency Standing Committee (IASC) reference group on mental health and psychosocial support in emergency settings, My Hero is You: How Kids Can Fight Covid-19. (children’s book). 2020. https://interagencystandingcommittee.org/iasc-reference-group-mental-health-and-psychosocial-support-emergency-settings/my-hero-you (free download; translations into many languages are available)
Johns Hopkins Center for American Indian Health. Our Smallest Warriors, Our Strongest Medicine: Overcoming COVID-19. (children’s book). A book written for indigenous American Indian, Alaska Native, First Nations, Métis, and Inuit children. 2020. https://caih.jhu.edu/programs/strongmedicine (free download)
Paediatric Society of New Zealand and Starship Foundation. Resources to help explain coronavirus (covid-19) to children. 2020. https://www.kidshealth.org.nz/resources-help-explain-coronavirus-Covid-19-children
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.
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.