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 pandemic1-5. 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 Pandemici , Lockdown Lowdownii, Co-SPACEiii & Co-SPYCE studies, Office for National Statistics routine survey of 16+iv, and the Carers Trust Survey of Young carersv.
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 students7 . 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 quarantined8,9: in this case, criteria for PTSD was met by 30% of quarantined children. A study from India, during the COVID-19 pandemic, yields similar results10 and further studies conducted in China find that young people report increased depressive symptoms and anxiety symptoms11 and can experience negative psychological consequences as a result of the COVID-19 pandemic12.
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 example13,14. 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 participants15. 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 college16 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 period17. 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 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 people18. 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 18-2419, 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 wellbeing18,21. #
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 wellbeing24.
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 exercise25, factors that can support the mental health and wellbeing of children and young people21. 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 household26.
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 childhood27. 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 household28.
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 parents8. The same study found links between PTSD criteria in adults and their children having PTSD symptoms8. 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 adults30. 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 usual31, or COVID-19 related stressful life events e.g. bereavement/having an acquaintance infected14,31,32. 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 trauma31.
Impacts on key workers
The psychological impacts are particularly important to consider in cases where parents are front-line workers4 with much evidence showing that those working in health care in particular, experience negative psychological consequences during health emergencies33,34. Moreover, in the case of healthcare workers, quarantine has been associated with distress, exhaustion, detachment, anxiety, and PTSD symptoms over time9, 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 quarantined9 , all of which have been shown to have negative effects on the mental health and wellbeing of children in such households28. 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 symptoms15.
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 younger9,13,31,35, female9,13,14,31,32,33,35,36, with a history of psychiatric illness or chronic illness/ poor health (diagnosed or selfreported) 14,31,32,33,35,36, and single parent adolescents1 . There is mixed evidence on the impact of education level as a predictor of impact of lockdown on mental health9,13,36. Post-quarantine stressors can include: finances9,37 and stigma for healthcare workers9 . 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 measures32. These groups include: disadvantaged communities, people with disabilities, BAME groups, people experiencing homelessness, those affected by violence, older people, and frontline health and care staff32. Particular note should also be given to the increases in both calls and referrals to domestic abuse charities38,39, 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 security19. Parents who are working have also reported difficulties in balancing the needs of their child with the demands of working23. 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 behaviour23. 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 system24.
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 wellbeing4.
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 people17,19,41. In particular, young adults are experiencing concerns about their education being interrupted and their future career opportunities19. 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 stresses17. 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-1942. 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 infection16, 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 learning43. 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 undertaken43. 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 engagement43. 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 year44.
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 situation45. In this study, schools had reservations about the need for closures/quarantine, including a lack of understanding about the rationale for this action45. 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 crises45. This variability in response may have implications for parents and children. For example, there may be parental concerns about going back to school23, 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 incomes23.
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 calls1, 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
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 anxieties16. 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 weeks16.
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 crises8 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 recovery32 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 people45. 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.
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.
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.
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.