Child and adolescent mental health during COVID-19

Clare Lally

Charities and academics have expressed concerns that children’s mental health is disproportionately affected by the intervention measures used during the pandemic.
Child and adolescent mental health may be compromised by factors such as strained family relationships, academic stress and reduced social contact with friends.
Child and adolescent mental health services (CAMHS) have been reduced during the pandemic. They are likely to be under strain to meet increased demand.
The UK Government has announced funding to ensure that charities can continue supporting those in need.
This is part of our rapid response content on COVID-19. You can view all our reporting on this topic under COVID-19.

Early research suggests that the pandemic and subsequent measures are having significant impacts on the mental health of children and young people. This group are already at higher risk of developing mental health issues compared with adults. Children may be experiencing increased anxiety and stress about the virus, and school closures and social distancing measures have led to a loss of structure and social contact. Such circumstances, coupled with reductions in support services, could lead to a range of poor mental health outcomes.

Children and young people from certain groups (such as those from poorer households, young carers and those with disabilities) are already disproportionately affected by higher levels of mental health issues. For example, one study found that children from the poorest 20% of UK households are four times as likely to have serious mental health difficulties by the age of 11 as those from the wealthiest 20%. Experts express concern that the COVID-19 outbreak may widen these mental health inequalities, as well as increasing the overall prevalence of mental health issues in children.

Kooth, a digital mental health service for children and young people commissioned by the NHS, has released a report based on data from over 75,000 users aged 11–25 years. The report shows an increase in sleep issues (161%), loneliness (63%) and self-harm (27%) compared with the same period last year. There has been a 133% increase in health anxiety, with many children and young people worried about contracting COVID-19 or passing the virus on to others. Kooth also reported mental health issues were exacerbated in young people in black and minority ethnic groups compared with their peers.

A review of 63 studies from previous pandemics, such as SARS in 2003, has demonstrated the potential for long-lasting effects. The length of time that children felt lonely predicted mental health problems up to 9 years later, particularly depression. Children who had experienced more extreme isolation, such as quarantine, were five times more likely to require support from mental health services and experienced higher levels of post-traumatic stress.

Mental health risk factors

Strained family relationships

Evidence from previous pandemics shows an increase in regressive behaviours (such as thumb sucking and bed wetting), disruptive behaviours (such as inability to pay attention or bursts of anger) and sleep disturbances. These challenging behaviours can cause frustration for children and their caregivers.

Relationships are likely to be further tested as caregivers are experiencing increased mental strain under lockdown measures. This can have an impact on children’s mental health if caregivers’ own anxieties lead to harsh parenting. Strenuous situations may be exacerbated, as both caregivers and children have reduced access to support from peers as a way of coping with stress.

The restrictions may pose challenges for those who have been in local authority care, a group in which mental health issues are more frequent. In an Adoption UK survey of 674 parents and carers, 50% reported that their child was experiencing emotional distress and 31% had observed an increase in aggressive behaviour since school closures in March. However, 54% said that the increased time spent together was improving their relationship with their child.

Young carers (of which there are nearly 800,000 under the age of 18 within the UK) are already at higher risk of mental health issues due to their responsibilities, which may have increased due to reduced social service provision during the pandemic. They often care for somebody who is elderly or clinically vulnerable, which may escalate fears of passing the virus on.

A young carer — While care is often undertaken by dedicated professionals, there are nearly 800,000 young carers under the age of 18 in the UK.

Reduced social contact

Researchers at the University of Oxford have found that over 1 in 3 people aged 13–18 years are reporting high levels of loneliness. In a Barnardo’s poll of 4,000 8–24 year olds, 68% said that not seeing friends was the most difficult thing. Children and young people are likely to be disproportionately impacted by separation from their peers, as the measures coincide with critical stages of their social development. Children without siblings or access to outside space are particularly at risk.

For young children, playing with friends contributes to healthy emotion regulation and social skill development. Without this opportunity, children can feel lonely and isolated. Academics urge that play is particularly important during uncertain times, such as the current pandemic, as it supports coping and resilience.

School closures have drastically reduced peer-to-peer contact in adolescents, who have a heightened need for social interaction during this stage of life in order to develop independent skills required for adulthood. Adolescence is a vulnerable time for mental health, and restrictions on social and emotional learning may exacerbate this further. Social deprivation presents a greater risk of developing antisocial behaviour, which has consequences for community stability. Studies have suggested that social media can help adolescents feel connected and access support, but that it is not a substitution for face-to-face interaction.

Two children sharing a swing in a playground. Many outdoor play areas have been closed during the COVID-19 pandemic. — Without play, children can feel lonely and isolated. Play can be especially important during crises.

Academic stress

Disrupted education, cancelled assessments and predicted economic downturn may mean that young people are increasingly stressed about their future. Many young people are feeling anxious about returning to school and handling education virtually.

Academics have pointed out that low employment prospects and financial stressors are well-recognised risk factors of suicide, which is the leading cause of death in 5–19 year olds. They urge that these stressors are not only linked to individuals’ current situations but also their futures. Adolescents are particularly at risk of adopting harmful behaviours.

Studies have found that 70% of young people who report self-harming or suicidal thoughts are within a non-clinical range of mental distress. This means that small increases in stress during COVID-19 could cause far more young people to be at risk of suicide than can be detected through psychiatric assessment.

Abuse

For many children, school closures restrict access to a place of refuge, and abuse patterns are less likely to be noticed by a professional. The Children’s Commissioner for England has also warned that reduction of services could lead to many children becoming ‘invisible’, such as those receiving help from non-statutory services or those deemed ‘lower risk’ by social workers.

A report by the Children’s Commissioner found that 830,000 children in England live in homes where domestic abuse has taken place in the past year. The current measures pose a greater risk of children witnessing or experiencing abuse, which can lead to depression, aggression and anxiety, which may continue long-term into adult life.

There is evidence that rates of child abuse increase during periods of economic downturn. School-Home Support (a charity supporting state school pupils) has observed a 750% increase in safeguarding referrals compared with the same period in 2019.

Accessing support

In 2017, an NHS England survey found that one in eight children aged 5 to 19 years had at least one mental health problem. Over 350,000 young people accessed NHS child and adolescent mental health services (CAMHS or CYPMHS) in England alone in 2018–19.

Experts are concerned about whether the NHS will be able to cope with greater demand. The average wait time for a young person to receive mental health treatment is 53 days, and the current pandemic risks this being delayed further. Provision is also likely to vary, as the NHS average spend per child ranges from £14 to £191 in regions across England.

Mental health charity YoungMinds found that the longer children were left to wait for mental health support, the more likely it was that their mental health worsened. In a survey of over 2,000 parents, 76% said that their child’s mental health deteriorated while waiting for CAMHS.

YoungMinds conducted a separate survey of over 2,000 people (average age 16–17 years) with a history of mental health illness. 83% reported that the pandemic had made their mental health worse. 74% said that they were still able to access some form of mental health support. Some reported reduced access to support due to financial difficulty, such as being unable to continue private counselling as the result of a parent losing their job.

Mental health services have experienced decreased referrals, despite an anticipated increase in needs during this time. For example, there has been a 50% reduction in referrals to NHS CYPMHS in Birmingham since March. This could be because of reduced contact with GPs and schools, which are two of the main referrers for mental health support.

Many services have been reduced or suspended at a time when children and young people are experiencing higher levels of anxiety and depression. Reduced access to mental health services is likely to contribute to higher rates of mental health disorders, self-harm and suicide. In some areas, staff from community services have become ill or been redeployed to support COVID-19 patients. Children, young people and their families may be unsure on how to access support when their regular channels have been interrupted.

A young woman contemplating calling a mental health support line. — Many mental health support services have been reduced or suspended.

Digital interventions, such as those for education or physical health, can be effective in improving outcomes for young people, although the evidence base is smaller for mental health. However, many young people may be unable to access digital interventions, or they may have privacy concerns. This could come from not having a personal device or worries about being overheard.

Informal sources, such as charities and digital services, will likely become increasingly important to ease the demand on the NHS. Charities have suggested education around coping and self-management will be beneficial for those unable to access professional services, particularly if delivered by other young role models.

Policy responses

School closures

As children return to school, mental health charities urge that the primary focus should be on promoting well-being and re-integration, rather than solely focusing on academic achievement. School benefits children’s mental health by providing a sense of routine and safe-guarding for children deemed at risk. However, social distancing measures may reduce the social and emotional benefits.

Schools in England, Wales and Northern Ireland will not open for all pupils until the next academic year in September. Scottish schools will open to all students during August, with social distancing relaxed to 1 m.

Currently, schools are using a blended approach for some or all year groups, which is a combination of school attendance and remote learning in order to facilitate social distancing with limited classroom space. Children are taught in limited bubbles of peers in order to reduce the risk of transmission.

Commentators have expressed that on-going school closures are causing wider ‘collateral damage’ to the mental health of children, who are at a much lower risk of COVID-19 but are disproportionately affected by the consequences of intervention measures. Academics have urged the Government to prioritise play and face-to-face contact without social distancing. They suggest that close play could be safely permitted in bubbles that allow repeated mixing with a small number of contacts.

Clinicians have also suggested that well-being can be improved by a programme of summer activities that will enable young people to “connect with peers, re-establish routines, and be actively engaged beyond the home”.

Academics and charities have published open letters calling for further government action on protecting children’s well-being. According to the British Science Association, almost nine in ten 14–18 year olds do not think that scientists or politicians are considering their views when discussing COVID-19 related measures.

Funding

Chancellor Rishi Sunak has announced that charities that support the well-being of young people, such as Childline and Adoption UK, will receive funding from the £750 million UK-wide support package announced in April. The aim of the funding is to ensure that charities can continue supporting those in need and meet increased demand as a result of the pandemic.

The Welsh Government has further announced £1.25 million to provide additional mental health support for children who may be experiencing increased stress or anxiety as a result of the COVID-19 pandemic.

Guidance

Organisations such as the World Health Organization have published advice on how to support children and young people’s mental health during this time. This includes caregivers looking after their own mental health and maintaining a routine, and social contact with peers. The NHS has published guidance on supporting children when they show distress and how to look out for changes in behaviour.

Several organisations have published resources, such as booklets and story books, to explain COVID-19 to young children in a way that they can understand and help them manage their well-being. Children’s concerns should be acknowledged and they should be encouraged to find positive ways to express their feelings, such as through creative activities.

Further support for parents and caregivers:

Advice for transitioning back to school:

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