Researchers have stated that children and adolescents may be extremely vulnerable to the biopsychosocial stressors brought about by the pandemic, as a result of their limited understanding of the pandemic and restricted coping strategies (Imran et al, 2020; de Figueiredo et al, 2021). COVID-19 is expected to give rise to many mental health problems in children and adolescents, as well as worsen those that already exist (Imran et al, 2020; de Figueiredo et al, 2021). Because youth are especially vulnerable to stressors during developmentally sensitive times, their mental health during and after the pandemic requires heightened attention (Courtney et al, 2020; Golberstein et al, 2020). If children are left untreated, mental health problems can lead to negative health and social outcomes in the future (Golberstein et al, 2020).
The review
To better understand the impact and risk factors of coronavirus disease 2019 (COVID-19) on the mental, physical, and social health of children and adolescents, a literature search was performed. Numerous databases were searched for literature related to the COVID-19 pandemic and its impact on children's and adolescents' mental health. The databases included CINAHL, PsycINFO, PubMed, and Academic Search Premier. Key search words and phrases were used: COVID-19, mental health, children and adolescents, school nursing, COVID-19 and mental health interventions. The search yielded a total of 29 066 publications. To condense the yielded results, only articles that were written in English and published after 2016 were reviewed. The search terms were further narrowed to mental health of school-aged children, mental health interventions and COVID-19 and yielded 100 peer-reviewed journal publications mostly within the United States (USA) and China. After identifying the 16 most applicable studies, a more thorough evaluation was conducted. Each article was published within the last 5 years and contributed to the consistent themes and findings. When analysing papers, articles that focused on the psychological impact of COVID-19 were selected, instead of those that focused on the physiologic effects on children who contract COVID-19.
Mental health trends
There has been an increase in the number of children and adolescents with mental health disorders since the start of the pandemic, particularly anxiety and depression (Courtney et al, 2020; Knopf, 2020; de Figueiredo et al, 2021; Hill et al, 2021). A study recently conducted in China revealed that of 1 036 quarantined children and adolescents, 112, 196, and 68 presented with symptoms of depression, anxiety, or both respectively (de Figueiredo et al, 2021). Longitudinal studies containing baseline measurements of mental health in children and adolescents are needed to truly detect changes related to the COVID-19 pandemic. However, there is no such research at this time.
With the sudden loss of the ability to interact socially with others, concern has been expressed that over a sustained period, depressive symptoms in children and adolescents may worsen and that the expression of anxiety disorders will change (Courtney et al, 2020). In children and adolescents, anxious feelings are often centred around higher-order needs like self-esteem; however, Courtney et al (2020) have hypothesised that those anxious feelings will shift to basic needs like food and physical safety because of the stress of the pandemic.
Hill et al (2020) found that rates of suicidal ideation and attempts in children and adolescents were greater during the pandemic when compared to 2019. In this study, the Columbia-Suicide Severity Rating Scale was used among 9 092 adolescents ages 11 to 21 who presented to the paediatric emergency department in Texas, USA. By comparing rates from January to July 2019 and January to July 2020 with electronic health records, the authors found a 92% increase in emergency department visits resulting from suicidal ideation and attempts. Additionally, the odds of recent suicide ideation were 1.60 times higher in March 2020 compared with March 2019 and 1.45 times higher in July 2020 compared with July 2019 (Hill et al, 2020). Furthermore, 15.8% of adolescents in the study had suicidal ideation in the past month and 4.3% attempted suicide in the previous 3 months during the study. Compared to pre-COVID-19 data, the odds of a recent suicide attempt were 1.58, 2.34, 1.75, and 1.77 times higher in February, March, April, and July 2020 compared with those same months in 2019, respectively (Hill et al, 2020).
Risk factors
Online education and social isolation
Adolescents who felt disconnected and isolated from their peers and community because of COVID-19 restrictions had higher rates of depression and anxiety, and poorer life satisfaction compared to their counterparts who felt socially connected during the lockdown (Imran et al, 2020; Magson et al, 2020).
According to Magson et al (2020), online education does not increase the risk for anxiety or depression, but students who struggle with online learning, experience technology problems, or struggle with the educational material have higher rates of depression and anxiety. These findings are the result of a study that relied on respondents to communicate the impact COVID-19 had on their mental health via a survey. Participants were part of the Risks to Adolescent Wellbeing Project in Australia, which consisted of 248 adolescents.
Additionally, children diagnosed with COVID-19 are four times more likely to develop post-traumatic stress disorder (PTSD) because of the necessity to quarantine (Imran et al, 2020; Cui et al, 2020). Being infected and quarantining away from a primary caregiver is associated with higher rates of PTSD, nightmares, and unwanted memories of past trauma (Cui et al, 2020; Magson et al, 2020). These findings were from national surveys completed by 33 hospitals in China (Cui et al, 2020) and surveys completed by adolescents as part of the RAW Project in Australia (Magson et al, 2020).
Family structure
Many parents may be experiencing social, emotional and economic losses related to the pandemic, and may be finding it more difficult to deal with and buffer their children's stress (Courtney et al, 2020). When parents lose the ability to properly address their children's stress, it increases the risk that the COVID-19 pandemic will become a traumatic experience for the child or young person, with potential long-term negative mental health outcomes (Courtney et al, 2020). In addition, economic instability and increased stress on the family unit increases the risk for child abuse and domestic violence, which in turn increases the risk for adverse mental health outcomes (Witt et al, 2020). Some states in the USA have reported an increase in child abuse and domestic violence during the pandemic, with child protective care agencies operating at maximum capacity (Fegert et al, 2020; Imran et al, 2020; Witt et al, 2020).
Impact on daily life and mental health
Children and adolescents' daily lives have been completely transformed, namely because of school closures (Golberstein et al, 2020). In the USA, for children of families that lack access to primary care services, school nurses often serve as the primary care provider for mental health services (Golberstein et al, 2020). This is because ‘educators, counsellors, and school social workers provide critical support to students in need, particularly those from low-income and rural families, and often are the first to observe warning signs of mental health issues or unsafe situations' (Benner and Mistry, 2020). Therefore, this lack of care and attention to mental health further worsens existing mental health issues and has the potential to lead to an increase of such issues in previously mentally healthy individuals (Benner and Mistry, 2020). Additionally, 35 million children in the USA rely on school cafeterias for most of their nutritional needs (Benner and Mistry, 2020). Lack of adequate nutrition exacerbates mental health issues by increasing the risk for developmental delays and increasing family stress both economically and by worsening food insecurity (Benner and Mistry, 2020). These trends are ‘particularly problematic given the links among food insecurity and school-age children's academic and socio-emotional skills and their physical and mental health’ (Becker and Gregory, 2020).
Nutrition, physical activity and sleep
For adolescents trying to discover their identity, express themselves, and connect with their peers, social isolation can lead to ‘less physical activity, increased negative affect, more lethargy or napping behaviours, and greater screen time’, and lead to increasing mental health issues as a result (Becker and Gregory, 2020). Wider literature indicates that the COVID-19 pandemic may lead to negative impacts on sleep in children and adolescents; however, further data is needed to understand the effects completely.
Quarantine guidelines have presented an additional barrier in participating in daily exercise related to a lack of organised activities and childcare resources for parents, leading to increased screen time, sedentary behaviour, fat intake, intake of high caloric foods, and weight gain (Bates et al, 2020; de Figueiredo et al, 2021). These data comes from several surveys conducted in various countries including China, South Korea, and Canada. The sample sizes varied from 97–2427 children and adolescents ranging from 6–17 years old.
Additionally, COVID-19 has had a drastic impact on the availability of produce globally as a result of agricultural challenges, which may lead to increased intake of highly processed food sources. This in turn can lead to neurologic synaptic changes, altered intestinal microbiota and altered brain development (de Figueiredo et al, 2021; Pérez-Escamilla et al, 2020).
One of the greatest implications for the paediatric population is disrupted sleep (Becker and Gregory, 2020). Sleep disruption in general may be related to increased sedentary behaviours, unhealthy dietary choices, lack of adequate sunlight essential for circadian regulation and increased blue light exposure in both children and adults (Bates et al, 2020; de Figueiredo et al, 2021). Changes in sleep patterns related to the stress of the pandemic have been shown to include difficulty falling and staying asleep, increased nightmares, the inability to nap during appropriate times and increased frequency of tantrums or attention-seeking behaviours before bedtime (Imran et al, 2020). A lack of adequate sleep increases children's and adolescents' susceptibility to mood and anxiety disorders, distractibility, and increased opposition (Becker and Gregory, 2020).
School nurse interventions
School nurse interventions for individuals
Children and adolescents have an increased need to explore, express curiosity and release energy in comparison to adults, meaning that social isolation from the pandemic can lead them to feel disconnected (Imran et al, 2020). Therefore, school nurses should encourage children and adolescents to maintain social interactions with their friends while social distancing by setting up phone or video calls and incorporate this practice into their daily routines to decrease feelings of loneliness (Imran et al, 2020).
Furthermore, to release stress, reduce anxiety, and promote optimal physical and mental health, children and adolescents should prioritise outdoor activity, perhaps by developing a daily routine, and mindfulness activities such as yoga, playing relaxing music or participating in guided meditation or imagery (Bates et al, 2020; Imran et al, 2020).
To further improve sleep, children and adolescents should maintain a structured sleep schedule to promote optimal mental health and cognitive functioning (Bates et al, 2020).
Many outdoor parks and play areas have been closed because of the pandemic, and so children have fewer options regarding play, leading to increased screen time (Bates et al, 2020). Children and families can overcome these barriers to physical activity and play through a number of activities, including those recommended by Bates et al (2020):
- Creating obstacle courses out of items found at home
- Incorporating physical activities into daily lessons (e.g. writing words on the sidewalk in chalk and jumping over them)
- Doing outdoor activities such as hiking
- Participating in fitness challenges such as attempting to stand for a minute every hour, which will break up sedentary behaviour
- Engaging in enjoyable activities like dancing or going for family walks
- Completing household chores or duties with family members to free up time for family play.
If children do want to engage in screen time to play games or search social media, they should explore educational applications that will enhance their learning (de Figueiredo et al, 2021).
School nurses can play an important role in helping children and adolescents overcome the barriers to mental and physical wellbeing that the COVID-19 pandemic has imposed. For example, school nurses can help to create an environment that is attentive to the students' mental health (Green et al, 2013). Nurses can do this by holding meetings and creating health information tip sheets, among other things. To promote healthier routines and habits, school nurses may also choose to hold assemblies or classroom meetings with the children and adolescents. By engaging with students and providing educational information tailored to their educational level, it may encourage them to implement healthier interventions into their routines.
School nurse-driven parental interventions
For children to feel safe and thrive during the pandemic, school nurses should encourage parents to develop schedules and routines, encourage physical activity and time outside and foster support within the home (Imran et al, 2020). For younger children, a routine may consist of taking 10–15 minutes before bed for play or quality time (Imran et al, 2020). For older children, this may consist of setting up times for a few regular activities like tutoring, phone calls with friends or playing outside (Imran et al, 2020). Additionally, ‘bedtimes/waketimes should be established (and not vary by more than 30 [minutes] from night to night), and screened devices should be removed from bedrooms 30 [minutes] prior to sleep’ (Bates et al, 2020) because research has shown that blue light exposure from electronic devices can suppress melatonin release, interfering with sleep.
School nurses should encourage parents to incorporate healthy nutritional habits into daily routines to decrease the risk of obesity and to enhance immune and neurological functioning to combat the increased risks of weight gain and sedentary behaviour during the pandemic (de Figueiredo et al, 2021). Additionally, optimum immune functioning is important for protection against COVID-19 and mental health issues, as dysregulated neuroendocrine-immune functioning can contribute to psychiatric issues (Raony et al, 2020).
Additionally, school nurses should encourage parents to prioritise their own mental health. Parental stress related to social isolation, remote learning, telecommunication, financial stressors, fears of job loss, and contracting COVID-19 impacts children and adolescents in that they sense this anxiety and tension in parents (de Figueiredo et al, 2021; Imran et al, 2020). Therefore, parents need to practise effective coping mechanisms to properly care for their children because stable and nurturing parents are better able to give their children an environment that fosters resiliency and enhanced mental and overall health (Imran et al, 2020). Furthermore, school nurses should encourage parents to engage in open, age-appropriate communication because ‘honesty not only offers a coherent explanation for what children are observing, but also grants permission for children to safely talk about their own feelings’ (Dalton et al, 2020). A nurturing relationship ensures children are receiving the emotional attention required for proper development, while a lack of emotional expression can lead to anxiety related to suppressing emotions (Dalton et al, 2020; Imran et al, 2020).
Specific school nurse interventions
School nurses are in a unique position to help children and adolescents affected by the pandemic. Prior knowledge of a student's medical, mental health and physical conditions, as well as pre-established provider relationships uniquely position school nurses to provide assistance for children. School nurses can begin by educating the teachers, administrative staff members, parents and children about preventative behaviours outlined by professional organisations like the World Health Organization, and the National Association of School Nurses (2018). The school community can benefit from the promotion of mental health and wellbeing by school nurses teaching mindfulness, deep breathing, and relaxation techniques. Virtual ‘office hours’ can afford school nurses the opportunity to talk with students about their concerns and provide a mental health check. Targeting at-risk students with known mental health conditions may be an effective strategy, as well as including those who want to come in for a mental health break. School nurses are also an excellent resource for early identification and referral assistance for parents with concerns regarding their child's mental health (Lodes et al, 2020; Boden et al, 2021).
Castillo et al (2019) suggest collaborative care models as one way to combat mental health issues in the community. Programmes such as primary care-based intervention programmes allow school nurses and primary care providers to connect young people to appropriate intervention programmes (Castillo, 2019). Durlack et al (2011) found that schools who collaborated with community-based interventions improved students' academic outcomes. These partnerships showed positive school climate, decrease in truancy rates and increase in graduation rates (Durlack et al, 2011).
School nurses are in a unique position to work with schools when opening back up to monitor and protect youth. Implementing some interventions to help youth with the transition of being back at school will help with those struggling with mental health issues. Green et al (2013) recommend providing early intervention services to youth who may need additional support with things like grief, anger, anxiety, stress. School nurses can provide community- and school-based resources and support to parents and youth (Castillo, 2019). School nurses can assist the school in developing a culture in which students, administration and teachers are trained to recognise signs of mental health issues in youth (Green et al, 2013). School nurses can develop a process to refer students to outside community resources ensuring all students in need receive proper support and treatment management.
Conclusions
COVID-19 has led to increasing levels of mental, physical, and social health issues including problems related to disturbed sleep patterns, altered levels of exercise, and changes in dietary habits resulting from social isolation and quarantine in children and adolescents; therefore, it is imperative that the appropriate resources and parental support are offered and available. Without such interventions, children will not be empowered to thrive, and mental health and wellbeing will suffer on a population level. Therefore, school nurses should advocate for communities and governing bodies to take this societal threat seriously and implement nationwide programmes in addition to suggested interventions to enable children to develop appropriately and reach their full potential.