Original articlePsychological impact during COVID-19 lockdown in children and adolescents with previous mental health disorders
Introduction
The pandemic of novel coronavirus disease (COVID-19), first reported in Wuhan (China) on 31 December 2019,1 has led to more than 500,000 cases in Catalonia and more than 3 million in all Spain to date.2 The Government declared a state of emergency in order to manage the health crisis3 and confined adults, adolescents and children to their homes by Royal Decree 463/2020, of 14 March 2020.
Once the risk of the collapse of the health system was reduced, around 4 May 2020, the Spanish Government managed the economic, social and mobility recovery through five 2-week phases, depending on the number and location of newly detected cases.
One month after the start of the lockdown, Spain entered phase 0, the preparation phase for a gradual relaxation. Children younger than 14 started to go outside, for an hour a day, accompanied by an adult. They could not interact with peers, go to school or share face-to-face activities with relatives with whom they did not live. Schools were closed for 3 months and little or no social contact by young people has been the norm during these months.
It was an unprecedented situation, and no one knew the psychological impact on the population. Recent articles warn of the possible long-term consequences to mental health, especially those with previous psychiatric pathology, underprivileged environments or in situations of risk.4, 5
Children and adolescents are already considered a vulnerable group in emergency situations or health crises. There is a need to determine the mental health status of young people and how the situation described has affected their well-being.6, 7 In the adult population, the mid and long-term effects of a lockdown due to health crises have been described, such as, an increase of post-traumatic stress disorders, a lower mood, a higher level of anxiety, poor concentration, insomnia and increased irritability,8 and it has been concluded that these effects can be wide-ranging and long-lasting. However, studies on children and adolescents are still scarce. In a study on the impact on mental health of Chinese students during the COVID-19 pandemic, more than 7000 participants answered an online questionnaire: 0.9% suffered from severe anxiety, 2.7% from moderate anxiety and 21% from mild anxiety.9
A systematic review and meta-analysis10 synthesized fifteen studies which describe the behavioural, emotional and psychological problems of children and adolescents as a result of pandemic and isolation measures. They found that overall, children and adolescents without pre-existing psychopathology were suffering from irritability (42.3%), depression (41.7%), anxiety (34.5%), and inattention (30.8%). The behavioural/psychological state of a total of 79.4% of children in the study were found to be negatively affected. At least 22.5% of the children were found to have a significant fear of COVID-19, and 35.2% and 21.3% of children had boredom and sleep disturbance, respectively. Similarly, 52.3% and 27.4% of caregivers developed anxiety and depression, respectively, while being in isolation with children.
Another systematic review carried out in Italy and Spain11 indicated that 85.7% of the parents reported changes in their children's emotional state and behaviours during the quarantine. The most frequent symptoms reported were: difficulties concentrating (76.6%), boredom (52%), irritability (39%), restlessness (38%), nervousness (38%), feelings of loneliness (31%), and feeling more uneasy and more worried (30%).
Results show that Spanish children were more affected than Italian children on most symptoms, probably due to the fact that differences in restrictions put in place by the Spanish government were more severe than those decreed by the Italian government. In addition, and the fact that there are fewer terraces and gardens in Spanish homes further exacerbates symptoms. characteristics of the homes. Furthermore in general, when the level of stress at home was higher, parents tended to report more emotional problems in their children.
There is little has been published about the psychological impact of the lockdown and restrictions due to COVID-19 in children and adolescents with a pre-existing mental disorders. In a study carried out by the mental health charity Young Minds in the United Kingdom,12 they found that 83% of the respondents (in a total sample of 2111 young people with a history of mental health needs) reported that their mental health was worse or much worse due to the current pandemic and lockdown. Many reported higher levels of anxiety, problems with sleep, panic attacks or more frequent urges to self-harm among those who already self-harmed.
Some studies were carried out during the lockdown in children and adolescents with a specific pre-existing diagnosis of a mental disorder. Specifically, in children with Attention-Deficit/Hyperactivity Disorder (ADHD), a study13 found that 34.71% of children experienced a worsening in well-being, 34.33% showed no significant changes and 30.96% were doing better, according to their parents. The subgroup of children whose condition deteriorated manifested as oppositional/defiant attitudes and emotional outbursts. Their parents also showed cited increased sleep problems and anxiety in this context. They also found an improvement reduction in of their children's level of anxiety as well as improved self-esteem, related to less school-related strain, flexible schedules and a lesser exposure to negative feed-back. In another study,14 a 53.94% of parents reported a worsening in their children's ability to stay keep focused (only children with a previous diagnosis of ADHD), 67.22% reported on increased frequency of anger frequency, and 56.02% on worse daily routine. On the other hand, more than half of the parents reported that children's behaviours in other domains areas improved or maintained the same level.
Studies with children and adolescents with a pre-existing diagnosis of Autism Spectrum Disorder (ASD) showed an increase in the frequency and intensity of behavioural problems, respectively, related with prior or behavioural co-morbidities.15 Another study16 of ASD patients found that 72.1% had negative changes in behaviour, whereas 67.9% of (72.1%), compared with children from the control group, where they mostly found reported no changes (67.9%). The majority of parents of ASD children reported a negative impact in emotion management compared to against those in control group, which reported mostly positive impact or no impact. ASD caregivers reported higher mean scores of anxiety levels in themselves than in their children. ASD children and their parents had higher levels of anxiety than their healthy counterpart ones. In the ASD group with ASD, children that who did not maintain routines had higher mean levels of anxiety than children those that who maintained routines. Another study17 compared 82 parents of children with neurodevelopmental disabilities (NDD) and 82 parents of typically developing children (TD). The results revealed a general increase in parental stress and child externalizing behaviours while self-isolating at home. Parental stress is predicted by externalizing behaviours regardless of the child's clinical status. Specifically, in the NDD group, the reduced therapeutic support produced an increase in children's externalizing behaviours.
In a study of 159 former inpatients with anorexia nervosa (AN),18 aged 13 and above, carried a study the sample consisted of 159 ormer inpatients with an age from 13 years onward. They found that approximately 70% of patients reported concerns about eating, shape and weight concerns, drive obsession for with physical activity, and loneliness, sadness, and inner restlessness increased levels of loneliness, sadness, and inner restlessness during the pandemic. In another study19 with a sample of fifty-five former inpatients with bulimia nervosa (BN), almost half of them (49%) reported a deterioration of their eating disorder symptomatology and 62% reported a reduced quality of life. The frequency of binge eating increased in 47% of patients and self-induced vomiting in 36%. Furthermore, depressive and general psychopathology symptoms increased in up to 80% of patients.
We did not find studies carried out in children with other mental health conditions, such as mood disorders, anxiety disorders or psychotic disorders. Thus, further research into the impact of lockdown and pandemic on the mental health of children and adolescents with previous psychopathology is necessary. This is a crucial concern for clinical settings and may help in the planning of actions to reduce the psychological distress of vulnerable children in the coming months.
Our main objective was to get to know the evolution of various clinical symptoms during lockdown and the coping strategies used by a sample of children and adolescents with pre-existing psychopathology who are being treated at a Child and Adolescent Mental Health Unit (CAMHS). Our first objective was to observe the impact of the lockdown in terms of specific symptoms and behaviours. Our second aim was to analyze the influence of age, gender and differential diagnosis on the psychological state of these patients. Our third objective was to observe the impact of the lockdown on the mental health of the primary caregivers. Finally, our fourth and last objective was to analyze the relation between sociodemographic data (income level, square metres of housing, outside housing spaces) and some increased risk factors for stress (percentage of reduced income, relatives engaged in the frontline fight against COVID-19, relatives at increased medical risk of COVID-19 infection, severity of medical outcome in relatives infected by COVID-19) with the total impact on patient symptoms and use of coping skills by children and adolescents.
In line with these aims, an invitation to complete an online survey was sent in May 2020 to all the families currently being treated at our Child and Adolescent Mental Health Unit (CAMHS).
Based on previous studies and on our clinical observations, we hypothesized a general increase in irritability and anxiety, and a decrease in well-being in our sample. Specifically, an increase in symptoms in anxiety disorders, an increase in irritability, anger frequency and behavioural problems in ADHD, ASD and Conduct Disorders, as well as an increase in body dissatisfaction in adolescents with eating disorders. We also hypothesized an increase in parental stress during lockdown as well as increased stress in families that have experienced loss of income, have had a relative with COVID-19 or were living with someone involved in the frontline fight against COVID.
Section snippets
Sample
The target population of this present study was the parents or principal caregivers of patients who attended the CAMHS, which is located in the Eixample district of Barcelona, in the year prior to the start of the lockdown (March 2019 to April 2020). The total sample consisted of a total of 1089 families. Of these, 122 were unreachable, since they did not provide their email address to the CAMHS administrative services on the grounds that they did not wish to receive communications by email.
Results
Of the 967 families invited to participate in the survey, the caregivers of a total of 541 (56%) outpatients logged into the app to answer the questionnaire, of whom 441 completed all sections of the ECIPNA (a total of 40.5% of the study participants).
Discussion
The various COVID-19 lockdown restrictions imposed by governments across the globe have had a psychological impact on the adults, children and adolescents of their respective populations.
There were increases in symptoms such as irritability, attentional problems, oppositional behaviours, fatigue, sleep problems, anxiety, sadness, isolation, cognitive inflexibility, body disturbances and dissatisfaction, and COVID-19- and death-related worries. Younger children showed a tendency to externalizing
Limitations and strengths
Although the findings of this study are promising, they are not without their limitations. Regarding the sample, respondents were selected from a specific region with specific sociodemographic characteristics (considerable presence of middle to upper-middle class participants and university graduates) that differ from other districts or regions of the city and country. Another limitation of the sample was that the survey was mostly completed by parents of pubescents and adolescents, which is
Conclusions
The COVID-19 pandemic has had an impact on the mental health of children and adolescents. Both previous and present studies indicate an increase in symptoms and risk behaviours among young people. The results obtained from the present study show that young people with a history of psychiatric psychopathology may have been affected by the COVID-19 pandemic and the concomitant lockdown measures implemented by authorities. The early detection of mental disorders in young people is important.
Funding
None declared.
Authors’ contributions
All authors contributed to the study's conception and design. Material preparation, data collection and analysis were conducted by Jara López-Serrano, Sara Lera-Miguel and Rosalía Díaz-Bóveda. Data analysis was conducted by Laura Gonzalez-Vallespí and Sara Lera-Miguel. The first draft of the manuscript was written by Jara López-Serrano and Sara Lera-Miguel. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Conflicts of interest
We have no conflicts of interest to disclose.
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