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Life in Lockdown: Child and adolescent mental health and well-being in the time of COVID-193EXECUTIVE SUMMARYMethodology and overviewOur findings are based on systematicreviews and studies coveringmore than 130,000 children andadolescents across 22 countries.The review conducted systematicdatabase searches of PubMed,PubCovid-19, the Cochrane Collaborationand the Wellcome Trust COVID-MindsNetwork, covering studies publishedbetween 1 November 2019 and30 November 2020. We screenedstudies in two stages according topredefined inclusion and exclusioncriteria. Out of a total of 4,323 studiesidentified, we included a final set of84 peer-reviewed sources for dataextraction and evidence synthesis. Fourresearchers undertook data extractionand evidence synthesis, with eachresearcher cross-checking the extractionand synthesis of another researcher toensure quality control. A formal qualityappraisal of included studies wasnot undertaken.Of the 84 studies, the 77 primarystudies reviewed include data fromover 130,000 children and adolescents from 22 countries. The studiesfocused on children and adolescentsaged 0–19 years, with about 50 percent focusing on adolescents aged10–19 years. The studies reviewedreported on data collected up toAugust 2020 during the early stagesof the pandemic. Consequently, anylonger-lasting mental health impacts –including during subsequent waves ofthe virus and phases of the lockdowns– are not fully captured. Moreover,the timing of government-imposedcontainment measures, includinglockdowns and school closures, variedconsiderably across countries, limitingthe generalizability of specific findings.Most studies were from high- andupper-middle-income countries thatwere sharply affected by high infection and death rates early in thepandemic’s trajectory.The largest share of studies reviewedwas from China (26 per cent), followedby the United States (23 per cent) andItaly (13 per cent): all countries thatwitnessed high infection and death ratesearly in the pandemic. The distributionof studies by region was 36 per centfrom Europe and Central Asia, followedby 30 per cent from East Asia and thePacific, North America (25 per cent),South Asia (4 per cent), the Middle Eastand North Africa (3 per cent), Easternand Southern Africa (2 per cent), andLatin America and the Caribbean(2 per cent). One study was conductedin multiple regions (Eastern andSouthern Africa, West and Central Africa,and the Middle East and North Africa).Only one study was from a low-incomecountry (Ethiopia), and most were fromhigh- or upper-middle-income countries.Distribution of studies by region36%East Asia and the Pacific 30%North America 25%South Asia 4%Middle East and North Africa 3%Eastern and Southern Africa 2%Latin America and the Caribbean 2%Europe and Central AsiaNote: Percentages add up to 102% due to rounding figures.

4Life in Lockdown: Child and adolescent mental health and well-being in the time of COVID-19EXECUTIVE SUMMARYKEY FINDINGS:attitudes, behaviours andmental health conditionsHigher levels of depression, fear,anxiety, anger, irritability, negativity, conduct disorder, alcoholand substance use and sedentary behaviours compared withpre-pandemic rates were commonlyreported in children and adolescents in 2020, but there were alsopositive perceptions of time spentwith family.angerfear2020depression .family timeMost studies assessed the effects ofCOVID-19 and containment measureson mental health outcomes relating toanxiety, depression, behavioural issuesand positive mental well-being (operationalized as life satisfaction, quality oflife and self-esteem). Findings of specificoutcomes in the early stages of thepandemic are summarized as follows:Depression: Depressivesymptoms (including sadness, loss ofinterest in activities, hopelessness,low energy, irritability and guilt) werecommonly reported in children andadolescents during the COVID-19pandemic. Moderate increase indepressive symptoms and sadnesswere reported, especially among olderadolescents and females.Fear and anxiety: Higher thanpre-pandemic rates of mild and moderateanxiety were reported by children andparents across regions and age groups,especially because of disruptions to dailyroutines and school closures as well as togrowing worry and concern over risk totheir own health and that of their families.Suicidal behaviour: Limitedevidence from preliminary reportsindicates that increases in suiciderates among children and adolescentsin the context of COVID-19 shouldnot be assumed, as there are alsoseveral protective factors that couldarise in the context of this crisis.Trauma and post-traumaticstress: Studies showed increasedstress and adjustment issues amongadolescents, especially because offear of infection and uncertainty dueto quarantine and disruptions to dailyroutines. Studies did not, however,find significantly higher PTSD ratesin children and adolescents since thepandemic onset, and follow-up researchis needed to assess the long-termimpact of the pandemic on PTSD.

Life in Lockdown: Child and adolescent mental health and well-being in the time of COVID-19EXECUTIVE SUMMARYExternalizing behaviouralproblems: The living conditions broughtupon by the response to the COVID-19pandemic led to an increase in anger,negativity, irritability and inattention,particularly among children with attentiondeficit hyperactivity disorder (ADHD) and/or autism. Parents also reported worsening of conduct problems and disruptivebehaviours among adolescents, as wellas clinginess among younger children.Alcohol and substance use andabuse: Studies indicated an increasein hazardous and problematic alcohol andsubstance use among adolescents sincethe outbreak of the pandemic and foundthis to be associated with behaviouralproblems (including anger and irritability),especially among boys.Lifestyle behaviours: Studiesidentified associations betweenCOVID-19 containment measures (e.g.,home confinement and school closure)and increases in sedentary behaviourand lifestyle changes (e.g., less physical activity, higher exposure to screentime and irregular sleep patterns). Someof these lifestyle changes (especiallyirregular sleep and exercise) were associated with lower quality of life (e.g., lowself-esteem) and increased psychologicaldistress (e.g., anxiety and depression).Use of digital technology during thepandemic provided social connectedness, remote learning opportunities, anda way to cope with isolation and stress.Photo: UNICEF/UNI320964/Positive mental health outcomes:Not all mental health consequencesassociated with the pandemic werenegative. Children and adolescentsreported perceived benefits from homeconfinement (e.g., increased quality timewith family members) and school closure(e.g., respite from schoolwork, examstress and school-related bullying) thatseemed to positively correlate with lifesatisfaction. Engaging in positive copingstrategies (e.g., physical and recreationalactivities), having more time for oneselfor to spend with one’s family and havingmore flexible schedules contributed tochildren’s and adolescents’ well-beingduring the COVID-19 outbreak.5

6Life in Lockdown: Child and adolescent mental health and well-being in the time of COVID-19EXECUTIVE SUMMARYKEY FINDINGS:risk and protective factorsThis section highlights key risk andprotective factors reported acrossstudies that shaped the way in whichthe COVID-19 pandemic affectedmental health outcomes for children and adolescents, including asmediating and moderating factors.Sex: In most of the studiesreviewed, females reported greaterdepressive symptoms, anxiety and externalizing behavioural symptoms thanmales, while males reported greateralcohol and substance use duringCOVID-19 than their female counterparts.Age: Older children andadolescents reported higher and moresevere rates of depressive symptoms and anxiety than younger onesduring the pandemic. Mixed resultson age differences were reportedfor other mental health outcomes.Location: Children living inmore-affected areas, rural areas,or near the epicentre of COVID-19outbreaks were associated with stresssymptoms, depressive symptoms,anxiety, alcohol and substance use,and increased sleep disturbance.Socio-economic status:Children living in poverty or in families with lower socioe-conomic statuswere found to be at greater risk ofstress and depressive symptoms,whereas higher socio-economicstatus was found to be a protectivefactor for externalizing behaviouralproblems during the pandemic.Moreover, the living conditions andlivelihoods of families were adverselyimpacted by financial hardships duringCOVID-19, exacerbating sadness andworry in caregivers and children.Pre-existing conditions: Childrenand adolescents with pre-existing conditions were more significantly affectedby pandemic-related changes. Childrenand adolescents with neurodevelopmental conditions (e.g., ADHD andautism spectrum disorder) and healthconditions such as HIV, diabetes andcancer had greater fears relating toCOVID-19 risk. Moreover, children livingin low- and middle-income countries(LMICs) or conflict-affected settingswho were exposed to widespreadpoverty, displacement and genderinequalities, experienced depressionduring the pandemic and struggled toadapt to online education. Mental healthservices and other services for children with pre-existing conditions werealso disrupted during COVID-19, withgrave consequences for children withpre-existing mental health conditions.Adverse childhood experiences:Children and adolescents who reportedpre-existing adverse childhood experiences and maltreatment, including abuse,neglect and family dysfunction, wereat increased risk of stress and anxietysymptoms since the pandemic onset.Parenting: Family conflict increasedthe risk of mental distress among children and adolescents, while separationfrom families and parental depression and anxiety were risk factorsfor stress and adjustment issues,

Life in Lockdown: Child and adolescent mental health and well-being in the time of COVID-19EXECUTIVE SUMMARYdepressive symptoms, and externalizing behavioural problems amongchildren and adolescents. Positiveparenting and caregiver–child communication about the pandemic improvedcoping and well-being among children, adolescents and caregivers.Stigma and discrimination:Stigma based on ethnicity and allforms of racial discrimination (online,in-person and health care related)since the outbreak of the pandemicwere associated with greater anxietyamong these adolescents. In USstudies, discrimination towardsChinese American adolescents wasfound to be particularly acute.Lockdown and isolation: Socialisolation and loneliness during lockdownscontributed to a range of outcomes,including depression, irritability, anxiety,stress, alcohol use and sedentarybehaviours. However, in some studies,children and adolescents reportedperceived benefits from home confinement (such as spending time with family)and school closure (relief from academicstressors), which correlated positivelywith life satisfaction.Coping strategies: Spendingmore time on physical activity and maintaining daily living routines protectedagainst depressive symptoms and wereassociated with better mood states.Stress management, leisure-time activities (e.g., learning an instrument orcooking) and regular communicationwith loved ones were other proactivecoping strategies used to deal withpandemic stressors and lockdowns.Social support andconnectedness: Engaging in recreational activities, including usingtechnology to communicate with lovedones, having more time for oneself orfor one’s family and having more flexibleschedules, protected against anxiety andcontributed to children’s and adolescents’overall well-being during the pandemic.Adherence to stay-at-home ordersand social support and connectednessprotected against depressive symptomsand anxiety.Risk perception: Experienceor fear of exposure to COVID-19 andperceived seriousness of the pandemicwere predictive of stress and depressive symptoms, anxiety and hoardingbehaviour, but they were also associated with health promotion andinfection-prevention behaviours such asgreater physical distancing, disinfectingand news monitoring.Photo: UNICEF/UNI313778/Georgiev7

8Life in Lockdown: Child and adolescent mental health and well-being in the time of COVID-19EXECUTIVE SUMMARYImplications of findings forpolicy and programmingThe pandemic has impacted all areasof children and young people’s lives.Our review found evidence of increasedstress, anxiety and depressive symptoms, externalizing behavioural problems,and alcohol and substance use sincethe onset of the pandemic. Associationswere also identified between COVID-19containment measures and lifestyledysregulation. However, children andadolescents also reported positive copingstrategies, resilience, social connectedness through digital media, morefamily time and relief from academicstress. The influence of factors suchas demographics, interpersonal relationships and pre-existing conditionsis critical when considering the typeof mental health outcomes reportedsince the COVID-19 outbreak.Several primary recommendationsemerge from the report thathave strong implications forpolicy and programming. Begin early to build mental healthassets of children and adolescents.As positive mental health starts earlyand continues to grow over time withnurture and support, it is imperative to begin building mental healthassets early in life, using provenapproaches in the home, at school andin the community. Foster family-friendly policies.Promoting positive action throughplay, support to parents and qualityfamily time have proved helpful inalleviating stress and fear associated with the pandemic and mobilityrestrictions. The potential benefitsof family-friendly interventions suchas parenting programmes and socialprotection are increasingly clear andapplicable across diverse contexts,including in countries and contextswith underinvested health systems,and they should be strengthenedas the pandemic continues. Invest in age- and gender-sensitivechild and adolescent mental healthcare interventions and services.The COVID-19 crisis has underscoredthe depth of the global mental healthcrisis, including among children andadolescents. Mental health caremust become an increasing prioritywhen designing, implementingand expanding primary health careservices for children and youngpeople – particularly through buildingcapacity of health professionals andother child-related frontline workers.In particular, it will be important forpolicymakers and practitioners todevelop and scale age-appropriate andgender-sensitive interventions, and toadapt evidence-based activities thathave proved beneficial in high-incomecontexts to those children and youngpeople in resource-poor settings. Promote physical activity andgood nutrition for young people.Studies show that those childrenand adolescents who fared well for

Life in Lockdown: Child and adolescent mental health and well-being in the time of COVID-19EXECUTIVE SUMMARYpositive mental health during the earlystages of the pandemic had accessto physical recreation and improvednutrition. Going forward, governmentsacross the world should invest inindividual, interpersonal and community mental health interventions thatfoster the holistic development andwell-being of children and adolescents,including through promoting theirphysical health and social networks. Make schools a safe space forpositive mental health. As millionsof children and young people return toschool, it is vital that families, frontlineworkers and governments listen tothem and seek to address some of themental distress that both the absenceof school, and schooling itself, maycause them. Ways should be exploredto help them catch up while alsoreducing exam stress to bolster theirmental health, and avenues to makeschools safer and more inclusive for allstudents should be found. Focus on at-risk young populations.Children and adolescents sufferingfrom pre-existing child and adolescent mental health conditions – andthose most affected by exclusionand discrimination based on income,gender, disability, ethnicity and otherdelineators – have been amongthose whose mental health has beenmost affected by the pandemic.Studies show clearly that childrenand adolescents facing the driversof exclusion and discrimination haveseen markedly increased risks. Forpolicy and programming, it will beessential to place greater emphasis onunderstanding even further the mentalhealth stresses that these at-riskpopulations face, and on prioritizinginterventions for them. Address stigma and discrimination in mental health, includingnew and emerging forms. Thepandemic has coincided with a widerglobal discussion on mental healthissues, on inequality, and on racismand discrimination based on ethnicity,and on ways to combat these challenges. Policies and programmesfocused on child and adolescentmental health must address bothgeneralized and continuing stigmarelated to mental health issues, andspecifically stigma against certaingroups as related to the pandemic. Support digital technologies asa force for change. The COVID erahas underlined the essentiality bothof access to digital technologiesfor young people to learn, communicate and grow, and of protectivemechanisms to protect them fromharm and abuse and safeguardtheir mental well-being. Digitaltechnologies can also offer alternative and promising modes ofdelivering mental health psychosocial support services. Therefore, itwill be important to develop innovative, evaluated and ethical strategiesand interventions that can be scaledup to support the mental healthof more children and adolescents,and their parents and caregivers.9

10Life in Lockdown: Child and adolescent mental health and well-being in the time of COVID-19EXECUTIVE SUMMARYImplications of findingsfor researchOur report has noted four keyevidence gaps to address inthe rapidly growing body ofresearch on COVID-19 and itsmental and psychosocial impacton children and adolescents. 1Build a wider body ofresearch on child and adolescentmental health in LMICsOur findings are largely drawn fromevidence of the countries most affectedby COVID-19 disease early on in 2020 –especially China, Italy and the US. Moreevidence is needed of how it affects childand adolescent mental health in low- andmiddle-income regions and countries –and especially in those regions such asLatin America and Caribbean and SouthAsia where the pandemic has beenparticularly hard-hitting so far, and alsosub-Saharan Africa and the Middle East,where the evidence base of child andadolescent mental health is nascent.2Examine how COVID-19affects mental health in earlyand middle childhoodIn addition, more evidence is required ofearly (0–4 years) and middle childhood(5–9 years), as most of the researchreviewed captured the situation ofadolescents aged 10–19 years. Researchon younger age groups could examinehow COVID-19 affects the developmentoutcomes in early childhood andinvestigate any long-term implicationsof the suspension of primary health careservices during the pandemic.3Widen the evidence base toinclude vulnerable populationsof children and adolescentsOur review did not find evidence ofthe impact of COVID-19 on the mentalhealth of a wide array of vulnerablesocio-economic groups of childrenand young people. These include childmigrants and displaced persons, childlabourers, adolescent parents/caregivers and adolescent pregnant girls,children facing domestic violence, children facing sexual and gender-basedviolence, children living in institutionalcare, children with disabilities, and youthwith non-binary genders and LGBTQI youth. Future research should andmust examine the impacts (especiallythe enduring impact) of the COVID-19pandemic on the mental health of thesevulnerable populations.4Investigate the longer-termimpact of the pandemic on childand adolescent mental healthOur findings are limited to studiespublished between 1 November 2019and 30 November 2020. It should benoted that mental health conditions mayc

iv Life in Lockdown: Child and adolescent mental health and well-being in the time of COVID-19 ABBREVIATIONS ADHD attention deficit hyperactivity disorder ASD autism spectrum disorder COVID coronavirus disease DSM Diagnostic and Statistical Manual of Mental Disorders EVD Ebola virus disease GAD generalized anxiety disorder H1N1 influenza A virus subtype H1N1