In attempts to slow the spread of the Coronavirus Disease 2019 (COVID-19), daycares, schools, and recreational centres worldwide abruptly closed and have since had inconsistent reopening.1 During the initial months of the pandemic, an estimated 1.4 billion children were out of school and childcare, without access to group activities, team sports, or playgrounds, which has significantly influenced the lives of children.2 Simultaneously many parents have worked, and continue to work from home, whereas others are working in high-stress environments and/or facing unanticipated income loss. Collectively, these experiences have caused substantial and unique change for families. To inform policies aimed toward protecting today, it is imperative to draw parallels to past pandemics. Concerns regarding the impact of the COVID-19 pandemic on mental health impacts, academic losses, malnutrition and child abuse have been raised.3–7 An understanding of the potential impact of the COVID-19 pandemic on children is necessary to plan for the eventual return to socialized life, and to design programmes and policies that support families in the short- and long-term. The aim of this scoping review was to examine the impacts of previous and current pandemics/epidemics on children’s mental health, nutrition, academic performance, and recreational habits, as well as family wellness.
The five-stage Arksey & O’Malley’s (2005) methodological framework for scoping reviews was used.8 Two avenues were implemented to identify existing literature: academic articles and grey literature searches.
Academic articles examining the relationship between child- and family-related outcomes during prior and current pandemics/epidemics were searched within the Medline, PsycINFO, Global Health, and CINAHL databases on June 11, 2020 (see Online Supplementary Document, Appendix 1). Sixteen searches were completed within each database. Child, pandemic, and outcome of interest were present within the title, keywords, and/or abstract of all identified articles. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines9, articles were screened independently by KM and TW for eligibility. Articles were screened at the title and abstract level, and if deemed eligible, a full-text screening was completed. Any disagreements were discussed to consensus. When a consensus could not be reached, KJ reviewed the article and conflicts were resolved. Articles were deemed eligible if they: (a) included children between 0 to 18 years old, (b) involved a prior or current pandemic/epidemic [exceptions to this include: (1) the Zika virus because this virus is associated with severe cognitive impairment and/or fatality which is not observed in those with COVID-19 and (2) HIV/AIDS which, although classified as a pandemic, does not transmit to children the same as COVID-19] , (c) included a child- or family-related outcome of interest (e.g., nutritional, financial, and child safety outcomes) as specified in Online Supplementary Document, Appendix 1, (d) were written in English, and (e) were original research with the exception of case studies.10,11 No limits were placed on the year of publication to broadly identify the extent of available literature examining child outcomes in prior and current epidemics/pandemics. The reference lists of all eligible articles were screened for eligibly following the steps above.
The grey literature was searched using Google Advanced (https://www.google.ca/advanced_search) within the World Health Organization (WHO; https://www.who.int/) and United Nations Children’s Fund (UNICEF; https://www.unicef.org/). Grey literature searches within the WHO domain commenced on July 23, 2020 between 16:01 and 18:26 CDT and continued on July 24th, 2020 using the WHO and subsequently the UNICEF domain between 10:11 and 14:08 CDT. Sixteen searches were completed within each domain. Grey literature searches were restricted to portable document format (PDF) and those published in English. Only published reports were included herein. The first two pages (or 20 articles) of search results in Google Advanced were examined for each of the 32 searches. As a preliminary screen the following groups of terms were searched using the control + F function: (1) child, (2) pandemic, epidemic, virus, infectious, communicable, bacteria, influenza, quarantine, and (3) and outcomes of interest, such as, nutritional, financial, and child safety outcomes (see searches 17-32 in Online Supplementary Document, Appendix 1 for specific searches). If the above terms were not found, the report was excluded; whereas if any of the above terms were found a full-text review was conducted. The full texts of all reports were screened independently by KM and TW to determine whether they met eligibility criteria. All disagreements were discussed to consensus. When a consensus was not reached, a third reviewer KJ reviewed the report to resolve the conflict.
Data extraction and synthesis
Data from academic articles and grey literature reports were extracted based on pre-identified domains. All domains were selected based on recommendations made by Arksey & O’Malley’s (2005) and expert librarians.8 All extracted data was independently reviewed for accuracy by KM and TW. Findings were collated based on the outcome of interest. Outcomes included: mental health, anxiety, loneliness/depression, stress, grief, stigma, nutrition, academics, entertainment, family conflict, child abuse, family economic impact.
The literature searches yielded 17,352 academic articles and 320 grey literature documents. Ninety-five additional academic articles were included from the reference lists of eligible articles. In total, 9,435 duplicates were removed, leaving 8,332 articles and reports to be screened at the title and abstract level. After excluding 8,018 articles/reports which did not meet eligibility, 326 full-texts were assessed (Figure 1). Collectively, 35 articles and 38 reports were included, which assessed child well-being during previous and current pandemics/epidemics. The characteristics of all studies included are in Tables 2-4.
In total, 21% reported on symptoms of anxiety. Of these papers, one suggested minimal to no anxiety, one indicated increased levels of anxiety, and the remaining indicated prevalence rates. The lack of security and confusion regarding the changing environment during a pandemic can instill fear and panic in children.13–15 Sprang et al., 2013 reported that generalized anxiety, which represented 20% of diagnoses, was the most commonly diagnosed disorder in youth during and after the H1N1 pandemic.16 Elsewhere, most children were concerned about the pandemic, which resulted from them being uninformed, misinformed, and having unanswered questions about the nature and mode of transmission (Table 2).17–20 Such concerns contributed to anxiety and feelings of guilt and responsibility if a family member fell ill.13–16,20–25 In contrast, an Australian study found that 90% of children had minimal or no parent-reported anxiety due to school closure during the H1N1 pandemic.26
The COVID-19 pandemic represents the first large-scale pandemic during which mass media is a major source of misinformation, defined as “incorrect or misleading information” by Merriam-Webster dictionary.18,27,28 This misinformation could lead to unnecessary anxiety as illustrated above. One study reported that 36% of adolescent participants thought that mass media was alarming and caused wide distrust in social networks.18 However, a 2011 hospital-based study reported reduced concern when the news, regarding the H1N1pandemic, was read alongside a healthcare worker.17 Collectively, the literature highlights that anxiety has been a significant challenge during pandemics for children largely due to miscommunication and influence from the mass media.
Overall, 12% of papers reported on depression and/or loneliness, of which one indicated an increase in depression, and the remaining indicated prevalence rates of depression symptomology. Due to confinement, physical distancing requirements, and stay-at-home orders during previous pandemics, children altered their way of play.29 Qualitative data collected from children impacted by the Ebola epidemic suggest that they are "lonesome [and] no longer enjoy [their] childhood"– Boy, Sierra Leone. 29 Similarly, children hospitalised during the Severe Acute Respiratory Syndrome (SARS) pandemic were only allowed one visitor at a time which caused feelings of loneliness, fearfulness, and sadness, while parents could not be a source of comfort or support for their child.20,30 Data from previous pandemics, and from the current COVID-19 pandemic, indicate that children experience depression.25 Factors that correlated with higher levels of depression include living in a rural region, gender, school grade level, level of optimism, and location (Table 2). 15,21–24,31 Pandemics and epidemics highlight how isolation can lead to feelings of loneliness, sadness, and symptoms of depression.
Overall, 10 % of included papers reported on the influence of a pandemic or epidemic on stress-related disorders in children. Of these, 57% indicated the presence of post-traumatic stress disorder (PTSD), 29% on adjustment struggles, and 14% on acute stress disorder. Pandemics typically disrupted the structure and routine of children’s lives, causing difficulties in adjustment, stress reactions, and trauma.14–17,32 Stress may manifest in different ways for different age groups of children14 (Table 2). However, school-aged children tend to manifest symptoms of stress through behavioural issues, such as being withdrawal from friends and family, as well as decreased interest in daily activity.14 Children affected by grief, such as orphaned children, often experience further isolation, have more nightmares about the death of their parents, and live in ongoing fear about what the future will hold.29,33 Also, in an American study, 30% of children who isolated or quarantined during the H1N1 pandemic met criteria for a PTSD diagnosis, a stark contrast to the 1.1% of non-isolated children who met criteria.16 Importantly, the intergenerational impacts of parental mental health is evident; in the same study, PTSD was diagnosed in 85.7% of children who had parents with PTSD resultant of the pandemic.16 The extant literature demonstrates how sudden changes, such as, the disruption of routine or the death of a parent can lead to stress-related disorders, including PTSD.
In total, 7% of included articles reported on grief. Of these articles, 40% indicated there is a need for attention and counselling services for grieving children and adolescents, while 20% indicated physical distancing measures complicated matters. Whereas both children and adults grieve, the manifestations of grief change with age34 (Table 4). The loss of a loved one during a time of physical distancing is a unique circumstance, in which standard processes of closure, such as funerals and family gatherings, are restricted. This poses a new threat to grieving children, in which feelings of isolation may be exacerbated.35 The threat to the emotional well-being of children due to loss of peers, loved ones, or teachers is significant and has been well-documented.14,29 Professionals in pediatrics and pandemic preparedness stressed the importance of involvement of children and families in pandemic planning, clear communication to the public, and accounting for missing plans and services, such as grief and bereavement counselling for children.36 These findings demonstrate grief in children and adolescents can present itself through different manifestations and indicate that in times of physical distancing, the negative mental health impacts of grief can be exacerbated.
Overall, 12% of papers reported outcomes related to children experiencing stigma as a result of a pandemic or epidemic. The stigma surrounding infectious disease typically impacts those who are diagnosed with or have family infected by a disease (as reported in 86% the articles/reports presented here) and children of certain ethnic backgrounds, such as children from countries where a disease originated (as reported in 28% of the articles/reports presented here).13,33,37–39 In a study focussed on Ebola survivors, in which 20% of the sample was children, 26% of participants were stigmatized by the public.38 The isolation associated with stigma increases the risk of harm to a child’s psychological well-being.13,29,37,39,40 The psychological impact of stigma can lead to social rejection, complete isolation, and exclusion from social events.29 Children may be discriminated against, especially those orphaned as a result of a pandemic.22,33,37 During the Ebola epidemic, children’s drawings of their peers who were orphaned due to Ebola were images of children who were ostracised, isolated, and discriminated.40 Moreover, children orphaned due to Ebola, but who remain sero-negative, are less likely to be adopted by families.41 In some of these cases, relatives, neighbours, or friends adopt the child, although over 20% of adults surveyed believe these children are not properly supervised or well-fed.29 In summary, the findings suggest that stigma is mostly problematic for children who are associated with the disease, such as children who were infected, had family who was infected, or are from countries where the disease originated.
A total of 33% articles provided evidence that pandemics and epidemics have a significant impact on children’s nutritional status.23,29,42–48 Due to pandemic-related school closures, many families (one study reported 41% of participants) have lost access to subsidized meal programs, thereby finding themselves in a position where they must provide meals for their children. In many circumstances, these meals are less nutritious than those provided by the school.42,43,47,49,50 Concurrently, pandemic-related increases in unemployment have also impacted the quality and volume of food that families can afford, thus having a further negative impact on children’s nutrition.22 One UNICEF report anticipates food insecurity will increase by 80% from last year in West and Central Africa, largely due to the COVID-19 pandemic.51 These losses are further exacerbated by decreased food availability and increased food costs due to border closures, market closures, and quarantine requirements. These restrictions create obstacles to acquire nutritional foods for economically-disadvantaged families.29,31,33,39,45,52–55 Taken together, these obstacles lead to child malnutrition.48,51,56–59 During the COVID-19 pandemic, Italian students’ intake of potato chips, red meat, and sugary drinks increased significantly, whilst the number of meals per day increased by 1.15±1.56.44 In contrast, during and immediately subsequent to the Ebola epidemic in Sierra Leone, diagnoses of both moderate-acute and severe-acute malnutrition doubled, from 3.6% to 8.2%, and 1.5% to 3.5%, respectively.23 Due to COVID-19, an estimated 67,500 children in Mozambique alone will require treatment for malnutrition in the next 9 months.60 Conclusively, the findings suggest that nutrition is often negatively impacted by pandemics either by over-eating inexpensive, unhealthy food, or by facing varying levels of starvation.
During pandemics and epidemics, 23% of the articles highlighted academic impacts on children. Twenty-three percent of these articles revealed unequal access to learning tools, such as radios, televisions, and power supply in rural regions.22,50,61,62 During the Ebola epidemic, lectures were accessed through radio. Some lacked both access and finances to buy batteries for the radio.29 This unequal access is also evidenced during the COVID-19 pandemic, as 1.6 billion children were crisis schooled at home.53 Furthermore, a UNICEF COVID-19 report indicated that internet access for school children ranged from 1-2% in low income countries to < 50% in most countries.53 These observations are now described as the “digital divide,” resultant of differences in socioeconomic status and pre-existing vulnerabilities.50,63–66
During school closures children struggle to complete their schoolwork from home, causing learning delays in some and increasing the risk of dropout for others.15,18,58,61,67 For example, Cui et al. indicated only 58% of children completed their school work online.15 Females, those with ill caregivers, those who have a disability, or are in an economically-disadvantaged household were especially at-risk for learning challenges during pandemics/epidemics.22,33,50,53,57,61,68 School closures also disrupt the development of children socially and emotionally and also impact the development of coping skills.13,63 These findings and reports indicate that school closure impacts child learning, widens the socioeconomic gap, and impacts child development.
Twenty-one percent of articles discussed the nature of children’s activity during a pandemic or epidemic. Play is critical for healthy development and self-confidence.20,22,48 Yet, subsequent to home confinement, reduced access to group activities, playgrounds, team sports, and spaces for socialization, evidence from pandemics and epidemics point toward changes in the way children play.15,43,44,48,49,69–71. One report indicated most children only played at home and did not play in groups (Table 4).29
A unique consequence of the COVID-19 pandemic is significantly increased screen time due to confinement in a time where technology has greatly advanced.31 Whereas online communities help to keep children socially connected, engage in play and education, risks for negative outcomes, including reduced online safety (i.e. sexual exploitation), privacy concerns, harmful marketing practices and cyberbullying, must also be acknowledged and monitored.27,65,72,73
Family conflict is on the rise during pandemics and epidemics, as indicated by 8% of articles.13,61 Pandemics and epidemics have demonstrated that increased stress due to confinement and economic pressures can lead to an increase in familial conflict and child exploitation.63 These outcomes are often related to authoritarian parenting styles, a parenting style found to be ill-suited for pandemic situations.15 During the Ebola epidemic, parents qualitatively described changes in parenting styles and disciplinary methods. Moreover, parents exposed to the virus reported significantly more household conflict and personal anxieties, as well as an increased preference for harsh punishment. In contrast, parents not exposed to the virus experienced decreased preferences for harsh punishment by 28.1%.74
In addition to changes in parenting styles, parent-child relationships may suffer during quarantine due to altered communication and social interactions.75 A new-found focus on responsibilities, such as household tasks, also had negative impacts on the parent-child relationship.75 These findings suggest family conflict and relationships between parents and children are negatively impacted by quarantine resultant of pandemics and epidemics.
Heightened levels of stress and isolation for families in the home, coupled with reduced access to social supports for children during pandemics, creates opportunity for increased risk of child abuse as indicated by 25% of included articles.49,62,65,75–77 During the Ebola epidemic, 89% of reported cases of rape in Liberia were against children ages 0-17. The report further indicated rape and violence, specifically, were common amongst girls and increased during Ebola in West Africa.78 Child abuse is often associated with a lack of effective coping strategies during periods of elevated stress. Child maltreatment reports during the COVID-19 pandemic include increased sexual assault, child trafficking, child marriage. Parental substance abuse also increases which is associated with greater levels of child maltreatment.39,50,60,79,80 Physical distancing during COVID-19 has disrupted protective social networks and safe spaces for children, resulting in an elevated risk of child exploitation.48,79,81,82 Extant literature suggests specific groups of children may experience more harm. For example, girls are more likely to experience gender-based violence, be sexually exploited, and suffer from increased rates of teenage pregnancy during a pandemic or epidemic.50,68,78,80 Limited research to date during the COVID-19 pandemic points toward negative mental health outcomes associated with child abuse including anxiety, trauma, and psychological relapse.13,54 In brief, the literature indicates increased instances of child abuse during pandemics and epidemics, especially for girls.
Family economic impact
Twenty-five percent of articles described the socioeconomic impact on families during pandemics and epidemics. Pandemic-related closures place additional stress on caregivers to find childcare or provide childcare themselves at the expense of missing work.15,26,43,70,71,75,83 After the 2009 H1N1 pandemic, 27% of parents reported work absenteeism and 18% lost wages.83 In contrast, one study focused on the H1N1 pandemic found the majority of parents did not lose any time at work. However, this sample contained many “stay-at-home parents”, thus influencing the number of missed work days.69 Economic downturns caused by pandemics can also result in job loss, increased poverty, and price hikes for daily goods and services.48,57,61,77,84,85 Those from a low socioeconomic background and those with pre-existing vulnerabilities face harsher economic impacts during economic downturns related to pandemics.39,50,81 Notably, during 2008 Kentucky school closures consequent to an influenza outbreak, only 14.9% of parents had the opportunity to work from home.49 This is alarming, given the acuity of work from home directives imposed on an unprecedented number of employees, many of whom are concurrently parenting from home, during the COVID-19 pandemic.70,75,77 The majority of studies found that many parents lose income during pandemics, due to work absenteeism and job loss; low socioeconomic status households are disproportionately impacted.
The COVID-19 pandemic, and subsequent school closures, loss of social contact, impoverished diets, greater screen time, and reduced physical activity and outdoor time have adverse effects on child mental health.31,44,53,63,71 Alarmingly, many families are facing greater food insecurity, due to losses to school lunch programs or household income, or because of decreased food availability,45,47,59 and socioeconomic stress and confinement have contributed to increase familial conflict and child abuse.53
Scoping reviews are intended to identify the extent of knowledge and gaps in an area of research.8One gap that was found herein was that mental health outcomes/diagnoses were lacking in specificity. Some studies did have the percentage of diagnoses, such as anxiety and depression, but most approached mental health outcomes from a general perspective, pointing toward a need for additional research on child mental health outcomes both now and after the pandemic. Of the research that did indicate prevalence of diagnoses, minimal studies had pre-pandemic data to compare to pandemic data, and much of the literature included short-term outcomes only. Thus, it is difficult to draw direct comparisons between pre-pandemic and during/post-pandemic data. Therefore, longitudinal studies are warranted to identify long-term sequelae of pandemic-related childhood mental health consequences. One unique aspect related to the COVID-19 pandemic is the increased amount of screen time for children. Although there are many positive outcomes to having access to these technologies, the long-term mental health effects are not currently well known, therefore, the impact of increased technology use on children should be monitored over time.
We acknowledge the limitations of this scoping review. Scoping reviews are not intended to analyze the quality of the included studies. Additionally, our search strategy covered a broad range of outcomes, thus necessitating a balance between breadth and depth. We also restricted our search to English-language publications only, raising the possibility that relevant studies in other language may have not been identified. Another limitation of the current study is that COVID-19 has had greater impacts on most individuals in some significant way. Therefore, one should keep this in mind as a limitation when making comparisons with epidemics or pandemics that may have a smaller scale impact (e.g. measles). Also, societal factors such as geographical location, culture, government, and socioeconomic status can pose a challenge for generalizing the results to the greater population (see Tables for identifying regions).
This scoping review also adds to the literature in several ways. A comprehensive search strategy, from both academic and grey literature databases, to identify relevant articles was comprehensive and included diverse child-related outcomes to ensure as much breadth and depth as was possible which would help guide the development of future research. This review may be viewed as a starting point toward creating programs and solutions for the many challenges children face during pandemics, including the prevention of long-term impacts subsequent to the COVID-19 pandemic, with particular emphasis on mental health services and resources, for children facing food insecurity, maltreatment, and economic disadvantage.
Insight gleaned from pandemics and epidemics provide evidence on the negative impacts, including psychosocial, nutritional, financial, and child safety outcomes, pandemics and epidemics can have on children and their families, which can help inform family-centered policies. Increased psychological supports for children and their families are essential both now and for years to come.
We would like to thank Mê-Linh Lê, Victoria Ho, and Ellen Tisdale, who are Librarians from the University of Manitoba, for their contributions guiding the process of this scoping review.
Ms. Merrill wrote this manuscript while receiving a summer studentship jointly funded between Dr. Jennifer Protudjer’s start-up funds from the Children’s Hospital Research Institute of Manitoba (CHRIM), and the Canadian Society of Allergy and Clinical Immunology. Mrs. William wrote this manuscript while being funded over the summer by the Undergraduate Research Award through the University of Manitoba’s Vice-President, Research and International Office, in partnership with UMSU. Ms. Joyce’s graduate studies in clinical psychology were funded by a Master’s Studentship Award from Research Manitoba in partnership with the CHRIM and a fellowship from the University of Manitoba. The other authors received no external funding. The funders/sponsors were not involved in the preparation of the manuscript and had no influence on the results presented herein.
K. M. and T. W. contributed to developing the study design, data collection and collation, as well as writing, editing, and approving the manuscript.
K. J. led the development of the study design and data collection; wrote, edited and approved the manuscript.
L. R. contributed to developing the study design and editing the manuscript.
J. P. oversaw the review for the duration of the project as senior author; contributed to developing the study design; wrote parts of the manuscript; and, was involved in the editing process.
All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
The authors completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf, and declare no conflicts of interest.
Dr J Protudjer
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