Covid-19 and mental health of children and adolescents: A systematic review

Figures & data

Table 1. Review question in PEO format

P- population	E- exposure	O-outcome
Adolescents/Children	COVID-19	mental health state

Table 2. Search strategy using Boolean Operators (OR & AND)

P—Population	Children* OR adolescent OR teenager AND
E—Exposure	COVID-19 OR COVID 19 OR lockdown OR lock-down OR quarantine OR AND
O—Outcome	Mental health OR anxiety OR depression OR stress

Table 3. Inclusion & exclusion criteria

Inclusion criteria	Exclusion criteria
Human studies Peer reviewed Published in English Published between 1 December 2020 and 10 June 2021 Participants ≤18 years COVID-19 related	Participants >18 years Not published in English Not reported on age Data format not binary Qualitative design

Figure 1. Updated PRISMA2020 flow diagram showing the study selection process.

Table 4. Excluded papers and reasons for exclusion

Participants age >18 years	Duplicates	Unclear outcome data
X. X. Chen et al. (2021)	L. Zhang et al. (2020a)	J. Zhang et al., (2020)
Yeasmin et al. (2020)	Raviv et al. (2021a)	Oosterhoff et al. (2020)
Hawke et al. (2020)	Garcia de Avila et al. (2020a)	X. Zhang et al.,(2020)
Hermosillo-de-la-Torre et al. (2021)	Dyer et al. (2021)	Raviv et al. (2021b)
S.-J. Zhou et al. (2020)	S.-J. Zhou et al. (2020a)	Saurabh and Ranjan (2020)
Khan et al. (2020)	Ademhan Tural et al. (2020a)	Nuñez et al. (2021)
Liu et al. (2021)	McKune et al. (2021a)	Okely et al. (2021)
Dyer et al. (2021)	Pisano et al. (2021)	Melegari et al. (2021)
Mohler-Kuo et al. (2021)	SaSama et al. (2021)	Kang et al. (2020)
		Ezpeleta et al. (2020)
	Yeasmin et al. (2020)	Zreik et al. (2021)
		Jackson et al. (2021)
		Qin et al. (2021)
		Cusinato et al. (2020)
		(Ademhan Tural et al., 2020b)
		(Di Riso et al., 2021)
		(Durcan et al., 2021)
		(Magson et al., 2021)
		(Paiva et al., 2021)
		(Pınar Senkalfa et al., 2020)
		(Rogers et al., 2021)

Table 5. Characteristics of studies included in the review

Code.	Study reference	Country	Study design	Population	Age range	Sample size (N)
2.	Abawi et al., (2020)	Netherlands	Mixed-methods	Obese Children	10.5(mean)	75
3.	S. Chen et al., (2020)	China	Cross-sectional	Adolescents	Grade 7-12	7772
5.	Duan et al., (2020)	China	Cross-sectional	Children/adolescents	7-18	3613
7.	Garcia de Avila et al., (2020)	Brazil	Cross-sectional	Children	6 – 12	289
8.	Kılınçel et al., (2021)	Turkey	Cross-sectional	Adolescents	12 – 18	745
9.	Ma et al., (2021)	China	Cross-sectional	Children/Adolescents	7 – 15	668
10.	McKune et al.,(2021)	USA	Cross-sectional	Children	K-12 schools	280
14.	Pisano et al., (2021)	Italy	Cross-sectional	Adolescents	14 – 19	326
16.	Sama et al., (2021)	India	Cross-sectional (WB)	Children	School/KG-going child	310
17.	Segre et al., (2021)	Italy	Cross-sectional	Children/Adolescents	6 – 14	82
18.	Shek et al., (2021)	China	Longitudinal	Adolescents	13.15(mean)	4981
19.	Tang et al., (2021)	China	Cross-sectional	Children/Adolescents	6 – 17	4391
20.	Wang et al., (2021)	China	Cross-sectional	Children/Adolescent	15.6(mean)	6435
21.	L. Zhang et al.,(2020)	China	Longitudinal – Cohort	Children/Adolescent	9.3-15/9	1241
22.	C. Zhang et al., (2020)	China	Cross-sectional	Teenagers	13.93	1025
23.	S.-J. Zhou et al.,(2020)	China	Cross-sectional	Adolescents	12 – 18	8079
24.	J. Zhou et al., (2020)	China	Cross-sectional	Female adolescents	11 – 18	4805
29.	Pizarro-Ruiz & Ordóñez-Camblor, (2021)	Spain	Cross-sectional	Children/Adolescents	8 – 18	590
33.	F. Chen et al., (2020)	China	Cross-sectional	Children/Adolescents	6 – 15	1036
36.	Li et al., (2021)	China	Cross-sectional	Adolescents	12 – 18	7890
40.	Xie et al., (2020)	China	Cross-sectional	Children	Grade 2-6	1784

Table 6. Data extracted from the studies on outcome measures

Code. Reference	Brief description	Sample size	Study Measures	Prevalence of mental health problems	Correlates of mental health problems	Score	Quality appraisal
2. Abawi et al. (2020)	This study was carried out to describe COVID-19 related anxiety among children and adolescents with severe obesity	Sample size: N = 75 Sampling strategy described	Paediatric quality of life inventory	The proportion of participants who experienced anxiety: 24/75 (32%). Thus, 32% of participants experienced anxiety.	Fear of contracting COVID-19 and fear of infecting family members	3	Low
3. S. Chen et al. (2020)	The researchers compared levels of anxiety and depression of adolescents from Wuhan (the city of origin of COVID-19) with adolescents of other cities (Beijing & Hangzhou)	Total sample size (N = 7772) Sampling strategy adequately described.	1. Patient Health Questionnaire (PHQ-9) for depression 2. Generalized Anxiety Disorder −7 (GAD-7) for anxiety. All instruments are standardized	Anxiety: 26.9 (2091/7772) Depression: 42.9% (3334/7772)	Female gender, lower grade level, family member infected with COVID-19	7	High
5. Duan et al. (2020)	This study investigated anxiety and depression among Chinese children and adolescents and also identify the influencing factors.	Sample size: N = 3613	Spence Child Anxiety Scale (SCAS) for anxiety The Child Depression Inventory (CDI)	Depression: 22.28% (805/3613) .	Smart phone use and internet addiction. .	6	Moderate
7. Garcia de Avila et al., (2020)	This study assessed anxiety in Brazilian children using Children’s Anxiety Scale (CAS) and the Numerical Rating Scale	Sample size: N = 289	The Child Anxiety Questionnaire (CAQ) and Numerical Rating Scale (NRS),	Anxiety: 19.4% (56/289; CAQ) to 21.8% (63/289; NRS).	*Female gender *Working parents *socially isolated without parents.	6	Moderate
8. Kılınçel et al. (2021)	This study aimed to determine how home quarantine affected adolescents and the factors affecting the result.	Sample size: N = 745	State of Anxiety Inventory	Anxiety: 37.4% (279/745). Worry: 64%	*Exposure to TV news about the COVID-19 pandemic *Past psychiatric referral *Having COVID-19 positive person in the family	5	Moderate
9. Ma et al. (2021)	This study evaluated the impact of the COVID-19 pandemic on education and mental health of Chinese children aged 7–15	Sample size: N = 668	1 Impact of Event Scale-Revised (IES-R) for PTSD. 2 Short Mood and Feeling Questionnaire(SMFQ)—for depression	Depression: 7.2% (48/668) PTSD): 20.7% (138/668)	*Resident in boarding house	7	High
10. McKune et al., (2021)	This study was conducted to describe the psychosocial health of children and adolescents during the COVID-19 pandemic and lockdown.	Sample size: N = 280	Questionnaire	Anxiety: 34.6% (97/280 Depression: 35.4% (99/280) OCD symptoms: 32.1% (90/280)	*Loss of household income *Female gender *Lower school level	6	Moderate
14. Pisano et al. (2021)	The study was conducted to determine anxiety and depression in adolescents	Sample size: N = 326	1 State-Trait Anxiety Inventory (STAI) 2 Mood and Feelings Questionnaire—short form (MFQ-SF) 3 Strength and Difficulty Questionnaire (SDQ)	Severe Anxiety: 47.5% (153/326) Depression symptoms: 14.1% (46/326)	* Female gender *Previous psychopathology	6	Moderate
16. SaSama et al. (2021)	The study was conducted in 4 districts of Punjab in India to assess the impact of lockdown on mental status of children.	Sample size: N = 310.	Web-basedquestionnaire	Anxiety: 21.3% (66/310) Depression: 21.0% (65/310) Irritation: 72.6% Anger: 66.1%	*Economic status of family *Educational levels of mother * Area of their house and type of residential facilities available *Number of children in the family	3	Low
17. Segre et al. (2021)	The study aimed at investigating psychological distress (anxiety and mood swing) and changes in routines.	Sample size:: N = 82	Anxiety Clinical Scale	Anxiety: 78% (64/82) Terrified: 75.6%. Constantly afraid and in fear of the dark:30.5%. Increased irritability and intolerance to rules:53.3% Mood problems: 43.9%(36/82)	None significant detected	3	Low
618. Shek et al. (2021)	The study examined the effect of COVID-19 pandemic on Chinese adolescents in terms of the prevalence of post-traumatic stress disorder (PTSD) symptoms and also to determine the moderating effect of positive youth development on PTSD.	Sample size: N = 4981	Chinese Positive Youth Development Scale (CPYDS)—for (positive Youth Development (PYD) Children’s Revised Impact of Event Scale (CRIES-13)—for PTSD	Severe PTSD: 10.4% (517/4981) .	Fear of being at risk of COVID-19 infection PositiveYouth development PYD)	6	Moderate
19. Tang et al. (2021)	The study was carried out to mainly ascertain the impact of COVID-19 pandemic on mental health dimensions such as stress, depression, and anxiety among children and adolescents in China.	Sample size: N = 4342	Depression Anxiety Stress Scale (The Chinese Version—DASS 21)	Depression: 19.7% (857/4342) Anxiety: 24.9% (1080/4342) Stress: 15.2% (659/4342)	* Adolescence is associated with a higher prevalence of depression, anxiety and stress.	6	Moderate
20. J. Wang et al. (2021)	This study was conducted on adolescents in China to ascertain depression, difficulty in studying at home as well as factors associated with the development of depression among study participants.	Sample size: N = 6435	Child Depression Inventory (CDI)	Depression 17.1% (1140/6435)	* Poor parent-child relationship.	6	Moderate
21. L. Zhang et al., (2020)	This study was part of a longitudinal cohort in China study that was started before the COVID-19 pandemic. During the pandemic, the participants were followed up to ascertain if they were experiencing psychological impacts as a result of the COVID-19 pandemic.	Sample size: N = 1241	long version of the child self report Mood and Feelings Questionnaire (MFQ) MacArthur Health & Behavior Questionnaire (HBQ) Non-suicidal self-injury (NSSI) Questionnaire “middle school questionnaire” of the 2013 Youth Risk Behaviour Surveillance System in the USA	Depression: 24.7% (309/1241) Anxiety: 197/1241 (15%) Suicidal ideation: 29.7% (369/1241) Suicidal plan: 14.6% (181/1241) Suicidal attempts: 6.4% (79/1241)	None reported	6	Moderate
22. C. Zhang et al., (2020)	The researchers explored the psychological impact of COVID-19 on junior school and senior high school teenagers in China. They assessed depression, anxiety, and stress symptoms. They also explored mitigating factors for these psychological effects of the COVID-19 pandemic.	Sample size: N = 1025	1 Depression Anxiety Stress Scale (DASS—21) 2 Brief Resilience Scale 3 Coping Style Questionnaire 4 Impact of Event Scale-Revised	Depression: 226/1025 (22.0%) Anxiety: 276/1025 (26.9) Stress: 271/1025(26.1%) Post Traumatic Stress Disorder (PTSD). 21.70%	*High school students Positive coping Resilience	6	Moderate
23. S.-J. Zhou et al., (2020)	The study was conducted to explore depression and anxiety symptoms among adolescents during the COVID-19 pandemic.	Sample size: N = 8079	1 Generalized Anxiety Disorder scale (GAD-7)—for anxiety 2 Patient Health Questionnaire (PHQ-9) for depression	Anxiety symptoms: 3020/8079 (37.4%) Depression: 3533/8079 (43.7%).	1 Adolescence 2 Rural dweling 3 Female gender 4 Higher student grades	8	High
24. J. Zhou et al., (2020)	The researchers aimed at describing depression among Chinese adolescent females and also to identify determinants of depression.	Sample size: N = 4805,	Centre for Epidemiological Studies Depression Scale (CES-D),	Depression; 39.5% (1899/4805)	Risk factor: 1 Female adolescent 2 Living in an infectious area 3 Age 15–18 associated 4 sleep <6 hr 5 Exercise < 30 min	6	Moderate
29. Pizarro-Ruiz and Ordóñez-Camblor (2021)	The study was conducted to determine the effect of 8 to 10 days of lockdown/confinement on the mental health of children and adolescents.	Sample size: N = 590	Assessment System for Children and Adolescents (SENA)	Anxiety: 16% (95/590) Depression: 11.0% (65/590).	Adolescent going through strict quarantine for 8 to 10 hours *Being a teenager/adolescence	6	Moderate
33. (F. F. Chen et al., 2020a)	The study was conducted in China to determine the prevalence of anxiety and depression among children and teenagers between the ages of 6 to 15 years.	Sample size: N = 1036	1 Depression Self Rating Scale 2 Screen for Child Anxiety Related Disorders (SCARED	Depression: 11.8% (122/1036) Anxiety: 18.9% (196/1036)	1 Female adolescence 2 Parent educational level 3 older adolescent 4 without companion on weekdays *Exercise	6	Moderate
36. (Li et al., 2021b)	The study investigated the prevalence of depression and anxiety among adolescents in Wuhan in China between the ages of 12 and 18 years.	Sample size: N = 7890	Hospital Anxiety And Depression Scale (HADS)	Depression: 1941/7890 (24.6%) Anxiety: 1708/7890 (21.6) .	1 Long-term home restriction 2 Going outside of the home, 3 Insufficiency of food, 4 Perceived discrimination, poor sleep quality, *less face-to-face communication, less pleasure from interests/hobbies Browsing information about COVID-19 Mitigating factors 1 Physical activity	6	Moderate
40. (Xie et al., 2020)	The researchers recruited children and adolescents in primary schools in China to determine prevalence of anxiety and depression related to COVID-19 pandemic, school closure and lockdown.	Sample size: N = 1784.	1 Children’s Depression Inventory–Short Form (CDI-S) 2 Screen for Child Anxiety Related Emotional Disorders,	Depression: 403/1784 (22.6%) Anxiety: 337/1784 (18.9%)	*Living in places with high infection rate *Worried about COVID-19 Optimism	6	Moderate

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Data availability statement

This review manuscript report on previously published data. The individual articles forming the basis of the manuscript are included therein. Readers can search for the articles online or request for the articles by writing to the corresponding author.