Public mental health during the COVID-19 pandemic: impacts on children's rights

ABSTRACT

Restrictions on social and economic activities imposed by governments around the world in response to COVID-19, including the closure of schools and childcare facilities, have had a detrimental impact on children's mental health and wellbeing. Initial responses to support mental health during the pandemic have largely focussed on immediate support and crisis management. However, as governments plan for recovery from the pandemic it is important to focus on the wider determinants of children's mental health including their relationships and the environments and societies in which they live in order to prevent a future global mental health crisis. This narrative review draws on the Independent Children's Rights Impact Assessment on the response to COVID-19 in Scotland to evaluate how the measures implemented by the Scottish Government have impacted on children's rights related to the wider determinants of mental health. The review reflects on the indivisibility of both children's rights and the different aspects of children's lives, particularly when considering issues such as mental health. Using the Scottish context as an exemplar, it highlights the value of a rights-based framework for providing a holistic view that can inform preventative approaches to support better mental health among children in the future.

KEYWORDS:

• Children’s rights
• mental health
• public health
• COVID-19
• pandemic

Introduction

There is growing concern that the COVID-19 pandemic may cause a global mental health crisis.¹ Prior to the pandemic, children's mental health was already recognised as a major global public health challenge, with worsening trends in recent years.^2,3,4 It is estimated that 10–20% of adolescents experience mental illness,⁵ with 50% of all mental illness in adults beginning before the age of 14.⁶ Children's experiences of mental health, both positive and/or negative, have clear long-term implications, with those experiencing poor mental health more likely to have poorer educational attainment and employment prospects, social relationship difficulties, worse physical health and substance misuse problems.⁷ There is growing evidence that the pandemic has exacerbated mental disorders among children,^8,9 and fears over the impact of restrictions such as school and childcare closures, social distancing and isolation policies on their long-term mental health outcomes.

Box 1. Mental health terminology

For the purposes of this article the following terminology has been used with reference to mental health:

  - Mental health: encompasses all aspects of emotional, psychological and social wellbeing, including both positive mental health and wellbeing and mental disorders.

  - Public mental health: supra-individual influences on mental health and wellbeing encompassing social, behavioural, organisational, environmental and cultural determinants of health.

  - Mental disorders: encompasses a wide range of diagnosable mental health conditions that affect mood, thinking and behaviour, such as depression, anxiety disorders and addictive behaviours.

The realisation of children's rights enables children to develop and reach their full potential, of which positive mental health is key. The United Nations Committee on the Rights of the Child (UNCRC) focuses on securing children's rights to survival, dignity, wellbeing, health, development, participation and non-discrimination.¹⁰ In response to the COVID-19 pandemic, in April 2020 the UNCRC issued a statement warning of the ‘grave physical, emotional and psychological effect’ of the pandemic on children, especially in countries that have declared states of emergency or mandatory lockdowns, and urged states to respect the rights of the child when implementing measures to tackle the virus.¹¹ In addition, the World Health Organisation (WHO) recognises the importance of ensuring that mental health interventions respect the rights of the child,¹² and highlighted the importance of integrating human rights protections into the response to the COVID-19 pandemic.¹³ However, some have argued that the rights of children have been ignored in the response to the current pandemic with potential for long-term harm.¹⁴ It is therefore important to consider how government responses to support children's mental health during and beyond the pandemic have, and in theory will continue to, fulfil obligations to uphold children's rights.

An Independent Children's Rights Impact Assessment (CRIA) was commissioned by the Children and Young People's Commissioner for Scotland to look at the impacts on children's rights across all of the Scottish Government measures introduced in response to the COVID-19 pandemic.¹⁵ The Independent CRIA was published in June 2020, as Scotland was emerging from the first nationwide lockdown and consequently many of the measures assessed focused on crisis management. It is now important to refocus on wider recovery strategies that fulfil children's rights, prevent further deterioration of children's mental health and focus on children whose pre-existing disadvantages have been escalated by the pandemic.

While mental health is, in part, determined by individual characteristics (e.g. genetic, physiological and psychological factors), it is also heavily influenced by supra-individual factors including people's relationships, and the environments and societies in which they live.¹⁶ These social, behavioural, organisational, environmental and cultural determinants of health are widely recognised in established models of public health.¹⁷ Public mental health approaches focus on prevention and early intervention at the population level, while also recognising that there are certain groups who are at greater risk and may need additional, targeted support.¹⁸ Türmen et al. (2001)¹⁹ start to unpick the connection between public health and rights as they describe a WHO health promotion approach based on a children's rights framework, which focusses on a commitment to realising rights across the spectrum as a framework for meeting healthcare needs:

In addition to basic needs, survival, and maximum development, access to health and to health services are fundamental human rights. However, the effective respect, protection, and fulfilment of these rights depends on the realization of other rights, including the rights to education and access to appropriate information; to privacy; to protection from all forms of violence; to rest, leisure, and play; to an adequate standard of living; and to participation.

The Independent CRIA focussed on nine different aspects of children's rights, linked to recommendations from the UNCRC in response to the pandemic²⁰: physical health;²¹ mental health;²² education;²³ poverty, food and digital access;²⁴ rest and leisure;²⁵ children's protection, children's hearings and care;²⁶ domestic abuse;²⁷ children with additional support needs (ASN) and disabilities;²⁸ and children in conflict with the law and children in secure care.²⁹ While this provides a useful framework for analysing the impact of government measures, the interrelatedness and indivisibility of children's rights means that it is challenging to draw clear distinctions between the different aspects of children's lives. The mental health analysis focussed largely on rights related to access to mental health services and information and only touched on the wider determinants of children and young people's mental health. This review article looks more closely across the different analyses of the Independent CRIA to evaluate how the measures introduced by the Scottish Government impacted on children's rights in relation to the wider social and economic determinants of mental health. The analysis is an exemplary illustration based on the Scottish context of how a government response to the pandemic has affected children's mental health and impacted on children's rights. Although other countries’ responses to the pandemic have varied in the timing and level of restrictions, many of the points raised here will be pertinent in other contexts, and particularly those where similar ‘stay at home’ orders were imposed at some point during the pandemic. These insights will be important as countries move towards recovery to ensure that society and the economy can be restructured in a way that upholds children's rights and, in doing so, incorporate preventative approaches to support their mental health.

Materials and methods

Full details of the methodology and impact assessment templates used for the Independent CRIA have been published.³⁰ Briefly, the Independent CRIA looked at the impact of emergency measures enacted in Scotland in response to the COVID-19 pandemic on the rights of children up to 18 years of age. In the context of the assessment, measures relate to legislation, policy and guidance enacted in Scotland. The analyses were conducted between 22 May and 16 June 2020, and focused on the measures and available evidence at this time.

This review article looks across the nine analyses shown in Figure 1 below and discusses links between mental health and children's rights as set out in the UNCRC and its General Comments. The review is structured around the UK Office of National Statistics (ONS) children's wellbeing measurement framework.³¹ This framework was developed in 2014 in consultation with children and experts in children's health and wellbeing, and was revised in 2020 to ensure it remains consistent with the circumstances in which children now live.³² The revised framework covers eight domains related to children's wellbeing that reflect key social and economic determinants of public mental health as shown in Figure 2. Although the ONS wellbeing framework is used for this analysis, it is important to recognise that children's wellbeing and children's rights, while are often paired together, are conceptually different and are implemented differently in policy and practice.³³ The analysis identifies key children's rights associated with the different ONS framework areas and aims to assess how policy decisions during the pandemic uphold both children's rights and their mental health and wellbeing separately, recognising that the fulfilment of one of these obligations may be possible without the other.

Figure 1. CRIA framework of children's rights.

Figure 2. ONS children's wellbeing framework (Jordan & Ress, 2020).

Results

The results below are presented under each of the eight ONS wellbeing domains. However, it must be recognised that these domains are not always distinct and there is inevitable overlap. This is explored further in the discussion.

Personal wellbeing

The WHO describes mental health as ‘a state of wellbeing in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community’.³⁴ Although some view wellbeing as a distinct concept from mental disorders,³⁵ others argue that wellbeing represents positive aspects of mental health.³⁶ During the pandemic emotional wellbeing has been identified as key area of concern among children, and evidence shows a reduction in subjective wellbeing and mood, particularly among older children and girls.^{37,38,39,40,41,42} Increases in mental illness such as anxiety and depression among children have also been reported.^43,44 However, there are also reports of improvements in some children's wellbeing, mainly due to reduced academic pressure and the opportunity to spend more time with their families.^45,46,47

Articles 17 and 24 of the UNCRC recognise children's right to access information aimed at the promotion of wellbeing and health. However, evidence reviewed for the Independent CRIA indicated that not all children were able to experience these rights. A survey of 2418, 11–24-year-olds in Scotland indicated that 40% were not confident in accessing information about support for their mental health and wellbeing,⁴⁸ and among 5000 parents of 0–16-year-olds in the UK, 42% felt that they would benefit from support around managing their child(ren)s emotions during the pandemic.⁴⁹ Within the Scottish Government measures, the detrimental impact of the pandemic on children's mental wellbeing has been recognised,⁵⁰ and provisions have been made including establishing a working group to ensure health and wellbeing is a focus for children in the return to school,⁵¹ and provision of additional funding for youth work organisations to develop resources for children and parents to support mental health and wellbeing.⁵²

A further issue raised within the Independent CRIA was that some groups of children, such as those with disabilities or ASN, may find it difficult to communicate their wellbeing needs effectively, particularly during a time of crisis.⁵³ Concerns were raised that increased distress as a result of the pandemic may result in behaviour that causes some young people to be criminalised rather than receive the support that they require,⁵⁴ with potential implications for their rights under UNCRC Article 37 regarding punishment and imprisonment.

Relationships

Relationships with family members, peers and other adults during childhood provide the basis for children to learn how to positively relate to others throughout their lives.⁵⁵ Children who have positive relationships with family and friends have higher levels of wellbeing,^56,57,58 while lack of good relationships and long-term feelings of loneliness or isolation are associated with depression, anxiety and suicidal behaviours.^59,60,61

Within the UNCRC, General Comment 20 recognises that strong relationships and support from key adults, as well as opportunities for building and sustaining friendships, are important for promoting resilience among adolescents. Similarly, General Comment 7 recognises the role of relationships in early childhood development, particularly with parents and other caregivers, but also with other children.

The Independent CRIA identified the impact of Scottish Government measures upon children's ability to form and maintain relationships. For some, particularly younger children, positive impacts on family relationships were reported as a result of spending more time at home together with immediate family members.^62,63,64 However, the closure of schools, childcare settings, and community and sports venues, restrictions on gatherings and the requirement for people to stay at home⁶⁵ have resulted in many children struggling with loneliness and worrying about their social relationships with extended family or friends, and the loss of support they would usually receive through their families, schools and communities.^{66,67,68,69,70} In addition, physical distancing measures⁷¹ have also affected children, and limited their ability to form friendships and develop healthy relationships, including with trusted adults such as teachers, who can be key in providing psychosocial support. This may particularly affect younger children, whose main peer interactions are developed through play (see ’What we do’ section).⁷²

The relationships of children who already have limited family contact such as those in care,⁷³ secure residential settings or young offenders’ institutions have been disproportionately affected by these measures.⁷⁴ Many of these children have faced additional pressures on their mental health during the pandemic, and are particularly affected by the loss of informal support networks and social isolation. Physical distancing and isolation have made accessing professional support and maintaining interaction with family and friends more challenging for children in residential or secure care.⁷⁵

Health

There are close links between physical and mental health. Almost a third of people with long-term physical health conditions also experience mental illness, and almost half of those with mental illness also have a long-term physical health condition.⁷⁶ UNCRC Article 24 recognises children's right to access appropriate healthcare services to support both their physical and mental health. While emergency healthcare services continued to operate during the pandemic, measures were put in place limiting face-to-face mental health services and other non-emergency care.⁷⁷ There is evidence of parents and carers being fearful or reluctant to take children to hospital in order to avoid the virus and overburdening the National Health Service (NHS), although increased numbers of calls to the NHS24 healthcare phoneline (a free UK-wide medical advice service) were reported.⁷⁸ For many children, health issues would usually be picked up by and supported through schools, childcare settings and community services rather than formal healthcare settings. Therefore, the closure of these settings and services during the pandemic has implications for the longer-term health of children, as health conditions may not have been detected or treated as rapidly.

The Independent CRIA highlighted that the impact on children's right to access healthcare services has disproportionately affected those children with existing health conditions. Children who have a disability or serious illness are recognised as being at greater risk of mental disorders.^79,80 A survey of 1986 UK families with a disabled or seriously ill child reported that 82% of children had experienced a negative impact on their mental health as a result of the pandemic, and 65% of parents/carers wanted more information on how to support their child(ren)'s mental health and wellbeing.⁸¹ These families reported a reduction in access to the support services (including mental health support) provided through healthcare, education and other community settings they would usually rely on, with particular difficulties highlighted for children with ASN or disabilities in accessing online support due to communication or language barriers.⁸²

The pandemic has also had a detrimental impact on the mental health of children with pre-existing mental health conditions. A UK-wide survey of 2111 young people with a history of mental health needs reported that 83% had experienced a negative impact of the pandemic on their existing mental health.⁸³ As a result of the closure of face-to-face mental health services,⁸⁴ 26% of these children did not receive support services during this time largely due to difficulties accessing online support from home.⁸⁵

What children do

The closure of schools, childcare settings, recreational and leisure facilities⁸⁶ have had a major impact on children's daily routines. Many children have experienced boredom and frustration at staying at home and, although the majority of children felt that they had been making healthy choices, were getting enough exercise and that they had energy, there was a decline over time and older children were less likely to report this than younger children.^87,88

UNCRC Article 31 recognises the rights of the child to rest and leisure and to engage in play and recreational activities, and General Comment 17 highlights the benefits of play and recreation for children's mental health and wellbeing. Play can support mental health by developing children's abilities to form emotional relationships with others and resilience to cope with stress and anxiety.⁸⁹ There is also evidence that play might support children going through periods of isolation or quarantine, via promoting coping, expression, sociability, and skill development.⁹⁰ Young children have been particularly affected in this respect, as they are less able to engage with peers and services remotely.

The way in which children use their rest and leisure time changed substantially during the pandemic. Screen use increased among children who were reliant on this for accessing education, entertainment, and contact with family and friends.⁹¹ Time spent on screens may displace other health promoting activities such as sleep, exercise and family time.^92,93,94 In addition, while social media can help children maintain relationships and provide access to mental health support through social networking sites,^95,96 there are concerns about the detrimental impact of excessive social media use on children's mental health related to online harassment or cyberbullying, poor sleep, low self-esteem and poor body image.^97,98

One group of children at particular risk of reduced free time and recreational activities during the pandemic are young carers, whose responsibilities increased during lockdown, alongside losing access to respite activities and the regular support offered by schools and local services.^99,100 In a survey of 30 young carers in Scotland, 63% reported concerns about their mental health and wellbeing and 80% felt isolated or lonely as a result of the pandemic.¹⁰¹ The introduction of a measure to remove the duty of local authorities to assess the needs of carers,¹⁰² is likely to have had a negative impact on the rights of young carers under Article 31, and also Article 3 that states that all decisions should be made with the best interests of the child as a primary consideration. Other groups of children highlighted as being particularly vulnerable to the mental health impacts of reduced leisure opportunities include young offenders,¹⁰³ due to the suspension of programmes of work, education and counselling within young offenders’ institutions,¹⁰⁴ and disabled and seriously ill children,¹⁰⁵ whose families must find appropriate ways to educate and entertain them at home without access to support services and specialised facilities.¹⁰⁶

Where children live

Safe and supportive environments are essential for good health and wellbeing. This is recognised in UNCRC General Comment 4, which states that the health and development of adolescents are strongly determined by the environments in which they live including home, neighbourhood, school and online environments.

The importance of ensuring vulnerable children are protected while stay at home orders are in place was highlighted in the Independent CRIA with reference to Article 19, the right of the child to be protected from all forms of violence, abuse, neglect and maltreatment. It is well established that exposure to these adverse childhood experiences is associated with increased risk of mental disorders both during childhood and in adulthood, with a cumulative impact of multiple experiences.^107,108,109 Stay at home orders have put women and children experiencing domestic abuse at greater risk and some children may be staying in unsafe situations for longer.^{110,111,112,113} The closure of schools and early childcare settings is likely to have exacerbated this, as child protection issues are often picked up within these settings. While provisions were put in place for vulnerable children to attend educational hubs¹¹⁴ which might be seen as a safer and more supportive environment than at home, evidence suggests that a high proportion of vulnerable children did not attend these.^115,116

Children at particular risk include those whose families have multiple complex needs, such as families under additional financial strain (see household finances), or where parents have existing mental health conditions.^117,118,119 The pandemic reduced access to the professional support networks on which these families would usually rely. Where support services were still available, they were delivered almost entirely online and for some this was not as accessible or effective as face-to-face services.^120,121 In areas with high levels of poverty and disadvantage in Scotland, voluntary and community sector organisations within local neighbourhoods provided vital support to families and children during the pandemic including emotional support for families in crisis as well as practical support such as food parcels and help with caring responsibilities.¹²² However, this support was inconsistent, with neighbourhoods with higher levels of community connections and existing infrastructure finding it easier to mobilise support for vulnerable children and their families and ensure that the right families received the right support.

Inequity in access to safe, outdoor space to play and exercise, either within the home or local community, was another issue highlighted by the Independent CRIA. Time spent outdoors and in nature is associated with better mental health and wellbeing among children, with benefits including reduced stress and increased resilience.^123,124 Those living in deprived socio-economic circumstances have been particularly affected by this as they are less likely to have access to gardens, limited access to greenspace within local communities and may be experiencing overcrowding at home with limited space to relax and unwind.¹²⁵

Household finances

Children and families living in deprived socioeconomic circumstances are more likely to experience poor mental health and wellbeing,^126,127,128 and are also recognised as a group at particular risk of not having their rights realised. General Comment 20 on the rights of adolescents and General Comment 7 on the rights of young children, both highlight that growing up in poverty can create conditions less conducive to positive family functioning due to the challenges of coping with these stressors on a day-to-day basis.

A recurring theme across the Independent CRIA was that children living in deprived socioeconomic circumstances are likely to have experienced a greater impact of the pandemic than those living in wealthier circumstances. Groups of children particularly affected by issues associated with limited household finances include those with disabilities or ASN whose parents may be less able to work due to increased caring responsibilities, young carers, children with care-experience, and children supported by lone parents.^129,130,131 Despite measures implemented to support personal finances, including the UK Job Retention Scheme which paid 80% of wages of furloughed staff, and an uplift in Universal Credit (UK social security payment),¹³² many families have seen their income reduced during the pandemic.¹³³ There is a greater risk of stress, mental health problems and child protection issues among families who are out of work, struggling financially and under increased pressure.¹³⁴ In addition, children's mental health has been affected by stress and worry over family finances, with almost one in three 11–24-year-olds and one in five 8–14-year-olds in Scotland reporting concerns about their own or their family's financial situation.^135,136

UNCRC Article 24 recognises children's right to access nutritious food, and research shows associations between food insecurity and poorer mental health among children.¹³⁷ The Independent CRIA raised issues around food access for those living in deprived socioeconomic circumstances, particularly with school closures limiting access to free school meals. While measures were put in place to continue to provide free meals to eligible families,¹³⁸ the way in which this was implemented with a non-standardised approach across different regions added to the stress of families in already difficult circumstances, and there has been an increased demand on food banks during pandemic.¹³⁹

Digital exclusion due to lack of access to technology such as laptops, tablets, mobile phones and reliable internet connection was also recognised as an issue for children in households with limited finances.^140,141 UNCRC General Comment 17 acknowledges the central role that electronic media play in children's daily lives, and encourages states to take all necessary measures to ensure equality of opportunity for all children to experience those benefits. Digital exclusion was highlighted across many sections of the Independent CRIA, with particular reference to UNCRC Article 2 (the right to non-discrimination). During lockdown children became reliant on digital methods to access many of the things that support mental health, including information and services as well as the ability to participate fully in online education, entertainment and cultural activities and to maintain relationships with family and friends. While the Scottish Government recognised that the pandemic disproportionately affected those living in disadvantaged socioeconomic circumstances,¹⁴² and committed to supporting digital access for all children, evidence included in the Independent CRIA indicated that digital access continued to be an issue for many children living in low-income households.¹⁴³

Schools and skills

Schools and education environments influence children's mental health,^144,145 and there are close links between mental health and educational attainment.^146,147,148 UNCRC Article 28 recognises the right of every child to access education, while Article 29 and General Comment 1 set out the aims of education to include not only literacy and numeracy, but also life skills that give children the tools needed to pursue their options in life. Schools play an important role in educating children about health, wellbeing and relationships,¹⁴⁹ as well as providing opportunities to identify and support children who are struggling with their mental health, and facilitating peer interactions and other opportunities to develop supportive relationships.¹⁵⁰ The importance of schools for children's development, both in terms of their educational attainment and wellbeing, has been widely recognised in the Scottish Government's response to the pandemic, with an Education Wellbeing working group set up to ensure a focus on this as children returned to schools in August 2020¹⁵¹ and prioritisation of school access in future response to the pandemic.¹⁵²

School closures were identified as one of the key sources of worry and anxiety among children.^153,154 Among 2418, 11–24-year-olds in Scotland, 42% were extremely or moderately concerned about school closure and 49% about exams and coursework,¹⁵⁵ and among 3968, 8–14-year-olds 41% were concerned about doing schoolwork at home.¹⁵⁶ The cancellation of exams¹⁵⁷ also added to stress and anxiety among older children who worried about how estimated grades might penalise some pupils, particularly those from more deprived areas or those taking more practical subjects, and the long-term impact that may have on young people's future education and employment prospects.¹⁵⁸ However, for some children, learning from home was a positive experience with many enjoying the reduced academic pressure and finding it easier to work in a quieter environment at home where they could receive one-to-one support from family members.¹⁵⁹

A UK-wide survey of 871 parents/carers of children with ASN reported that among those who received support via schools before the pandemic, 80% had this support stopped or postponed during school closures.¹⁶⁰ Other measures brought in to extend the time for local authorities to confirm educational placements and appeals¹⁶¹ are also likely to have increased stress and anxiety for children with ASN or disabilities, who may need to access school placements that provide specialised support and facilities.

Future and voice

Future and voice is a new item within the ONS wellbeing framework. With regard to children's future happiness and wellbeing, voice refers to children wanting their needs to be considered by those in positions of power, and for them to be empowered to express themselves and have a say in decision that affect their lives.¹⁶² One of the most common worries among children was about the impact of the pandemic on their future, particularly around educational attainment and employment.^163,164,165 Groups of children already facing disadvantage were highlighted as the most likely to continue to be affected in the future.

Involvement in decision making is enshrined in UNCRC Article 12 and contributes to meeting other rights including those related to mental health (General Comment 20). Children's participation in decision-making about issues that affect their lives is vital for developing resilience and preventing discrimination. This is particularly true at times of crisis,¹⁶⁶ but within early measures there was a lack of involvement of children and their families, particularly around key issues such as school closures and exam cancellations. While evidence about children's experiences of the pandemic were included as part of the Independent CRIA, the majority was collected via online surveys or through remote data collection methods, meaning that those groups who faced digital exclusion were not fairly represented. Independent CRIA findings reinforce the need to put in place appropriate processes to ensure the voices of children, including vulnerable groups, are heard and taken into account in future decision-making.

Discussion

The Independent CRIA is a useful framework to capture the full range of impacts of COVID-19 measures on children's rights. However, any in-depth rights-based consideration of public mental health requires us to look across all domains of children's lives. While the Independent CRIA was based on nine separate domains, the relationship and interdependence between children's experiences within all aspects of their lives and their mental health was widely recognised. This adds further weight to the value of a public health approach that takes account of wider social, economic and cultural factors when developing strategies to support the mental health of children.

The indivisibility of rights has been central to the United Nations work since the 1950s. This view of rights as a system where every right is equally important, and both relies upon and is impacted by every other right, has been critiqued in the literature as being unrealistic and conceptually problematic.¹⁶⁷ It is beyond the scope of this paper to fully engage with this debate but, the evidence presented here makes it clear that a comprehensive consideration of public mental health requires engagement across multiple interrelated rights.

This review highlights how measures implemented in Scotland during the COVID-19 pandemic have impacted on a range of children's rights and are likely to have contributed to the growing mental health crisis among children.¹⁶⁸ It is acknowledged that many more children will require access to professional health-care services to support their mental health and it is important that national governments meet children's rights to access such services. However, it is also clear that for many children and their families the support they rely on for their mental health does not come from professional health-care services, but rather from the familial and social contexts in which they are situated. As the pandemic and subsequent lockdowns have put restrictions upon children's lives, some of these contexts have been temporarily removed and others have assumed a higher focus. It is no surprise to see that family context mediates children's experiences of the pandemic, and that inequalities in family circumstances are heightened during a period where children are spending more time at home and are more dependent on their families for support. Therefore, finding ways to re-establish, develop and maintain positive relationships among families, peers and service providers will be critical to future mental health strategies.

Arguably, the closure of schools and childcare settings has had the biggest impact on children's lives, with wide-ranging implications for children's rights across multiple domains including access to education, mental health support services and nutritious food; relationships with friends and trusted adults; opportunities for recreation and play; and provision of a safe space for vulnerable children. Schools are already recognised as a key setting through which public mental health interventions could be delivered.¹⁶⁹ This analysis has further highlighted the critical role that schools are likely to play in children's recovery from the pandemic, and the importance of prioritising schools and childcare settings remaining open if future restrictions are required.

UNCRC General Comment 25, on children's rights in the digital environment, recognises the importance of access to digital technologies to support children to realise the full range of their rights, including during times of crisis. However, General Comment 25 also highlights that if digital inclusion is not achieved, existing inequalities may increase, and new ones may arise. During the pandemic, government measures restricting face-to-face interactions led to a reliance on digital access across many aspects of children's lives, and digital exclusion was recognised as impacting on children's rights across multiple domains including access to information, support services, education and relationships. Although concerns about the potentially negative consequences of excessive screen time and social media use on mental health remain, it could be argued that digital access is now more critical than ever in supporting both children's rights and their mental health. Therefore, future strategies for children's mental health should consider how the use of digital technology can be optimised across settings to ensure child safety and equity of access for all.

Throughout the Independent CRIA it is clearly recognised that the impact of the pandemic on the mental health of children has largely been influenced by the circumstances in which they live and the opportunities they have available to them. This is supported by more recent evidence indicating signs of recovery among the majority of children as restrictions were eased in Scotland, but highlighting that there are still specific groups of children who are particularly struggling with their mental health and wellbeing.^170,171 The Independent CRIA identified several groups of children at-risk of not having their rights realised, raising issues with regard to UNCRC Article 2 (non-discrimination). Looking across the different analyses the intersectionality between these groups is clear, with many vulnerable children facing multiple challenges. This highlights the vital importance of developing public mental health strategies that recognise and offer targeted support for at-risk groups alongside universal approaches.

A final area of focus for developing recovery strategies relates to the importance of involving children in decision-making to support their mental health. Across all measures a lack of consultation with children was noted, and one of the key recommendations of the Independent CRIA was to redesign decision-making processes to ensure that children's rights to participate are embedded at a structural level. UNCRC Article 12 enshrines the right for children to be involved in both individual decisions about their lives, but also be provided with the opportunity to be involved in collective decision making, for example by informing the development of services, policies and research. While there is no hierarchy of children's rights, children's participation in structural decision making has the potential to underpin other elements of children's rights, as policies and services aimed at addressing children's needs that are developed without taking their views into account are likely to be less accessible and acceptable to children.¹⁷² However, there is little evidence of children's participation in collective decision-making during the pandemic. In a survey completed by children's participation and rights experts in April 2020, 70% could not identify a single COVID-19-related children's participation initiative and none were aware of any initiatives that had yet led to government action.¹⁷³ With children worried about their future prospects, their involvement in decision-making around public mental health strategies, for example mental health service delivery and education reforms, will ensure that future plans will address those areas most important to children to provide the greatest impact.

The Independent CRIA represents a snapshot of a moment in time during which Scotland was emerging from the first national lockdown (June 2020), and since then Scotland has experienced periods of easing and tightening of restrictions at both the local and national level. As long as the pandemic continues the response measures will continue to impact in multiple ways upon the lives and rights of children across Scotland and the world. In October 2020 the Scottish Government published a plan outlining their response to the mental health impacts of COVID-19.¹⁷⁴ Although it is not possible to know whether this was directly influenced by the Independent CRIA, the plan addresses some of the issues raised and, if implemented effectively, has the potential to support children's rights in relation to their mental health as they recover from the pandemic. In addition, further measures were introduced to address some of the wider determinants highlighted here including prioritising reopening schools,¹⁷⁵ increased food voucher availability¹⁷⁶ and laptops for pupils and families who need them.¹⁷⁷

While the Independent CRIA addresses Scottish legislation and policy measures, the pandemic will have consequences for the realisation – or lack of realisation – of children's rights in every country and context. The impact of the pandemic and lockdown on children's mental public health is a global concern.¹⁷⁸ In this paper, we demonstrate the importance of recognising the full indivisible system of children's rights and the value of a rights-based framework to gaining a holistic view of public mental health. It is important to recognise that this analysis is based on the specific context and measures implemented Scotland, where children may have differing mental health needs compared with other countries, both as a result of the specific measure implemented by the government in response to the pandemic, and the underlying culture, and health, education and social care systems available. However, key areas for upholding children's rights identified here that will be applicable to all contexts are the need for equitable access to services and support (e.g. healthcare and education systems, digital access) for all children, but particularly those with pre-existing disadvantages, and the importance of involving children in the decision making process as countries set out a pathway for recovery from the pandemic.

Acknowledgements

We would like to thank the authors of each of the nine analyses that made up the Independent Children's Rights Impact Assessment and provided the basis for this review: Dr Zoe Picton-Howell, Dr Laura Colucci-Gray, Katie Reid, Prof. Morag Treanor, Theresa Casey, Fiona Mitchell, Claire Houghton, Fiona Morrison, Leah McCabe, Prof. Sheila Riddell, Dr Claire Lightowler and Deborah Nolan. We would also like to thank the co-ordinating team for the Independent Children's Rights Impact Assessment from the Observatory of Children's Human Rights Scotland, including Prof. Kay Tisdall, Dr Mary-Ann Powell and Katie Reid, for their support throughout the process. The views expressed are those of the authors and not the funding bodies.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Not applicable. No new data are included in this paper. The analysis reviewed data from other reports and publications, which are referenced within the document.

Additional information

Funding

Authors time for this work was supported by the Transdisciplinary Research for the Improvement of Youth Mental Public Health (TRIUMPH) Network, which is part of the Cross-Disciplinary Mental Health Network Plus initiative supported by UK Research and Innovation [UKRI] [grant number ES/S004351/1]. It is also supported by core-funding from the MRC/CSO Social and Public Health Sciences Unit at the University of Glasgow [grant numbers MC_UU_00022/1 and SPHSU16].

Notes on contributors

A. MacLachlan

A. MacLachlan is a Research Associate at the MRC/CSO Social and Public Health Science Unit, University of Glasgow, and Coordinator for the Transdisciplinary Research for the Improvement of yoUth Mental Public Health (TRIUMPH) network.

C. McMellon

C. McMellon is a Research Associate at the MRC/CSO Social and Public Health Science Unit, University of Glasgow and has responsibility for young people's participation in the Transdisciplinary Research for the Improvement of yoUth Mental Public Health (TRIUMPH) network.

J. Inchley

J. Inchley is a Reader at the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow and is Director of the Transdisciplinary Research for the Improvement of yoUth Mental Public Health (TRIUMPH) network.

Notes

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67 Fox et al., ‘Oxford Arc Study’.

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82 Ibid.

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84 Scottish Government Measure: Health Protection (Coronavirus) (Restrictions) (Scotland) Regulations 2020.

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155 Ibid.

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173 Larkins, ‘Building on Rainbows’.

174 Scottish Government Measure: Coronavirus (COVID-19): mental health – transition and recovery plan.

175 Scottish Government Measures: Coronavirus (COVID-19): framework for decision making – Scotland’s route map through and out of the crisis.

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