Mental Health Trajectories of Children and Caregivers Using School-Based Health Centers During the COVID-19 Pandemic

Abstract

Introduction

This was a prospective study of children registered at school-based health centers (SBHCs) in Canada. The objectives were to compare mental health trajectories of children and parents/caregivers who accessed SBHCs during the pandemic relative to those who did not.

Method

Parents/caregivers of children who attended SBHCs completed the Strengths and Difficulties Questionnaire (SDQ) and the Generalized Anxiety Disorder-7 (GAD-7) at three time points during the pandemic. The primary analysis used linear mixed models to examine the relationship between SBHC visits during the pandemic and children’s SDQ score trajectories. The secondary analysis was the same for parents’/caregivers’ GAD-7 scores.

Results

There were 435 children included. SDQ and GAD-7 scores worsened over time for children and parents/caregivers who attended SBHCs during the pandemic compared to those who did not.

Discussion

Children and parents/caregivers with worsening mental health symptoms may have sought care at SBHCs since they were accessible during the pandemic.

INTRODUCTION

The COVID-19 pandemic has had a major impact on children's psychosocial functioning (Samji et al., 2022). School closures and community lockdown measures isolated families and contributed to worsening mental health symptoms in children and their parents (Cost et al., 2022). Recent systematic reviews have found more depressive and anxiety symptoms in children and symptoms of loneliness, stress, and fear during the COVID-19 pandemic (Samji et al., 2022; Theberath et al., 2022). Similarly, a large European study demonstrated increased behavioral concerns in children, including internalizing problems during the pandemic (Orgilés et al., 2020). Children and families facing structural inequities related to poverty, race, newcomer status, and single-parent families have been disproportionately impacted by high rates of COVID-19, school closures, and lockdowns (Gallagher-Mackay et al., 2021).

A large survey demonstrated that parent-reported mental health problems in children during the pandemic were more common in those with a social disadvantage than those without (Geweniger et al., 2022). Longitudinal data also showed that financial disadvantage was negatively associated with children's psychological difficulties during school closures during the COVID-19 pandemic (Moulin et al., 2022). Similarly, parents of urban, racial, and ethnic minority school-aged children reported higher emotional and behavioral symptoms since the start of the pandemic (Spencer et al., 2021). In addition, distance learning was challenging for many children and required guidance from their guardians, who may have been unprepared and unable to support online schooling for extended periods (Abuhammad, 2020). This may have been especially true for parents/caregivers with language barriers and low literacy. Furthermore, health care access was restricted during the pandemic, and developmental and mental health assessment wait times were > 1 year (Autism Ontario, 2020).

School-based health centers (SBHCs) aim to improve access to health care for vulnerable children (Arenson et al., 2019). The important role of SBHCs in overcoming access barriers for students with developmental and mental health needs has been demonstrated in the literature (Rasiah et al., 2023; Rasiah, 2022). How SBHCs supported children's and parents’/caregivers’ development and mental health during the pandemic is unclear. This study aimed to examine the mental health trajectories of children and their parents/caregivers who used SBHCs during the pandemic. Understanding how SBHCs may have supported disadvantaged children with developmental and mental health concerns and their parents/caregivers during the pandemic may help inform mental health care delivery to at-risk children. Our primary objective was to compare the trajectories of parent/caregiver-reported child mental health symptoms for those who accessed SHBCs for pediatric development and mental health care during the pandemic relative to SBHC users who did not access SBHCs during this time. The secondary objective was to compare parent/caregiver self-reported mental health trajectories for those whose children used SBHCs during the pandemic compared with those who did not.

METHODS

This was a prospective longitudinal cohort study of children who used urban SBHCs to serve disadvantaged children with developmental and mental health problems. The SBHC program is a partnership between a large urban academic hospital network and Canada's largest school board. The SBHC program comprises two SBHCs that serve children from 75 surrounding urban elementary schools. The schools that house the SBHCs were chosen because they have many students who face external challenges, including low family income, single-parent homes, and parents with low educational attainment (Toronto District School Board, 2022). Children who attended the SBHCs from the host schools and the surrounding feeder schools were primarily from disadvantaged neighborhoods with a high proportion of newcomers and low-income families (Freeman et al., 2013). Children were referred to the SBHCs by school board staff (teachers, principals, allied school support staff) for developmental, mental health, and school-related concerns. Parents/caregivers could also self-refer to the SBHCs. During the COVID-19 pandemic, school closures occurred between March to June 2020 and January to February 2021. Schools remained open until April 2021, when they closed again for the remainder of the school year. This student population experienced school closures lasting 28 weeks, the longest of any province or territory in Canada (Bennett, 2022). During school closures, students participated in distance remote learning using online platforms. Students accessed the SBHCs using telephone and videoconference when schools were closed. When schools were open, clinical care was provided by phone, videoconference, and in person.

Using convenience sampling, all parents/caregivers of SBHC users who consented to chart review and thus part of the SBHC preexisting database were invited over the phone to participate in an online COVID-19 mental health survey delivered using a web-based platform (REDCap) at three-time points (i.e., baseline, 6-months postbaseline, and 12-months postbaseline). Verbal informed consent was obtained by a research assistant to participate in the COVID-19 mental health survey. Those who consented received an automated unique survey link in their email at each time point. All data collection using the online survey was completed between August 5, 2020 and November 12, 2021. Demographic characteristics, diagnoses, and treatment of children who visited the SBHCs were acquired through prospective medical record review. This study was approved by the Research Ethics Board at St. Michael's Hospital, Unity Health Toronto, on May 21, 2020 (Research Ethics Board study no. 19-060).

Exposure Variable

The primary exposure (independent variable) was an SBHC visit during the pandemic before and during the study survey period (August 5, 2020 to November 12, 2021).

Outcome Variables

Parents/caregivers completed the SBHC COVID-19 mental health survey, which included the following validated tools: (1) Strengths and Difficulty Questionnaire (SDQ) for children and (2) Generalized Anxiety Disorder-7 (GAD-7) survey for parents (Goodman, 1999; Mossman et al., 2017). The outcome variables (dependent variables) were parent/caregiver-reported total, externalizing, and internalizing difficulties SDQ scores for children, and the parent/caregiver self-reported GAD-7 score. The SDQ is a validated screening tool that is used to measure emotional and behavioral problems in children (He et al., 2013; Muris et al., 2003). The SDQ was scored on the basis of a total difficulties scale and emotional problems, conduct problems, hyperactivity, peer problem, and prosocial subscales (Goodman & Goodman, 2012; Hall et al., 2019). The total difficulties score (sum of all subscale scores except the prosocial score), as well as the internalizing difficulties score (sum of emotional problems and peer problems scores), and the externalizing difficulties score (sum of conduct and hyperactivity scores), were reported. Children who received an “abnormal” score on one of the SDQ subscales are 15 times more likely to meet the criteria for a mental health diagnosis (Aitken et al., 2015). The GAD-7 is a seven-item validated self-report anxiety questionnaire developed to assess a patient's anxiety symptoms in the last 2 weeks (Williams, 2014). The items probe the extent to which a patient has been troubled by issues including being easily agitated, irritated, and on edge; having difficulties relaxing; worrying about various things; being so restless that it is difficult to sit still; and feeling nervous, afraid that something terrible might happen.

The overall SBHC COVID-19 mental health survey was adapted from the Canadian Community Health Survey and the CoRonavIruS Health Impact Survey to assess child and parent/caregiver mental health during the COVID-19 pandemic (Cost et al., 2022; Nikolaidis et al., 2021).

Participant Information

Of the 1,804 children in the SBHC database, 964 parents/caregivers were contacted and invited over the telephone to participate in this study. There were 840 out of 1,804 parents/caregivers that were not able to be reached by phone or were unable to be invited because of language barriers. Of the 964 parents/caregivers contacted, 836 (87%) consented to participate, and 128 out of 964 (13%) declined. Of the 836 consented parents/caregivers, there were 366 incomplete surveys with either missing SDQ or GAD-7 scores which were excluded. There were 470 surveys with complete GAD-7 scores and 349 with complete SDQ scores. Of these, 35 children with SBHC visits during the survey period were analyzed separately because SBHC visits during the survey period could have influenced SDQ and GAD scores. Four hundred thirty-five participants were included in the main cohort for analysis (435 surveys with complete GAD-7 scores and 314 with complete SDQ scores; Figure ).

FIGURE.

Study participant flow chart.

Note. GAD-7, Generalized Anxiety Disorder-7; SDQ, Strengths and Difficulties Questionnaire; SBHC, school-based health center.

At baseline, the mean age of children was 10.7 ± 3.2 years. Two hundred and ninety-five children (67.8%) were males. One hundred and twenty-eight (29.4%) children had an annual family income of < $30,000.00. Table 1 describes demographic characteristics.

TABLE 1.

Demographic characteristics of participating children

Demographics	Total (n = 435)
Age at baseline, years	10.7 ± 3.2
Sex, male	295 (67.8)
Diagnosis of ASD	83 (19.1)
Diagnosis of ADHD	120 (27.6)
Prescribed medications at SBHCs	127 (29.2)
Annual household income
< $30,000	128 (29.4)
$30,000–$49,999	50 (11.5)
$50,000 to $74,999	38 (8.7)
$75,000 to $99,999	25 (5.7)
> $100,000	63 (14.5)
Home arrangement
Single parent	100 (25.3)
Two-parent household	212 (48.7)
Other	35 (8.0)
Child born in Canada	281 (64.6)
Child first language is English	263 (60.4)

Note. Values are mean ± SD or n (%). ADHD, attention-deficit/hyperactivity disorder; ASD, autism spectrum disorder; SBHC, school-based health center.

Analysis

Descriptive characteristics were used to describe the study cohort. The parent/caregiver-reported SDQ scores for children and parent/caregiver self-reported GAD-7 scores were categorized on the basis of which survey was completed by the participant (i.e., baseline, 6-months postbaseline, and 12-months postbaseline). The survey completion date was used to determine the time (in months) between the baseline and follow-up survey and was considered a continuous variable. A complete case analysis was employed. Supplementary Table 1 describes survey attrition.

Parametric t tests and Wilcoxon Rank Sum tests were used to compare continuous variables of interest, and chi-square tests or Fisher's exact tests, as appropriate, were used to compare categorical variables of interest.

The primary analysis used linear mixed models to examine the relationship between SBHC visits during the pandemic and SDQ score trajectories (total difficulties, externalizing and internalizing difficulties). The secondary analysis was the same for the GAD-7 trajectory outcome. The model adjusted for prespecified variables of interest: diagnosis of autism spectrum disorder (ASD), diagnosis of attention-deficit/hyperactivity disorder (ADHD), age at survey start, and sex. Additional variables, including medication prescriptions, family income, home arrangement, child born in Canada, and English as a first language, were included in a post-hoc supplementary adjusted model. The additional covariates were not included in the primary analysis as there was too much missing data, and including them would have led to a significantly reduced sample size. A random effect was used to account for repeated measures within the same individual. A likelihood ratio test was used to test the interaction. Because of attrition, only one participant in the cohort with visits during the pandemic completed the SDQ at the 12-month follow-up. A sensitivity analysis was performed to check if the single data point affected the results at 12 months in this group. All statistical analysis was performed using R statistical software (version 4.1.2, RStudio, PBC, Boston, MA).

RESULTS

The median and interquartile range for the total difficulties SDQ and GAD-7 scores are presented in Table 2 at each survey time point.

TABLE 2.

Median and interquartile range (IQR) for Strengths and Difficulties Questionnaire (SDQ) and Generalized Anxiety Disorder-7 (GAD-7) scores over time

Survey	Baseline	6-Month postbaseline	12-Month postbaseline
SDQ	314	121	42
Total SDQ score	14.0 (9.0–19.0)	15.0 (9.0–20.0)	15.6 (9.3–20.8)
Externalizing score	8.0 (5.0–10.9)	8.0 (5.0–12.0)	9.0 (5.0–11.0)
Internalizing score	6.0 (3.0–9.0)	6.0 (3.0–9.0)	6.0 (4.0–10.0)
GAD-7	435	213	98
GAD-7 score	5.0 (1.0–9.0)	6.0 (2.0–11.0)	5.0 (2.0–8.0)

Note. Values are presented as n or median (IQR).

For the primary analysis, adjusted linear mixed models showed that students with an SBHC visit during the pandemic had a 0.17 higher increment in total difficulties SDQ score per month compared with those who did not visit the SBHCs during the pandemic (0.17; 95% confidence interval [CI], 0.02–0.32, p = .020; Table 3 ). Specifically, the total difficulties SDQ score increased by 0.17 (95% CI, 0.03–0.31; p = .02) per month in those that accessed SBHCs during the pandemic, whereas the change in total difficulties SDQ score per month was −0.001 (95% CI, −0.041 to 0.040; p = .978) in those that did not. Similarly, the change in internalizing difficulties SDQ score differed between children who visited the SBHCs during the pandemic (0.14; 95% CI, 0.05–0.23; p = .002). For every month during the survey period, the internalizing difficulties SDQ score increased by 0.14 (95% CI, 0.06–0.23; p = .001) for those with a visit, whereas the change in internalizing difficulties SDQ was 0.001 (95% CI, −0.02 to 0.03; p = .91) for those without a visit. The externalizing difficulties SDQ score trajectory did not differ between children who accessed SBHCs during the pandemic and those that did not (0.03; 95% CI, −0.05 to 0.12; p = .44). Results are presented in Table 3 and Supplementary Figure 1.

TABLE 3.

Strengths and Difficulties Questionnaire (SDQ) and Generalized Anxiety Disorder-7 (GAD-7) score trajectories for those with a school-based health center (SBHC) visit relative to those without an SBHC visit during the pandemic

	Adjusted analysis
Scores	Estimate	2.5%	97.5%	p Value
Total difficulties SDQ score
Visit to the SBHC before survey period, during the pandemic	0.460	−1.489	2.409	.646
Time, month	−0.001	−0.041	0.040	.978
ASD, yes	1.041	−0.730	2.813	.254
ADHD, yes	2.421	0.676	4.165	.007
Age at baseline, years	−0.179	−0.436	0.078	.176
Male	1.733	0.138	3.328	.035
Visit to the SBHC before survey period, during the pandemic X time, month	0.169	0.024	0.317	.024
Internalizing SDQ score
Visit to SBHC before the survey period, during the pandemic	−0.247	−1.351	0.856	.663
Time, month	0.001	−0.023	0.026	.908
ASD, yes	0.778	−0.220	1.776	.130
ADHD, yes	0.470	−0.514	1.454	.353
Age at baseline, years	0.034	−0.111	0.179	.646
Male	0.488	−0.410	1.386	.291
Visit to SBHC before the survey period, during the pandemic X time, month	0.139	0.052	0.227	.002
Externalizing SDQ score
Visit to SBHC before the survey period, during the pandemic	0.705	−0.404	1.814	.217
Time, month	−0.001	−0.025	0.023	.911
ASD, yes	0.260	−0.744	1.265	.614
ADHD, yes	1.946	0.956	2.936	< .001
Age at baseline, years	−0.214	−0.360	−0.068	.005
Male	1.248	0.344	2.153	.008
Visit to SBHC before the survey period, during the pandemic X time, month	0.034	−0.052	0.122	.436
Total GAD-7 score
Visit to SBHC before the survey period, during the pandemic	−0.729	−2.167	0.710	.324
Time, month	−0.027	−0.056	0.001	.060
ASD, yes	−0.034	−1.348	1.279	.959
ADHD, yes	0.362	−0.837	1.561	.556
Age at baseline, years	−0.161	−0.334	0.011	.069
Male	0.319	−0.778	1.416	.571
Visit to SBHC before the survey period, during the pandemic X time, month	0.163	0.059	0.269	.002

Note. ADHD, attention-deficit/hyperactivity disorder; ASD, autism spectrum disorder.

In the secondary analysis, there were differences in the parent/caregiver self-reported GAD-7 score trajectory between parents/caregivers of children who accessed the SBHCs during the pandemic and those who did not (0.16; 95% CI, 0.06–0.27; p = .002). Every month during the survey period, parents/caregivers of children with an SBHC visit had a 0.16 higher increase in their score than those without. Specifically, the GAD-7 score increased by 0.14 (95% CI, 0.04–0.24; p = .008) per month in parents/caregivers whose children accessed SBHCs during the pandemic, whereas the change in GAD-7 score per month was −0.03 (95% CI, −0.06 to 0.001; p = .06) in parents/caregivers whose children did not. Results are presented in Table 3 and Supplementary Figure 1. The sensitivity analysis, in which the single data point at the 12-month mark for the cohort with visits during the pandemic was removed, yielded the same results as the primary analysis. Supplementary Table 2 shows the results of the models with the additional covariates.

The 35 patients who had SBHC visits during the survey period demonstrated no differences in total difficulties SDQ score, internalizing difficulties SDQ score, and external difficulties SDQ score compared with the cohort of children who did not visit the SBHCs during the pandemic (Supplementary Table 3; Supplementary Figure 2).

DISCUSSION

In this prospective cohort study, we found worsening total difficulties and internalizing difficulties in SDQ score trajectories reported by parents/caregivers for children who visited the SBHCs during the COVID-19 pandemic compared with those that did not. We did not find any meaningful differences in externalizing difficulties score trajectories. Parents/caregivers of children with an SBHC visit during the pandemic also demonstrated a worsening self-reported GAD-7 score trajectory compared with children without a visit.

Children and parents/caregivers with worsening mental health symptoms (particularly internalizing symptoms such as anxiety) may have sought care at SBHCs because they were accessible during the pandemic. Notably, health care access was difficult during the pandemic, with increased wait times for mental health and developmental services during lockdowns (Mental Health Commission of Canada, 2021). Across Canada, the pandemic increased the delay between seeing a family doctor and receiving medically necessary treatments to more than 25 weeks (Barua, 2021). Similarly, fewer children received primary care and mental health services during the pandemic in the United States (Sullivan et al., 2021). Our SBHC model may have reduced access barriers for children and parents/caregivers with mental health concerns by remaining accessible through virtual or in-person care during the pandemic. SBHCs in the United States also pivoted to virtual care during the pandemic, reducing access barriers for children with increased mental health symptoms (Sullivan et al., 2021).

Traditionally, SBHCs reduce health care access barriers for students in need, especially those from vulnerable populations, such as Black and Indigenous peoples, Two-Spirit, lesbian, gay, bisexual, transgender, queer (or questioning), immigrant communities, and other equity-seeking communities (Arenson et al., 2019; Freeman et al., 2013; Keeton et al., 2012). Children with fewer social connections and greater loneliness, such as newcomers, may have been at greater risk of internalizing symptoms; therefore, they accessed care at their SBHCs (Fegert et al., 2020). Similarly, children who experienced isolation in previous pandemics were more likely to experience anxiety and require mental health services (Loades et al., 2020). Because it may take several months for mental health interventions to improve internalizing symptoms such as anxiety, it is plausible that a longer follow-up period was required to show improvements in mental health symptoms for those who sought care at the SBHCs during the pandemic (McCarthy, 2022).

There is also a well-established relationship between parental/caregiver anxiety and child anxiety, which may have accounted for the similar internalizing symptom trajectory in children and anxiety symptom trajectory in parents (Crosby Budinger et al., 2013). Furthermore, children spent prolonged periods at home and required parents/caregivers to support distance learning during school closures, factors which may have exacerbated parental/caregiver anxiety. Increased symptoms of anxiety and stress in parents/caregivers may have been modeled by children unwittingly and contributed to maladaptive behaviors during this stressful time (Crosby Budinger et al., 2013).

Although we found no differences in the trajectories of SDQ and GAD-7 scores between the cohort of children who visited the SBHCs during the survey period compared to those who did not access the SBHCs during the pandemic, this cohort tended to have higher scores than those who did not visit the SBHCs during the pandemic reflecting worse mental health. This may be consistent with our findings that children with worse mental health accessed the SBHCs during the pandemic.

Our sample of 314 children demonstrated parent/caregiver-reported total difficulties SDQ scores in the “borderline” range at baseline and 6 months, with scores just below “borderline” at 12 months (Table 2). These findings are consistent with the literature showing that children were impacted throughout the pandemic with various mental health problems and school-related needs (Cost et al., 2022; Dudovitz et al., 2022; Gallagher-Mackay et al., 2021). A large meta-analysis of mental health symptoms in children during the first year of the pandemic showed that 25% of youth globally experienced clinically elevated depression symptoms, and 20% experienced clinically elevated anxiety symptoms (Racine et al., 2021). Furthermore, studies have shown that increased screen time, lack of exercise, and social isolation were related to worsening mental health in children from all socioeconomic backgrounds during the pandemic (Tandon et al., 2021). Our results showed that parents/caregivers demonstrated anxiety symptoms in the clinically mild range at all three-time points. This is consistent with other studies reporting parental stress and anxiety during the COVID-19 pandemic (Johnson et al., 2021). Because parental/caregiver stress is associated with negative parenting practices, including aggression and displays of anger (Kazdin & Whitley, 2003), health providers caring for children must be mindful of parental/caregiver mental health, especially during a pandemic, which exacerbates disparities and stressors in general.

Almost half of the families in our study were from low-income homes, almost one quarter were from single-parent homes and many experienced language barriers. Sociodemographic barriers have been shown to contribute to clinically significant mental health symptoms throughout the pandemic (Claes et al., 2021). Similarly, studies have also found that children and parents/caregivers experiencing social inequities demonstrated worsening mental health symptoms throughout the pandemic (Nagasu et al., 2021). There are many factors reported to contribute to mental health concerns in low-income communities during the pandemic, including job loss, under-housing, food insecurity, and school closures, which disproportionately impacted low-income families (Fang et al., 2021; Gallagher-Mackay et al., 2021; Groot et al., 2022).

Almost half of the children in this study had a diagnosis of either ADHD or ASD. Studies have shown that children with preexisting ADHD and ASD experienced worsening mental health symptoms during the pandemic (Cost et al., 2022). Some children with ADHD and ASD may have lost school-based support during school closures and experienced greater learning challenges with distance learning.

This study had some limitations. First, there may not have been a long enough follow-up period to show improvements in symptoms for those who visited the SBHCs during the pandemic. Second, there was a lower-than-anticipated response rate, as patient recruitment was challenging because of a high proportion of non-English speaking families. This is an important limitation because families with language barriers face more challenges accessing health care, and it would be important to understand whether or not they accessed the SBHCs during the pandemic. Furthermore, the low response rate contributed to a smaller sample size than anticipated. Third, there was attrition with the 6- and 12-month follow-up surveys, contributing to missing data. As a result, the confidence intervals were wide, especially for the cohort with SBHC visits during the pandemic. Results should not be overinterpreted. Fourth, we do not know if children in our study accessed mental health care outside of SBHCs during the pandemic; therefore, we cannot determine if SBHCs were accessed differently than other health care facilities. Fifth, this study was conducted in two SBHC settings within Canada's largest school board and may not represent at-risk students from other urban or rural communities.

Children with at least one SBHC visit during the pandemic had significant worsening of parent/caregiver-reported mental health symptoms and parent/caregiver self-reported anxiety symptoms compared with those in the SBHC database who did not visit the SBHCs during the pandemic. SBHCs may have decreased access barriers for children and their parents/caregivers with socioeconomic risk factors experiencing worsening mental health symptoms during the pandemic. Improved access to mental health care is necessary to support children and parents/caregivers during the pandemic and postpandemic periods. The long-term mental health impacts of the pandemic are not yet known. Longitudinal studies with longer follow-ups would help determine the role of SBHCs in supporting at-risk children and parents/caregivers with mental health needs during the pandemic.

Biographies

Sloane Jaye Freeman, Pediatrician, Women and Children's Health Program, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario.

Saisujani Rasiah, MSc, Women and Children's Health Program, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario.

Justine Cohen-Silver, Pediatrician, Women and Children's Health Program, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario.

Keying Xu, Research Bioatatistician, Applied Health Research Centre, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario.

Gerald Lebovic, Research Biostatistician, Applied Health Research Centre, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario.

Jonathon Maguire, Pediatrician, Women and Children's Health Program, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario.