Exploring the psychological impact on children and adolescents during the initial period of the COVID-19 pandemic-a systematic review

Abstract

The impact of the COVID-19 pandemic on the mental well-being of children and teenagers has gained increased recognition, but a systematic review to assess its effects on their mental health has not yet been conducted using the PRISMA and PICOS framework. Therefore, this review aimed to evaluate global changes in psychological well-being among young people by analysing longitudinal and repeated cross-sectional studies conducted before and during the pandemic. The review analysed data from 21 studies in 10 countries, involving 87,486 participants under the age of 19. The majority of the research found a long-term decline in young people’s psychological health, including higher levels of depression, anxiety, and psychological distress during the pandemic. Studies highlighted that factors such as confinement, stress, environmental hazards, and financial crises significantly impacted household dynamics, which in turn affected children’s development and psychological well-being. Emerging studies from various regions worldwide suggest a potential decline in the mental health of school-aged adolescents during the COVID-19 pandemic. This review underscores the need for further research to understand the severe and long-term consequences of the pandemic on children’s mental health.

Introduction

Since the initial detection of the first cases of the novel coronavirus in December 2019, the global community has been confronted with what may be one of the most severe public health crises in recent history [1]. To combat the disease’s transmission and its rapidly expanding fatalities, lawmakers enforced physical distancing and lockdown orders, leading to societal detachment, surging unemployment numbers, and ubiquitous risks to socioeconomic health [2]. The outbreak has had a notable impact on the mental health of individuals worldwide, causing excessive stress, feelings of hopelessness, and distress [3]. Despite a progressively growing number of scholarly investigations focusing on the adverse effects on human psychological health, there has been a lack of systematic research specifically addressing the psychological impact of the pandemic on children and adolescents.

Progressively growing number of scholarly investigations focusing on the adverse effects on human psychological health, the lesser focus was given to identifying how well this catastrophic event has influenced children, not solely regarding learning disruptions and cognitive difficulties, but also overall mental well-being. Nonetheless, there is considerable concern that the negative consequences would be broad and long-lasting [4].

Children’s and adolescents’ well-being is reliant on the health and well-being of the immediate family. Therefore, this reliance could become even more evident in the outbreak setting since youngsters are limited/or completely lack external support networks like a kindergarten, preschool, or school [5]. Interruptions to familial relationships, negative consequences on caretaker psychological health, parenting stress about considerations regarding disease and infection, significant distancing, lockdown, and the pervasive economic difficulties that several families and communities confronted potentially have an impact on youngsters’ mental health [6]. However, the literature has not adequately examined how such cumulative stressors impact child and adolescent mental health outcomes for broad demographic and socioeconomic populations.

Therefore, the review takes systematically available evidence into account in seeking a better insight into the psychological problems children had during the pandemic and to chart main risk and protective factors that influenced mental health. Past catastrophe studies indicate that children subjected to disasters have behavioural and emotional issues such as aggressiveness, anxiety, distress, and PTSD [7–11]. Taken alongside these findings, emerging research on the COVID-19 outbreak in China and other parts of the world suggests that the mental health of school-aged adolescents may deteriorate [7]. The impact of the COVID-19 outbreak on school children varies, with immediate psychological and social consequences. The Rapid Assessment of Pandemic Impact on Development Early Childhood Household Survey Project conducted weekly surveys among a broad US sample of children under five, revealing increased child behaviour issues and anxiety, particularly in racial minority and financially disadvantaged communities [8]. Despite these findings, there is a lack of a consolidated review that critically analyzes these variations across different populations and age groups.

Parents are required to satisfy requirements during outbreaks of infectious diseases, by dividing work and parenting duties, maintaining infection prevention, giving emotional and psychological support to their children, and focusing on their family’s basic needs, while at the same time establishing a safe environment under uncertainty, fear, and anxiety. These demands are heightened by a sense of loneliness and loss of previously utilized resources in school and society, thus rendering the situation more challenging to manage [9]. This review also considers the psychological burden on caregivers and the cascading effects on children’s mental health, emphasizing the importance of family support systems. A wide range of studies has been conducted on the psychological effects of environmental disasters on families and children [10].

Outbreaks differ from natural calamities, requiring intense infection management like confinement [11]. Unlike post-natural disasters, outbreaks demand interpersonal detachment to curb virus spread [12]. Understanding risks linked to children, parents, and parenting stress is vital in comprehending the outbreak’s impact on family members and identifying support needs before outbreak aid in addressing family concerns effectively. In light of such complexities, the present study attempts to provide a thorough, organized examination of psychological risk factors and coping mechanisms that influenced child and adolescent mental well-being during the COVID-19 pandemic. Therefore, exploring outbreaks’ impact on children, adolescents, and communities through systematic review is crucial. While preventive measures can mitigate consequences, understanding potential adverse effects remains imperative for ethical and public health reasons.

Existing literature extensively documents COVID-19’s psychological impact on various groups like parents, healthcare workers, university students, and children in different settings [13–19]. Notably, there is a gap in systematic reviews focusing on children and teenagers (< 18 years). Utilizing available literature, we attempt to explore the early-stage psychological impact of COVID-19 on this age group, generating data on various psychological outcomes, including parental and family impacts, financial difficulties, and the effects of quarantine, social separation, lockdown, school closures, and online education. The study aims to examine the early-stage prevalence of psychological outcomes, including depression and anxiety, among children and adolescents during the COVID-19 outbreak. It seeks to identify associated factors, evaluate diverse study designs and tools used in measuring psychological outcomes, pinpoint current knowledge limitations in COVID-19 studies, and provide recommendations for future research on similar epidemics. Through this systematic review, policymakers, healthcare providers, and educators will be able to understand the burden of mental illness among the youth and design effective support policies.

Methods

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to ensure a thorough and comprehensive evaluation of the available evidence [20].

Searching strategy

Electronic databases such as Web of Science, MEDLINE via PubMed, Cochrane Library, Embase, PsycINFO, Science-direct and Google Scholar were searched from January 2020 to March 2021 to collect the data using the keywords, including “COVID-19,” “COVID-2019,” “severe acute respiratory syndrome coronavirus 2,” “2019-nCoV,” “SARS-CoV2,” “2019nCoV,” “coronavirus,” “Children,” “Child,” “Adolescent,” “Toddler,” “Preschooler,” “Pediatric,” “psychiatry,” “psychology,” “mental health,” “mental illness,” “mental outcomes,” “mental disorder,” “depress,” “anxiety,” “stress,” “post-traumatic stress,” “PTSD,” “well-being,” “insomnia,” “coping,” “Sleep,” “Eating disorder,” “behavioral changes,” “ADHD,” “Autism,” and “Intellectual disability.” The search syntax shown was created for each database, which involved using the PICOS approach (Population /Intervention /Comparison/ Outcomes/ Study Design) as described by Methley et al. [21]. These search terms were combined using the Boolean operators ‘AND’ and ‘OR.’ The search was last conducted on March 31, 2021, and included all studies published up to that date.

Inclusion and exclusion criteria

This systematic review set specific inclusion and exclusion criteria based on research question. Inclusion criteria covered children and adolescents under 19 years, per WHO guidelines, focusing on psychological impact of COVID-19, including both genders. Only English peer-reviewed journal publications were considered, emphasizing observational studies with quantitative data. Exclusion criteria comprised those aged ≥ 19 with existing disorders and non-English studies. Interventional studies and those involving continuous psychiatric or physical comorbidities were excluded. Studies assessing physiological effects, immunological markers, genetics, and events’ statistical changes were also excluded. Additionally, studies on suicidal behaviors, ideations, and attempts during the pandemic were excluded, except for a significant increase in suicidal ideation in psychiatric settings in 2021. (Table 1).

Table 1.

Inclusion and exclusion criteria

PICO	Inclusion Criteria	Exclusion Criteria
Population	Children and adolescents under 19 years of age	20 years and older
Intervention	Psychological evaluation, psychological disturbance, emotion-regulation issues, sadness, sleeplessness, anxiety, and distress related to the COVID-19 pandemic	Existing psychological or physical disorders
Comparison	Studies that compared the psychological impact of COVID-19 between different groups of children and adolescents or no comparisons	Studies that compared typical and pre-existing psychological conditions before and during the pandemic
Outcomes	Studies reporting on psychological health outcomes related to the COVID-19 pandemic, including loneliness, peer problems, quality of life, psychological distress, anxiety, depression, negative and positive effects, attention deficit, and externalizing and internalizing problems	Studies reporting on clinical outcomes, physiological effects, immunological markers, genetics of COVID-19, or prevalence of suicidal behaviors and ideations among children and adolescents during the pandemic

Study selection

Via utilizing a structured approach delineated by the PRISMA study selection flow diagram, the pertinent studies were meticulously identified, screened, and ultimately chosen. The review’s selection procedure employed a rigorous double-screening methodology, wherein two independent reviewers consistently applied predetermined inclusion criteria to mitigate potential systematic biases. Elaboration on the intricacies of the selection processes can be found in the findings section of the manuscript. While some studies were published in early 2020, the data analyzed within these studies may have been collected prior to or during the early stages of the pandemic. This review includes studies that provide insights into both pre-pandemic and pandemic periods where applicable.

Data extraction and quality appraisal

Data extraction from chosen articles adhered to defined criteria, encompassing author details, publication year, and journal information. Notable aspects such as study objectives, duration of data collection, and participant specifics (age, sample size, gender, education) were systematically documented. Methodological features, including study design, tools, and statistical software, were also carefully recorded. Two authors independently conducted the extraction of quality assessment, key results, and outcomes, addressing any disparities through discussion or by engaging a third reviewer when necessary.

Further, to evaluate the study quality, this review employed Joanna Briggs Institute (JBI), Critical Appraisal Skills Programme (CASP), and Mixed Methods Appraisal tools (MMAT). As all studies shared a quantitative, cross-sectional design, it utilized JBI for analytical cross-sectional studies and MMAT for descriptive studies. The independent assessment involved evaluating studies against the screening criteria of JBI and MMAT. Instead of assigning overall scores, a qualitative approach was opted, offering a detailed evaluation of each study’s methodological quality. Categorization of studies into low, moderate, or high methodological quality was based on this thorough appraisal (Table 2).

Table 2.

Critical appraisal checklist

S.No	Question	Yes	No	Unclear	Not applicable
1	Were there clear criteria for inclusion in the case series?	✔
2	Was the condition measured in a standard, reliable way for all participants included in the case series?		✔
3	Were valid methods used for the identification of the condition for all participants included in the case series?		✔
4	Did the case series have consecutive inclusion of participants?	✔
5	Did the case series completely include participants?	✔
6	Was there clear reporting of the demographics of the participants in the study?	✔
7	Was there clear reporting of clinical information of the participants?		✔
8	Were the outcomes or follow-up results of cases clearly reported?				✔
9	Was there clear reporting of the presenting sites’/clinics’ demographic information?		✔
10	Was statistical analysis appropriate?	✔

Data analysis

The data analysis within the review encompassed a dual-tiered approach, comprising descriptive scrutiny of the encompassed literature’s overarching attributes, alongside a qualitative inquiry into pivotal discoveries drawn from said literature. For the descriptive analysis, Excel 2019 was utilized, deploying techniques such as frequencies, percentages, and the construction of tables and graphs to delineate the constituent elements of the included papers’ contextual characteristics. In the realm of qualitative analysis, amidst a spectrum of methodologies including content analysis, narrative analysis, discourse analysis, framework analysis, and grounded theory, this review opted for content analysis to scrutinize all salient data points. The investigator discerned thematic contours, recurrent patterns, and interrelations within the extracted data, employing a manual methodology to engage in open and axial coding of congruous findings, thereby classifying eight thematic constructs as pre-established in alignment with the review’s objectives. Ultimately, the prominent thematic elements were distilled and organized following the representatives of the aforementioned eight themes.

Ethical consideration

Systematic reviews inherently entail minimal ethical quandaries as they do not involve the direct collection of personal, sensitive, or confidential data from human subjects (Gough et al., 2017). Before embarking upon this review, the researcher diligently submitted an ethical dossier and review protocol to the institutional review boards of STIMU, Myanmar, and the University of Bedfordshire, UK, seeking their sanction. Both entities granted their approval to the protocol on the 13th of July 2022, under the auspices of the SSCHREC application number (STI011-6-2022-3-003). Throughout the course of this review, the researcher adhered strictly to the utilization of publicly accessible documents and took utmost care to neither unduly distort nor exaggerate the original research findings.

Results

This systematic review identified 21 studies from 9 different countries. From the initial 2500 articles identified through various databases, 1900 articles were removed based on strict inclusion and exclusion criteria. An additional 1100 articles were excluded after being deemed irrelevant based on their titles and abstracts. Following the full-text screening, 800 articles were removed, of which 250 studies focused on psychiatric disorders, 300 studies focused on age groups greater than 19 years, and 228 studies were reviewed. Ultimately, the review shortlisted 21 studies for inclusion (refer to Fig. 1). The combined sample size of these studies was approximately 87,486 subjects, with the highest number of participants, 41,365 being from a Chinese study [22] and the lowest number, 63 from a Pakistan study [23], as in Fig. 2.

Fig. 1.

Selection of studies based on PRISMA

Fig. 2.

Distribution of Sample size by Author, Year

Countries, age group representation and quality assessment

Among the countries studied (China, Greece, United States, Pakistan, Italy, Spain, Turkey, Bangladesh, and Portugal), China took the lead with seven studies, as shown in Fig. 3. 14 were cross-sectional, with all the studies aligning with the review’s goal of assessing psychiatric disorders prevalence and factors affecting children’s well-being during the pandemic.

Fig. 3.

Distribution of studies used by Author, Year

Out of the 21 studies, nine focused on children under 10, revealing diverse patterns in psychological outcomes. A unique study in China, encompassing school children aged 6–17, reported improved mental health (depression) symptoms during the pandemic. In Spain, a cross-sectional study on 6-17-year-olds indicated lower health-related quality of life, elevated conduct problems, hyperactivity, and peer issues, with no significant change in emotional symptoms. Additionally, eight studies involved adolescents aged 12–18, conducted in China, the United States, Greece, Pakistan, and Spain, while three encompassed individuals below 18. The quality assessment of the studies ranged from moderate to high, with most studies scoring between 3 and 4 on the quality assessment scales (Refer Fig. 4) (Table 3).

Fig. 4.

Quality assessment scale

Table 3.

Descriptive characteristics of the studies are included in the review

Author& Country	Study Aims and Objective	Data collection Period	Study participants (Children/Adolescents)	Sample size (Gender, n / %)	Age (years) Range/Mean/ Median	Study design	Quality assessment (NOS quality and JB Quality Score)
Zhou, S.J et al. [24] (2020) China	Explore the prevalence of psychological consequences, including anxiety and depression, among junior and senior-grade adolescents in China who were affected by the COVID-19 outbreak.	March 8 to 15, 2020	Adolescent	8079 (M = 3753 and F = 4326)	12 to 18	Cross-sectional study & online survey, Self-reported & Nonprobability, convenience sampling	4
Huang et al. et al, [29] (2022) China	Investigate the impact of mental health in Chinese adolescents by COVID-19  and assess depression and anxiety.	March 2022	adolescents	3184( M = 1502 and F = 1682)	6 to 19	Observational study &Multicenter cross-sectional comparative survey	3
Papadopoulos, [39] (2023) Greece	The current research sought to explore the effect of the COVID 19 on mental health and associated factors among primary caregivers of children in Greece.	NR	children and adolescents	156 (parents)	4 to 12	Cross-sectional study & convenience sample	4
Winnie W. Y. Tso et al. [22] (2020) Hong Kong	The research sought to identify elements that might improve psychological well-being in families during the COVID-19 outbreak.	March 2020.	children and adolescents	29,202 families, 12,163 children 2–5 yrs. & 17,029 aged 6–12 years (M-14,970 and F-14,140)	2 to 12	cross-sectional Online survey, convenience sample	4
Oosterhoff, B et al., [40] (2020) United States	Examine the justifications that adolescents provide for socially distancing from their contemporaries, as well as the connections between these reasons and the adolescents’ reported levels of social distance, their mental health, and their social health.	March 29th and 30th, 2020	Adolescent	683 (F-75.3%, M- 22.7% and Non-binary-4.9%)	13 and 18 years	Cross-sectional, online survey, recruited using social media.	3
Yang et al. [25] (2021) et al., China	The study’s goal is to analyze the attitude, knowledge, and anxiety of Chinese colleges towards COVID-19 based on a questionnaires’ approach.	February 2020 and August 2020	Adolescent	566 (male = 236 and female = 330)	18>	A structured questionnaire method and survey	3
Bai et al. [30] (2023), China	The study sought to determine the state of mental health in children by determining the factors of maltreatment and parental conflicts that arise due to lockdown.	April 21 to April 28 2020	Children & Adolescent	1286 (M-544 and F-645)	0 to 10	cross-sectional, online survey, convenience sampling	4
Magklara, K et al., (2022) [65] Greece	To explore the effects of the pandemic and the lockdown on the psychological health of children and adolescents in Greece.	March and May 2020	children and adolescents	1269 (M-676 and F-593)	< 13 to ≥ 13	Cross-sectional, online survey, convenience sampling	4
Zhang, Z et al. [26] (2020) China	Conduct a web-based questionnaire during the COVID-19 pandemic to learn more about the mental health of high school students in Shandong Province.	May 1–7, 2020	children and adolescents	1,018	< 16	Cross-sectional, online survey, convenience sampling	3
Zhang, C et al. [31] (2020) China	The investigation intends to conduct an online survey to assess high school students’ psychological condition during the COVID-19 pandemic.	April 7–24, 2020	Adolescent	1025 (M-528 and F-497)	15.56 (1.89)	Cross-sectional online survey, convenience sampling	3
Majeed, S. and Ashraf, M, [23] (2020) Pakistan	This study’s purpose was to address the missing literature and discuss the psychological consequences of social distance for adolescents during the COVID-19 pandemic lockdown, especially in metropolitan places like Lahore, Pakistan.	April 20 to May 10, 2020	Adolescent	63 (M-31 and F-32)	13 to 17	Cross-sectional online survey, convenience sampling	3
Orgilés, M et al., [28] (2020) Italy and Spain	The study aims to investigate the psychological responses of children and adolescents in the two countries most affected by COVID-19, Italy and Spain.	NR	children and adolescents	1,143 (parents)	3 to 18	NR	3
Segado et al., [38] (2023) Spain	This study intends to investigate the attitude, habit, and anxiety of young people in Spain mainly in their free time, and leisure time.	2021–2022	Adolescent	2020 = 13,498, 2021 = 26, 800, 2020 = 15,126 (Not specified)	16<	Quantitative design of study analysis using secondary data sources.	3
Çoban&Kaptan,, [33] (2022) Turkey	The research was designed to investigate behavioral alterations, physical, and psychological changes in children due to COVID-19 outbreak and the parental perception.	NR	children	975 (Male 417 and Female 424)	3–18	A qualitative survey model study	4
Pathan et al. [27] (2023) Bangladesh	The objective of this study is to investigate the influence of COVID-19 on the psychological wellness of people in Bangladesh during confinement.	NR	Adolescent	512 (Not specified)	18<	A cross-sectional study.	4
MireiaOrgilés et al., [42] (2022) Italian, Spanish, and Portuguese	The study aims to investigate the prevalence of anxiety and depressive symptoms in study subjects and identify the variables associated with it in three (Italian, Spanish, and Portuguese) countries.	NR	children	624 (M- 8.94, F-294)	3 to 18	A longitudinal study	3
Vallejo Slocker, L et al., [36] (2020) Spain	The purpose of this research is to characterize the psychological impact of the COVID-19 outbreak on children and adolescents and compare the findings to previous statistical data and some other investigations to detect variances.	May, 2020	children and adolescents	459 (M-=236 and F-223)	8 to 18	Survey online survey, convenience sampling	3
Vicario-Molina et al. [34] (2023) Spain	The purpose of the research was to investigate the mental health of youth during the first COVID 19 lockdown in Spain.	March, April, May 2020	Adolescent	1205 (M-301 and F-904)	18 to 24	online survey &  Non-probability virtual snowball sampling	4
Amorós-Reche et al., [32] (2022) Spain	This study aims to investigate the emotional problems of  children and adolescents during COVID-19 in SPAIN and to examine the impact of family variables on their emotional problems.	March and July 2020	Children and Adolescent	71 to 2,292	0 and 18	descriptive, correlational and cross-sectional design online survey, Quantitative, qualitative, or multimodal designs	4
Bosch et al. [35] (2022) Spain	The purpose of this research was to explore the psychological impact of COVID-19 lock down on children and adolescents and analyzing the behavioral problems in them before and after lockdown.	May 26 to June 15, 2020	children and adolescents	552 (M-217 and F-335)	6–17	cross-sectional online survey, convenience sampling	3
Lai et al. [37] (2024) China	The goal of this research was to investigate the relationship between COVID 19 in mental health of Chinese adolescents and coping strategy.	NR	Adolescent	4579 (M-2064 and F-2515)	12–18	cross-sectional online survey, convenience sampling	4

Psychometric measures

The following scales and questionnaires were used in the 21 studies: 1) PHQ 9 Patient Health Questionnaire and GAD 7 Generalized Anxiety Disorder Scale in studies by [24–27]. DASS-21 Depression, Anxiety, and Stress Scale-21 items in a study by [28–30] and GHQ-12 General Health Questionnaire in a study by Papadopoulos [28]. SDQ Strength and Difficulties Questionnaires studies in [22, 30, 31] CTSPC Conflict Tactics Scales: Parent-child Version, PSS Parental Stress Scale, PedsQLPediatric Quality of Life Inventory 4.0 Generic Core Scales were used in the study [22]. CBCL Child Behavior Checklist and multivariable regression model was used in the study by [32]. BRS Brief Resilience Scale, CSQ, IES-22 Impact of Event Scale and PTSD Post Traumatic Stress Disorder Scale in studies by [29]. Online questionnaires were used in the studies by [33, 34]. KIDSCREEN-10 index in a study by [35]. SELSA-S Social and Emotional Loneliness Scale for Adults-Short version, CHS-5 Coping Humour Scale, MHI-5 Mental Health Inventory-5 [36]. CMAS-R Children’s Manifest Anxiety Scale in study by [30] MSSMHS Mental Health Inventory of Middle-School Students and CSSMSS Coping Style Scale for Middle School Students in the study by [37] Shown as Fig. 5.

Fig. 5.

Psychometric measures used in studies

Risk factors for psychological outcome

Numerous factors linked to an elevated risk of psychological disorders have been identified in the literature, including female gender, senior high school attendance, urban residence, family or friend COVID-19 infection, separation anxiety, Internet addiction, parental income disparity, emotional stress, family dysfunction, and personal risk factors. Children with educational needs, acute/chronic illnesses, and parents with mental illness, single-parent homes, and low-income families face increased risk. Insufficient sleep, delayed bedtime, and extended electronic devices use increased parenting stress in preschoolers. Social distancing impact, feelings of burdensomeness, and belongingness are also studied. Social factors because of COVID-19 such as lockdown measures, home confinement, financial strain, lack of social interaction. Routine changes are also studied. Protective factors include anxiety coping strategies and pre-epidemic internet use, while negative childhood traumas and COVID-19 exposure elevate post-traumatic stress symptoms. Spanish children exhibit more psychopathological signs than their Italian counterparts. Figure 6 depicts the identified factors in reviewed studies (Table 4).

Fig. 6.

Number of Factors drawn by the author

Table 4.

Summary of study findings

Author & Country	Assessment Tools	Statistical software used/Any other method for analyzing the outcome	Psychological outcomes	Factors Predict the Psychological Outcomes	Study findings
Zhou, S.J et al. [24] (2020) China	PHQ-9 and GAD-7	SPSS version 24.0, Chi-square & logistic regression	Depression and anxiety	The results of the studies indicated a significant prevalence of psychological health issues among adolescents, with a negative correlation observed between these issues and COVID-19 awareness levels. Females and senior high school were at higher risk for depressive and anxiety symptoms.	Depressive, anxiety symptoms & combination of depressive and anxiety was 43.7%, 37.4%, and 31.3%, respectively,
Huang et al., [29] (2022) China	PHQ-9 and GAD-7	GraphPad Prism 8 and R 4.1.2.	Anxiety and depression	The results of this study demonstrate that adolescents mostly agreed with the increased time spent with parents, interference in academic performances and less travel. Also they disagreed with not going to school, feeling that homework has increased and not socializing with people. In conclusion, after the COVID-19 outbreak, the levels of anxiety and depression in chineses adolescents in different grades have improved.	Adolescents depressed before COVID-19 was 34.6%, 26.3% were prone to depression after COVID-19, adolescents with anxiety before COVID-19 was 24.4%, 23.5% were prone to anxiety after COVID-19,
Papadopoulos [39] (2023) Greece	DASS-21, GHQ-12	IBM SPSS 25.0, Statistical software: Chi-square test, Student’s t-test, Pearson’s correlation coefficient. Bivariate analyses: One-way ANOVA, t-tests for differences among variables.	psychological distress, anxiety, and depression	The results of this study suggest that children with disabilities have elevated mental health problems compared to children without disabilities. This study has highlighted the importance of families raising children with developmental disabilities to prioritize their mental health.	children with DDs scored significantly higher on the GHQ-12 (t = 8.51, p < 0.001), representing a high level of psychological distress. THEN in DASS-21 the levels of depression (t = 6.35, p < 0.001), anxiety (t = 5.71, p < 0.001), and stress (t = 7.84, p < 0.001) were higher than control.
Winnie W. Y. Tso et al. [22] (2020), China	CTSPC, SDQ, PedsQL, and PSS	R Statistical Software version 3.6.3., Pearson, Linear regression (adjusted models)	Stress, inadequate sleep, and psychosocial well-being	Children with specific educational requirements and acute or chronic illnesses, parents with mental illness, single-parent homes, & low-income families were at a greater risk of developing psychological disorders. Delayed bedtime and insufficient sleep or workout length, as well as prolonged use of electrical gadgets, were linked to significantly greater parenting stress and much more psychological difficulties among preschoolers.	SDQ total difficulties score was significantly associated with the increase in the time spent on electronic devices for learning in the 2–5-year age group (β = 0.05, p < 0·001) but not in the 6–12-year age group.
Oosterhoff, B et al., [40] (2020), United States	NC, Single item survey to capture social distancing, PROMIS anxiety scale, PROMIS depression scale, Interpersonal Needs Questionnaire,	R statistical program, multiple regression,	anxiety, depression, burdensomeness, and belongingness	Adolescents’ mental health suffered because of social distancing, and they chose to remain at home. Adolescents who opted to remain at home exhibited fewer negative psychological effects than those who went out and maintained social distance.	There is no evidence of a degree of social distancing engagement and indicators of mental or social health (p > 0.05). Because a friend told them reported greater depressive symptoms (p < 0.05)
Yang et al., [25] (2021) China	A four-domain questionnaire including attitude, COVID-19 anxiety, and demographic location. State-trait anxiety inventory.	Mean, standard deviation, t-test, SPSS version 19.0, chi-square.	Anxiety, depression, on Chinese and overseas Chinese students.	The anxiety symptoms of students who are studying in China and Chinese nationalize studying in the USA are determined. The results stated that the students studying in Chinese colleges are less prone to anxiety when compared to oversea students. The research highlighted the need for psychological support to students overseas.	Chinese students mean and SD are 39.46 ± 8.16, 39.25 ± 7.72 and overseas 59.48 ± 8.63, and 54.10 ± 7.20. The values are greater overseas compared to domestic students.
Bai et al. [30] (2023) China	CBCL, multi variable regression model.	SPSS 22.0, mean and standard deviation	Maltreatment, and parental conflict affect children’s mental health.	Parental conflict affects the child’s and young adults mental health directly or indirectly and is moderated by  COVID-19. A Parent’s method of harshness is considered as a primary risk factor on the child’s mental health. Strategic parental support can reduce the mental health of a child.	The maltreatment of children (β = 0.49 and p < 0.01), in comparison to maltreatment parental conflict problem on health is less (β = 0.18 and p < 0.001), exposure of COVID-19 and maltreatment (β = 0.06 and p < 0.05), academic pressure and conflict of parent (β = 0.06 and p < 0.05).
Magklara, K et al. [65] (2022) Greece	CRISIS	SPSS v.22, Logistic regression, and chi-square test	Psychological health - Stress and sleep	During the COVID-19 pandemic, vulnerable people are more likely to suffer from negative psychological effects. Parental unemployment, family conflict, and previous physical health issues were identified as risk factors.	Unemployment of parents (β = 1.87, p = 0.023) had a negative impact on a child’s psychological health.
Zhang, Z et al. [26] (2020) China	PHQ-9,  GAD-7	SPSS v.21, correlation analyses	Anxiety and Depression	About half of students in high school had depressed symptoms, and roughly one-third had anxious symptoms.	Depressive symptoms, anxiety symptoms, and a combination of depressive and anxiety symptoms were 52.4, 31.4, and 26.8%, respectively,
Zhang, C et al. [31] (2020) China	BRS, CSQ, IES-22, DASS-21 and PTSD	SPSS v.16, correlation, and regression	depressive, anxiety, stress, and trauma-related distress	In secondary school students, more than 20% showed signs of emotional distress. The results revealed that psychological and mental health may be enhanced via resilience and healthy coping. On the other hand, poor coping styles pose a threat to one’s psychological well-being.	Resilience and positive coping mechanisms were protective factors against the development of symptoms related to depression, anxiety, and stress in junior high and high school students (p < 0.05). Conversely, negative coping mechanisms were found to be a risk factor for these symptoms.
Majeed, S. and Ashraf, M, [23] (2020) Pakistan	DSM-5	SPSS v.21	depression, anxiety, anger, repetitive thoughts, and worries	According to the findings of the research, adolescents reported suffering symptoms of depression, anxiety, and irritation when they were socially isolated and in lockdown situations.	Girls showed more somatic symptoms (p.001), while boys reported anger problems (p = 0.001)
Orgilés, M et al., [28] (2020) Italy and Spain	Parent perception on how quarantine emotionally affects children 31 symptoms	SPSS v.26, Logistic regression, GENLIN model, Spearman correlation, multivariate analyses	boredom, irritability, restlessness, nervousness, feelings of loneliness, uneasiness, and worries	According to their parental figures, Spanish children exhibit greater psychopathological signs than Italian children, presumably because Italian children have much more opportunities to be physically healthy. Children’s psychological indicators in both nations appear to be significantly connected to their parent’s health, especially their level of distress.	According to the data, the most common signs experienced by individuals included trouble with focus, which was reported by 76.6% of the participants, followed by feelings of boredom (52%), irritability (39%), restlessness (38.8%), nervousness (38%), loneliness (31.3%), uneasiness (30.4%), and worries (30.1%).
Segadoetal. [38] (2023) Spain	Secondary quantitative, and longitudinal data source.	CIS study, INE	Social, leisure, financial, emotional state of young people.	The major outcome of the study describes that the young people in Spain are healthy. However, the impact of finance has greatly affected the minds of young adults. This affects the study, causing sleep paralysis and socialization among young people in Spain.	Between the age of 18–24, 5 out of 10 people are affected by posttraumatic stress during COVID-19. Family relationship decreased around 5.7% and 4.8% peak COVID-19.
Çoban&Kaptan, [33] (2022) Turkey	The psychological impact of the COVID-19 pandemic on children and adolescents questionnaire, Impact scale of the COVID-19 and home confinement on children and adolescent survey.	IBM SPSS 25, wilcoxon signed-rank test, skewness coefficient ANOVA test	Psychological and behavioral outcomes	Children are more affected in the pandemic and show anxiety related symptoms. About 75%  of the NEWS and school subjects were learned through phone or laptop. This increased the screen time in social media as well. In result the physical activity is decreased which is also seen post pandemic. The risk factor of  higher screen time leads to decreased sleep, and anxiety.	Difference were observed in sleep, behavior, mood, and cognitive thinking (P = < 0.001), behavioral change (F (2838) = 6.19 p < 0.05), appetite (F (2838) = 10.67, P < 0.001), cognitive alteration (F (2838) = 37.74, p < 0.001),  indecisive (F(2838) = 30.88, p < 0.001), and concentration difficulty (F(2838) = 30.88, p < 0.001)
Pathan et al. [27] (2023) Bangladesh	Online questionnaire	apriori association algorithm	Depression and anxiety	Implementation of lockdown has affected the mental state and behavior of people. The primary risk factor is finance which causes lack of sleep and weight loss. Children face anxiety, depression due to family pressure.	Unstable finance led to behavioral changes 38.6%, Family interruption 34.2%, depression 67.23%,  loss of concentration 66.25, boredom 73.15 and disturbance in mind 54.15%,
MireiaOrgilés et al., [42] (2021) Italian, Spanish, and Portuguese	Online questionnaire	SPSS 26.0, Kolmogorov–Smirnov test, chi-square test, Kruskal–Wallis test, Cramer’s V and Epsilon-squared.	Psychological symptoms	In European countries like Spain, Italy, and Portuguese home confinement has led to emotional and behavioral changes among children and adolescents. Results show that lockdown had a great impact on psychological conditions among children in all the three countries.	Anxiety in Spain children (OR = 0.35; CI [0.17, 0.69], p = 0.003), Portuguese (OR = 0.52; 95% CI [1.20, 2.34], p = 0.002), Italian (OR = 1.68; CI [0.28, 0.98], p = 0.004), Mood symptoms  Spanish (OR = 0.58; 95% CI [0.41, 0.83], p = 0.003) and Portuguese ones (OR = 0.64; 95% CI [0.46, 0.89], p = 0.008) Italian (OR = 0.74; 95% CI [0.59, 0.92], p = 0.007), behavioral disturbances, Portuguese (OR = 1.27; 95% CI [1.03, 1.57], p = 0.02) Spanish children (OR = 1.38; 95% CI [1.11, 1.72], p = 0.003) and Italian  (OR = 1.45; 95% CI [1.21, 1.73], p ≤ 0.001) and cognitive disturbances  (OR = 1.17; 95% CI [1.08, 1.27], p ≤ 0.001) common for all three countries,
Vallejo Slocker, [36] (2020) L et al., Spain	SDQ and KIDSCREEN-10 index	An independent sample t-test, one-way ANOVA, and the chi-square test were used	psychological well-being	The mental health of the children and adolescents in this research was much worse than that of the 2017 Spanish comparison, that is, before the COVID-19 outbreak. The standard of living remained constant. No variations in care methods were discovered.	There was no statistical difference in the Kidscreen-10 before and after COVID-19 p > 0.05.
Vicario-Molina et al., [34] (2023) Spain	SELSA-S, CHS-5, MHI-5	SPSS v. 26.0, Smart-PLS v. 3.	Loneliness, anxiety, depression, coping humor, mental health	The results of this study have explained the pandemic and confinement derived consequences caused by COVID-19. This condition seems to be severe for youths causing mental health vulnerability.	The mental health has a positive asymmetric distribution of 0.13, mean 17.85 and standard deviation 5.40 (H = 13.68; p > 0.05).
Amorós-Reche et al., [32] (2022) Spain	CMAS-R, SDQ, DASS-21	MMAT.	Emotional problems, anxiety, depression, emotion-regulation problems, mood problems and stress	The study has identified that the emotional problems were more common in older children and adolescents. Also the factors such as family variables like parental stress, low parental resilience, and unstructured parenting style, pandemic-related variables such as fear of contagion and changes in routines, emotion-oriented coping style, and other psychological problems were all considered as factors that predicted the psychological outcomes.	An increase in emotional problems was found in children and Adolescents  P < 0.05.
Bosch et al. [35] (2022) Spain	SDQ	SPSS 25.0.	Worsening in emotional symptoms, conduct problems, hyperactivity/inattention, and peer problems during the lockdown	The child’s situation before the quarantine, social routines and health concerns has to be compared with the quality and quantity of social networks during lockdown. The presence of economic and learning problems during the lockdown also reflects the mental health problems.	The proportion of children within the clinical range of SQD scale were mainly according to the parents perception before COVID-19 were 12.9% of emotional symptoms, 11.7% of conduct problems, 14.2 had inattention/hyper-activity, 13.4% had peer problem, 17.2% prosocial behavior, and 8.87% total problems. During home quarantine 19.3% had emotional symptoms, 18.9% had conduct problems, 22.6  had inattention/hyper-activity, 21.0% had peer problems, 14.6% prosocial behavior, and 18.6% total problems.
Lai et al. [37] (2024) China	CSSMSS, MSSMHS	SPSS 25.0, Data normality examination, ANOVA and Pearson correlation test	Depression, anxiety, and academic pressure	The study findings indicated that generally Chinese adolescents suffered from depression, anxiety, and academic pressure. They tend to use factors such as avoiding, patience and seeking help to cope with their mental health. Here the insights have provided instructions for educators on how the mental health of the adolescents can be coped by them with the pressure and stress.	During COVID-19 43.4% reported good mental health, 48.8% had mild mental health problems, 7.2% had moderate mental problems and 0.6% had severe mental health problems.

Abbreviations: SCAR - Spence Child Anxiety Scale, CDI - Child Depression Inventory, and CS - Coping Style Scale

Narrative summary

This systematic review examined 21 studies across 9 countries, involving 87,486 adolescents and children. The representation in China was highest. The majority of studies were cross-sectional, evaluating psychiatric disorders amid the COVID-19 pandemic. Psychiatric effects differed by age and country, with some of the studies documenting deteriorated mental health, whereas some reported enhanced well-being in specific groups.

Risk factors were female gender, urban living, socioeconomic inequality, family breakdown, internet addiction, and disrupted routines. Safe factors were good coping behaviors and pre-pandemic internet activity. Lockdown and social isolation led to heightened stress, while childhood trauma and exposure to COVID-19 were associated with post-traumatic stress symptomatology. Results underscore the imperative for specific mental health interventions.

Overall findings

The psychological effect of the COVID-19 pandemic has been immense on children and adolescents, and some of the significant factors that have affected their mental health have been highlighted through research.

Psychological distress and anxiety

Several studies have documented higher psychological distress in teenagers during the pandemic. Zhou et al. [24] established a high negative correlation between awareness of COVID-19 and teenage mental ill-health, prompting more government attention to the welfare of teenagers. Furthermore, Zhang et al. [26] found that more than one-fifth of Chinese high school and junior students were suffering from depression and anxiety during the pandemic and hence resilience building and efficient coping are of vital importance. Yang et al. [25] found that Chinese international students in the USA expressed higher levels of anxiety compared to Chinese students, and hence there is a necessity for psychological counselling for international students.

Effect of lockdowns and social lockdowns

The societal restrictions of the pandemic had variable effects on teens. Huang et al. [27] reported that while some teens appreciated aspects of the lockdown, including increased family time, they also struggled with limitations such as reduced social contact and school closure. Oosterhoff et al. [38] suggested that awareness of teens’ motivations for social distancing could improve engagement and mental health outcomes. Orgilés et al. [40] reported cross-country differences in mental health with more psychopathological symptoms among Spanish children than among Italian children, which could have been due to different physical activity opportunities during lockdowns.

Vulnerable populations and risk factors

Certain child and adolescent populations were more affected by the pandemic. Papadopoulos [28] found that children with disabilities experienced greater mental health challenges than their non-disabled counterparts, with the need for targeted interventions being emphasized. Tso et al. [22] identified vulnerable child groups and stressed the importance of family cohesion, physical activity, adequate sleep, and appropriate electronic device use in maintaining psychosocial well-being. Magklara et al. [39] emphasized that the vulnerable, particularly those encountering social unrest, had a greater predisposition to endure adverse psychological effects.

Family structure and economic stress

Parental conflict and financial difficulties were prime predictors that helped in deteriorating the mental well-being of children. Bai et al. [32] referenced that domestic conflict and negative parenting styles resulted in heightened depression and anxiety in children. Pathan et al. [33] also mentioned that economic deprivation under lockdown resulted in sleep disturbances and weight loss, exacerbating depression and anxiety among children. Segado et al. [41] emphasized that Spanish economic problems might have an impact on sleep and social life more than on the health of young adults. Amorós-Reche et al. [30] discovered that children’s feelings were an echo of parents’ stress, also adding to children’s psychological distress.

Educational and social implications

School closure and interruption in learning also had a huge effect on children’s mental health. Bosch et al. [31] reported lower psychological well-being, hyperactivity, and behavioral problems among children and teenagers during lockdown. Vallejo-Slocker et al. [35] concluded that Spanish children and teenagers experienced poorer psychological well-being compared to before the pandemic, although in other areas quality of life was unaltered. Lai et al. [37] also obtained strong correlation between mental health and social support among Chinese teens, while academic pressure yields avoidance behaviors with less help-seeking.

The COVID-19 pandemic has had a multi-dimensional effect on the mental well-being of children and adolescents. Social isolation, parental conflict, economic hardship, and school disruption were among the factors that led to heightened anxiety, depression, and psychological distress. These issues need to be addressed through specific interventions, such as increased mental health services for students, family-based approaches to stress reduction, and policies that foster social and emotional health in youth. By grasping these dominant themes, the stakeholders are able to frame better strategies for countering the long-term impacts of the pandemic on teen mental health.

Discussion

The COVID-19 pandemic, identified in December 2019, is now one of the most global public health crises [1]. Governments, to prevent the transmission of the disease, enforced physical distancing and lockdown policies, causing extensive social isolation, increased job losses, and socioeconomic uncertainty [43]. Such policies, essential for public health, had spillover effects on mental health, especially for children and young people. Internationally, the pandemic has been linked with enhanced stress, hopelessness, and psychological distress [44]. The present review examines the risk and protective factors linked to COVID-19 and how they affect the mental health of adolescents.

Research has noted increasing rates of depression, anxiety, and psychological distress in children and adolescents. Adolescents specifically were shown to be at greater risk than younger children, most likely because of the pivotal developmental stage of adolescence, during which emotional and social habits are established critical for psychological health [45]. The sudden changes resulting from the pandemic, including school closure and social distancing, brought huge pressures to teenagers, causing heightened symptoms of depression and stress [46]. This analysis is consistent with earlier research, including work by Paus et al. [47], indicating that student status was associated with increased depression and PTSD symptoms. Some research has indicated younger children and children in lower school years had lower depression and anxiety levels, possibly because they did not have as clear an understanding of the severity of the pandemic [48, 49]. The review identified several risk factors that lead to poor mental health outcomes, divided into individual, family, and community-based factors.

Personal factors

Age and stage of development: Adolescents were found to be at greater risk for depression and anxiety than younger children [45, 46].

Gender: Some studies indicated that girls were more likely to develop anxiety and depression than boys [48].

Pre-existing mental illness: Children with existing mental illness were more likely to have worsening symptoms during the pandemic [66].

Family factors

Financial instability: A reduction in family income, including wages, salaries, and government transfers, was a major risk factor for depression and anxiety [49].

Parental unemployment and stress: Loss of employment among parents during the pandemic rendered many incapables of providing for the fundamental needs of their children, leading to long-term mental health problems [24, 50, 51]. Parents who had lost their jobs were more likely to lose their optimism, which adversely affected parent-child relationships and heightened children’s risk of mental illness [52–54].

Infected family members: Anxiety and distress increased due to fear of infection with COVID-19 or having an infected family member [55, 56].

Community factors

Residence in high-infection or rural areas: Children residing in rural or high-infection regions experienced more mental health issues because they had less access to resources and healthcare [57, 58].

Social isolation: Limitations on mobility and fewer opportunities for physical activity and leisure activities elevated boredom, anxiety, and depression [59].

Protective factors

Despite adversity, several protective factors were found to mitigate the negative impacts of the pandemic on mental health.

Good relationships between parents and children: Having supportive families along with effective communication reduced stress and psychosocial problems [37, 63].

Regular exercise: Exercise had been associated with better mental health, although the lockdowns aimed to limit opportunities for exercise [60, 61].

Adequate sleep: Good sleep patterns alleviated children’s psychosocial difficulties and lowered parental stress [31].

Prosocial behavior: Adolescents who engaged in prosocial behaviors, such as adhering to social distancing for altruistic reasons, had better mental health results, particularly when combined with good governance and support from parents [38].

The pandemic also highlighted the role of media and technology in mental health. Excessive use of smartphones, internet addiction, and overexposure to COVID-19 news were linked with heightened depression, anxiety, and stress in children and adolescents. Parents were advised to restrict excessive viewing of news to minimize these risks. Notably, Gazmararian et al. [46] discovered that 51% of Georgia’s adolescents utilized social media to manage stress caused by the pandemic, which indicates that technology can be a coping mechanism if utilized properly.

Community-specific variables were a significant predictor of mental health outcomes during the pandemic. Children living in rural or high-infection areas were more likely to experience depression and anxiety because they had less access to resources and health care [58]. Urban children reported fewer instances of anxiety and depression, suggesting variations in access to resources and reactions to the pandemic.

The pandemic worsened some risk factors for mental illness among adolescents and children. Child maltreatment, domestic violence, and parental stress rose considerably during this time [35, 62, 63]. In rural China, 58.8% of adolescents had Adverse Childhood Experiences (ACEs), with 14.2% having four or more adversities, such as family abuse (17.7%), neglect (45.4%), and household dysfunction (30.1%). A Chinese meta-analysis of child maltreatment documented 27% physical, 20% mental, 9% sexual, and 26% neglect abuse. ACEs were significantly associated with Post-traumatic Stress Symptoms (PTSS) and anxiety globally, validating the “kindling” hypothesis that ACEs decrease the threshold for psychopathology [64].

Parental job loss became a serious risk factor, with economic distress the most acute consequence [39]. In Greece, where almost half of all children were living in material poverty as a result of the fiscal crisis, the mental health effects were especially serious [28]. Likewise, in Bangladesh, parental education, COVID-19 infection, and parental lifestyles were predictive of children’s mental health status [33].

Teenagers were particularly impacted by the pandemic due to the loss of routines, social contact, and school performance. School closures, decreased exercise, and the closing of sports centers were major risk predictors of depression and anxiety [44]. Sadness and anxiety increased as grade level went up, as high school students experienced intensified pressures [67]. These factors remain critical for effective intervention, particularly during emergencies such as the COVID-19 pandemic [68].

The chief strength of this systematic review lies in its broad scope, covering a wide range of studies and identifying risk and protective factors affecting the mental health of children and young people during the COVID-19 pandemic. However, there are several limitations. The lack of statistical meta-analysis due to heterogeneity in study design and mental health outcomes precludes quantitative inferences. Additionally, the exclusion of studies in non-English languages may have introduced language bias and overlooked important insights from non-English-speaking cultures. The inclusion was limited to 22 population-based datasets, which compromises the generalizability of the findings. Lastly, the focus on children above ten years and the initial stages of the pandemic may limit the external validity of the findings to other age groups or later stages of the crisis, emphasizing the need for more systemic and longitudinal research in the future.

Future studies should explore later pandemic waves’ impact on children’s mental health, as well as the effectiveness of interventions such as school-based mental health programs and community support initiatives.

Conclusion

This systematic review presents the negative psychological effect of the COVID-19 pandemic in children and adolescents as depression, anxiety, and stress. Parental stress, economic stress, extended social isolation, and school disruption were risk factors but a supportive family and availability of psychological resources as a protective factor. The findings put into the limelight the need for intervention with specially designed mental health programs and support systems to counter the psychological challenge of young generations in the age of global crises. Doctors, schools, and policy makers must work together to introduce mental health programs, early intervention, and access to psychological support services to facilitate prevention of long-term negative effects. This study contributes to the literature by providing a complete overview of previous research on child and adolescent mental health during the pandemic. Through an identification of significant psychological protective and risk factors, this review provides insight of relevance to future policy as well as research. Resolution of the said mental issues is also key in the promotion of resilience and well-being among children and adolescents in managing the long-term effects of the pandemic.

Abbreviations

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

JBI

Joanna Briggs Institute

CASP

Critical Appraisal Skills Programme

MMAT

Mixed Methods Appraisal tools

PHQ

Patient Health Questionnaire

GAD

Generalized Anxiety Disorder

DASS-21

Depression, Anxiety, and Stress Scale-21

GHQ

General Health Questionnaire

SDQ

Strength and Difficulties Questionnaires

CTSPC

Conflict Tactics Scales: Parent-child

PSS

Parental Stress Scale

CBCL

Child Behavior Checklist

BRS

Brief Resilience Scale

CSQ

Coping Strategies Questionnaire

IES

Impact of Event Scale

PTSD

Post Traumatic Stress Disorder

SELSA-S

Social and Emotional Loneliness Scale for Adults-Short

CHS

Coping Humour Scale

MHI-5

Mental Health Inventory-5

CMAS

Children’s Manifest Anxiety Scale

MSSMHS

Mental Health Inventory of Middle-School Students

CSSMSS

Coping Style Scale for Middle School Students

ACE

Adverse Childhood Experiences

PTSS

Post-traumatic Stress Symptoms

Author contributions

Thiha designed the review framework and developed a methodology for the review. Together with the review team and corresponding-author, Pa Pa performed the literature search, article screening, and relevant data extraction. Hla, prepared the initial draft of the manuscript and revise it for intellectual content. Louis, overviewed the entire review process and provide critical feedback and suggestions. Philippe, contributed in the final review of the article with editing and corrections. Francois, lead the collective review and approval of the final manuscript. All authors reviewed and approved the final manuscript.

Funding

No external funding contribution to this study.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The corresponding author diligently submitted an ethical dossier and review protocol to the institutional review boards of STIMU, Myanmar, and the University of Bedfordshire, UK, seeking their sanction. Both entities granted their approval to the protocol on the 13th of July 2022, under the auspices of the SSCHREC application number (STI011-6-2022-3-003).

Consent for publication

It is hereby declared that the work submitted for publication is entirely original, has not been published in any form elsewhere, and is not currently under consideration for publication by any other print or electronic media. All authors listed in the submission have agreed to this statement and are aware of the commitments made herein.

Competing interests

The authors declare no competing interests.