Abstract
Based on prior research on isolation and loneliness, children and adolescents are more likely to have high rates of depression, and, probably, anxiety, even after the enforced isolation resulting from the COVID‐19 pandemic ends, according to a study published in the Journal of the American Academy of Child and Adolescent Psychiatry. The longer enforced isolation continues, the greater the possibility of an increase in these disorders. The message to clinicians is that preventive and early intervention services should be offered where possible now, and that they should be prepared for these increases in the future.
Based on prior research on isolation and loneliness, children and adolescents are more likely to have high rates of depression, and, probably, anxiety, even after the enforced isolation resulting from the COVID‐19 pandemic ends, according to a study published in the Journal of the American Academy of Child and Adolescent Psychiatry. The longer enforced isolation continues, the greater the possibility of an increase in these disorders. The message to clinicians is that preventive and early intervention services should be offered where possible now, and that they should be prepared for these increases in the future.
It is known that for adults, the duration of quarantine, infection fears, boredom, frustration, lack of necessary supplies, lack of information, financial loss, and stigma increase the risk of negative psychological outcomes. For children and adolescents, social distancing and school closures further increase these problems at a time of life when they are already at a higher risk of developing mental illness.
Social isolation isn't necessarily the same as loneliness, the researchers point out in background material, but early reports indicate that more than a third of adolescents and almost half of 18–24‐year‐olds are lonely during lockdown. “Loneliness is the painful emotional experience of a discrepancy between actual and desired social contact,” the researchers note, adding that “there are well established links between loneliness and mental health.”
For the study, the researchers investigated what is known about the connection between loneliness and mental health problems in healthy children and adolescents, and what is known about whether quarantine, social isolation, and other disease‐containment efforts predict future mental health problems.
Study methods
The researchers looked for all articles published from Jan. 1, 1946, to March 29, 2020, capturing in their search “children” or “adolescents” AND “quarantine” or “social isolation” or “loneliness” AND “mental health,” with a focus on the most common mental health problems in this age group: depression and anxiety. All participants had experienced social isolation or loneliness and had a valid assessment of depression, anxiety, trauma, obsessive compulsive disorder, mental health, or mental well‐being.
The researchers synthesized the data within four categories:
the impact of loneliness on mental health in healthy populations, further divided into:
cross‐sectional and longitudinal evidence,
pandemic‐specific findings, and
intervention studies.
Results
Of the 83 articles the researchers found, 63 were on the impact of social isolation and loneliness on the mental health of previously healthy children and adolescents (n = 51,576; mean age: 15.3); 61 studies were observational, 18 were longitudinal, and 43 were cross‐sectional studies assessing self‐reported loneliness in healthy children and adolescents. Only one study was a retrospective investigation after a pandemic. Studies had a high risk of bias.
Social isolation and loneliness increased the risk of depression, and possibly anxiety. The symptoms occurred at the time loneliness was measured, and also from a quarter of a year to 9 years later. The duration of the loneliness was more strongly correlated with symptoms than the intensity of the loneliness.
Implications
The strongest association between loneliness related to isolation and mental illness was depression, a finding that was consistent across studies of children, adolescents, and young adults. Loneliness was more strongly associated with elevated depression symptoms in girls and with elevated social anxiety in boys.
The duration of loneliness is a predictor of future mental health problems, the researchers found, noting that this is particularly relevant during COVID‐19 with countries considering how long schools should be closed, and how to implement social distancing in schools.
The one study that examined mental health problems after enforced isolation and quarantine in previous pandemics found that children who had experienced isolation or quarantine were five times more likely to require mental health services and higher levels of post‐traumatic stress. “This suggests that the current social distancing measures enforced on children because of COVID‐19 could lead to an increase in mental health problems, as well as possible post‐traumatic stress,” the researchers write. These results, they add, are consistent with unpublished, preliminary data coming from China, where children ages 3 to 18 years are showing manifestations of anxiety, including “clinginess, distraction, fear of asking questions about the pandemic, and irritability.”
Young people need their peer group for identity and support, so they may be more likely to experience loneliness as an unintended consequence of disease‐containment measures. “This propensity to experience loneliness may make young people particularly vulnerable to loneliness in the COVID‐19 context, which, based on our findings, may further exacerbate the mental health impacts of the disease containment measures,” the researchers write.
Limitations
Not all of the studies involved enforced isolation, and none were in the context of a dangerous health threat, limiting the extent to which the researchers can extrapolate their findings in a predictive manner, they admit.
Measures such as the Loneliness and Aloneness Scale for Children and Adolescents that assess the duration and the intensity of loneliness, and that separate peer‐related loneliness from parent‐related loneliness, would be elucidating, the researchers write.
The review was conducted rapidly — in three weeks. The main limitation was the “lack of high quality studies investigating mental health problems after enforced isolation,” the researchers conclude. “All but one study investigated social isolation that was not enforced on young people and was not common across a peer group.”
Interventions
There are “practical and psychological strategies that may help promote child and adolescent mental health in the context of involuntary social isolation,” the researchers conclude. “Finding ways to give children and adolescents a sense of belonging within the family and to feel that they are part of a wider community should be a priority. Therefore, providing accurate information about the relative risks and benefits of social media and networking to parents who overestimate the dangers of allowing their children too much screen time may help young people access the benefits of virtual social contact.”
Digital technology that provides evidence‐based interventions to help young people to reappraise their thoughts and change their behavior within the confines of the home setting may be helpful as well. The researchers specifically mention:
the computerized cognitive behavioral therapy (CBT)–based self‐help program BRAVE‐TA and
computerized CBT such as MoodGym, SPARX, and “Think, Feel, Do.”
However, there's no evidence of effectiveness on outcomes of these technology. Computerized therapy and self‐help interventions such as bibliotherapy are not as effective as face‐to‐face therapies, the researchers note. “Importantly, reviews have tended to conclude that effects are better if there is some therapist input and if parents are involved especially for younger children,” they write.
Finally, the researchers say prevention and intervention approaches should be an “international priority.”
Loades ME, Chatburn E, Higson‐Sweeney N, et al. Rapid systematic review: The impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID‐19. J Am Acad Child Adolesc Psychiatry 2020 June 3; doi: 10.1016/j.jaac.2020.05.009. Epub ahead of print.