Child mental health in England before and during the COVID-19 lockdown

Although evidence has emerged of the effect of COVID-19 on adult mental health,¹ few studies around the world cover children.² Given the importance of probability sampling and similar prepandemic baseline measures,³ the follow-up of England's Mental Health of Children and Young People (MHCYP) survey provides a rare resource on what the pandemic has meant for children.⁴ We consider the clinical and policy implications of the initial study results.

The study showed that the increase in probable mental health problems reported in adults also affected 5–16 year olds in England, with the incidence rising from 10·8% in 2017 to 16·0% in July 2020 across age, gender, and ethnic groups. As in 2017, during the pandemic young women had the highest prevalence of probable mental health problems (27·2%), indicating they should remain a group of particular policy concern.⁴

More than a quarter of children (aged 5–16 years) and young people (aged 17–22) reported disrupted sleep and one in ten (5·4% of children and 13·8% of young people) often or always felt lonely. Both problems were more common in those with probable mental health problems, of whom 18·0% felt fearful of leaving the house because of COVID-19. Children with a parent in psychological distress were more likely to have a probable mental health problem. This is particularly concerning because parents, compared with working age adults without young children, have experienced larger than average increases in mental distress during the pandemic, which suggests that support for parents at this time matters for child mental health.¹

The results highlight how social protection systems must respond to the socioeconomic challenges facing families. Children with probable mental health problems were more than twice as likely to live in households newly falling behind with their bills, rent, or mortgage payments compared with those whose families were able to pay their bills. One in ten children and younger people reported that during the pandemic their family did not have enough to eat or had increased reliance on foodbanks compared with before the pandemic. These stark conditions matter more when schools close, highlighting the unequal effect of lockdown on learning. 12·0% of children had no reliable internet access at home, 19·1% no quiet space to work, and 26·9% did not have a desk at which they could study. Such socioeconomic information provides crucial context for schools planning pupils' home-based learning, and emphasises the need, where possible, to prioritise schools remaining open.

Our findings reveal disrupted access to health care: 44·6% of 17–22 year olds with probable mental health problems reported not seeking help because of the pandemic. Clinicians have raised similar concerns about timely access to services, and a sharp decrease in Child and Adolescent Mental Health Services referrals has been observed.⁵ Children and young people have been physically distanced from adults outside their family who might monitor their wellbeing and intervene: 21·6% of children and 29·0% of young people with probable mental health problems reported having no adult at school or work to whom they could turn during lockdown. Even after schools reopened, 16·1% children who could have attended stayed at home during the 2020 summer term. Academic practitioners anticipate that the cumulative effects of not intervening will result in widening health and education inequalities.⁶

Sound policy derives from strong evidence, with quality rather than quantity of data being crucial.³ The living systematic review² on the mental health effect of COVID-19 screened more than 33 000 abstracts, only 19 of which were identified as sufficiently rigorous to measure change in mental health (accurate as of Dec 21, 2020). None included children.

The few other studies in children with prepandemic data provide conflicting findings, which might relate to the age and circumstances of participants. A small study of 168 children (mean age 10·1 [SD 0·9] years during lockdown) in the east of England found an increase in depressive symptoms,⁷ while another of approximately 1000 13–14 year olds in south west England found little overall change in anxiety, depression, or wellbeing.⁸ In the study by Widnall and colleagues,⁸ mental health in those who were struggling in October 2019 improved on all three measures in Spring 2020. Although parents responding to the CoSPACE survey⁹ reported deteriorating mental health in children early in lockdown, young people reported no deterioration during this time, and parents of those with special educational needs and disabilities or pre-existing mental health conditions reported fewer emotional difficulties. In MHCYP,⁴ 54·2% of 11–16 year olds with probable mental health problems said lockdown had made their lives worse, but 27·2% said it had made their lives better.

The 2020 MHCYP survey benefits from a large, national, longitudinal probability sample spanning childhood, adolescence, and emerging adulthood, using detailed, validated, and consistent measures. These initial descriptive results compare cross-sections of 5–16 year olds before and during the pandemic, analysed at pace to meet the urgent need to understand the circumstances of children.

Our job is far from complete. Additional data collections and a range of longitudinal analyses are planned to improve understanding of the differential effects of the pandemic and inform the policy, commissioning, and practice response. Linkage of the survey responses to administrative records—such as the National Pupil Dataset—must proceed as fast as governance permits to enhance the ability to understand the effect of the pandemic on children's mental health and access to education and services over time. An enormous amount of work and engagement from children and young people underpinned the initial survey and this first follow up; therefore, there is a moral imperative to maximise the potential of the resulting data to improve the health and wellbeing of the next generation.¹⁰

© 2021 Paul Bradbury/Caia Image/Science Photo Library