Psychological Impact of COVID-19 in Children, Young Adults, and Caregivers
This country has been a beacon to the world when it comes to their protection, and our society has always taken pride in championing the welfare of the children. There are clear-cut rules and laws established to protect our children from harm, be it physical, sexual, mental, or another form of trauma. We go to great lengths to educate our teachers, as well as numerous other medical and mental health providers, and have implemented mandatory courses for recognizing and preventing child abuse. Therefore, this should come as no surprise when the issue of child welfare is addressed in the context of dangerous communicable diseases. All children are mandated to receive vaccinations after birth and before attending school. These vaccine mandates have been established not only for the individual but also for the safety and wellbeing of others in our society. There have been numerous instances when certain groups have defied these rules and, consequently, either the children have been refused entrance to school or schools have been shut down. Apart from a small segment of the society who has always challenged the wisdom of the vaccines, most parents have adhered to the vaccination guidelines without much thought or debate. Unfortunately, the politicization of COVID-19
guidelines, including those pertaining to vaccination, has led many to defy the kind of scientific approach one would expect when dealing with a deadly virus about which so much remains unknown.
guidelines, including those pertaining to vaccination, has led many to defy the kind of scientific approach one would expect when dealing with a deadly virus about which so much remains unknown.
In addition to worries about contracting the virus or spreading it, children have also had to deal with many of the same psychosocial stressors that have affected adults. This includes social isolation, a myriad of potential family difficulties often arising from the stress of parents or guardians, the indefinite suspension of regularly scheduled activities (especially school), and grief due to the death of family or friends. This chapter is meant to help one navigate through the maze of medical and mental health consequences of COVID-19 among children and to help caregivers have a better understanding of how to make an informed decision for the welfare of their child.
COVID-19 Pathology in Children
Adolescents infected with SARS-CoV-2 typically experience less severe bouts of COVID-19 than adults with rare exceptions. The reason for this remains unclear at this time, but several hypotheses have been postulated to explain the phenomenon. Adults may be especially prone to the illness because of damage to endothelial cells over the course of their lives, increased angiotensin-converting enzyme 2 or transmembrane protease serine expression, higher levels of inflammation, or low levels of vital nutrients. Children may also have enhanced immunity because of more recent exposure to common coronaviruses that do not cause severe illness (HCoV-229E, HCoV-HKU1, HCoV-NL63, or HCoV-OC43), a healthier microbiota, or a stronger and as-of-yet-identified immune system response to specific viral insults.1 As of September 2021, researchers are still without definitive answers.
What is known is that COVID-19 presents as a relatively minor respiratory illness in most pediatric cases.2 Common symptoms in pediatric patients include fever, chills, cough, and fatigue.3 Approximately half of pediatric patients with COVID-19 experience no symptoms or mild symptoms, and only a paucity of the children develop symptoms severe enough to warrant intensive care unit (ICU) admission or hospitalization. Preston and colleagues, who examined the discharge data from 869 medical facilities between March 1 and October 31, 2020, found that only 3.65% (756) of the total pediatric patients (20,714) who tested positive for COVID-19 were hospitalized with severe forms of the illness, that a similar number 3.61% (747) were admitted to ICU, and that only 0.83% (172) became ill enough to warrant the use of mechanical ventilation. Similar to
adults, children with underlying chronic illnesses faced an increased risk of developing severe COVID-19.4
adults, children with underlying chronic illnesses faced an increased risk of developing severe COVID-19.4
Leeb and colleagues, meanwhile, found that even fewer children were hospitalized. Their study, which involved over 277,000 students across 47 US states who tested positive for COVID-19 between March 2020 and September 2020, found that only 1.2% (3240) of the students were hospitalized, that 0.1% (404) were admitted to the ICU, and that only 0.02% (51) died. Furthermore, their findings revealed that younger children (5-11 years of age) were less likely to experience severe symptoms than older children (12-17 years of age). Approximately, 1.0% (1021) of the former group (n = 101,503) were hospitalized, 0.14% (145) were admitted to the ICU, and 0.0197% (20) died. Within the older group (n = 175,782), 1.26% (2219) were hospitalized, 0.15% (259) were admitted to the ICU, and 0.0176% (31) died.5
Children appear to be at less of a risk for developing long COVID though data on the subject remain scant. Zimmermann and colleagues performed a review involving 14 international studies including 19,426 children and found that, in the majority of studies, symptoms did not typically persist for longer than 12 weeks in those infected with SARS-CoV-2. Despite this seemingly positive conclusion, the authors noted multiple limitations in their study and strongly suggested more studies into the potential effects of long COVID on children to accurately determine the level of risk to children and the implementation of the most prudent policies.6
While there is a reduced risk of long COVID among individuals under the age of 18 years, children and very young adults are at an increased risk of developing multisystem inflammatory syndrome in children (MIS-C) (also known as pediatric inflammatory multisystem syndrome), a condition where multiple organs become inflamed following infection. The affected organs can include the kidneys, heart, lungs, spleen, eyes, gastrointestinal tract, skin, and even the brain.7 Symptoms include fever, vomiting, diarrhea, nausea, abdominal pain, neck pain, rash, bloodshot eyes, and drowsiness.8 Patients typically present with GI symptoms but can go on to develop myocarditis, cardiac dysfunction, and coronary artery dilation. While it is rare (occurring in 2.1 per 100,000 persons younger than 21 years in the United States), an estimated 60% of individuals who develop MIS-C are admitted to ICUs and most recover with intensive care support.9 The estimated mortality is 2% to 4%.10 As of September 14, 2021, a total of 4661 cases have been reported in the United States and 41 (0.9%) have proven fatal.11
Age does appear to affect prognosis. Children between 0 and 4 years of age typically have fewer complications and fewer admissions to
intensive care, while patients in the age group of 18 to 20 years with recent infection of COVID-19 have been more likely to experience myocarditis, acute respiratory distress syndrome, or pneumonia.9 Median age for MIS-C is 9 years and 60% of reported patients have been males.11 Like COVID-19, MIS-C has disproportionately impacted Black and Hispanic children—30% and 32% of cases, respectively.11, 12 Social determinants in health, particularly poverty, housing and employment dynamics within their families, and insurance status, have placed both Hispanic and Black individuals at greater risk of COVID-19 infection and greater risk of severe complications, including MIS-C.9
intensive care, while patients in the age group of 18 to 20 years with recent infection of COVID-19 have been more likely to experience myocarditis, acute respiratory distress syndrome, or pneumonia.9 Median age for MIS-C is 9 years and 60% of reported patients have been males.11 Like COVID-19, MIS-C has disproportionately impacted Black and Hispanic children—30% and 32% of cases, respectively.11, 12 Social determinants in health, particularly poverty, housing and employment dynamics within their families, and insurance status, have placed both Hispanic and Black individuals at greater risk of COVID-19 infection and greater risk of severe complications, including MIS-C.9
SARS-CoV-2 Transmission in Children
While there appears to be no question that healthy children without preexisting conditions are at less of a risk of developing severe COVID-19 symptoms than adults (especially seniors) or children from struggling communities, the risk of infection even in resource flush communities remains quite high, especially given the increased transmissibility of the Delta variant. In Marin County, California, an unvaccinated teacher read aloud to a classroom of 24 students 2 days after developing symptoms in May 2021. The teacher chose to read without wearing a mask, despite school requirements to mask while indoors. Consequently, 12 of the 24 students in the classroom—all of whom were too young to be vaccinated—received a positive test result for COVID-19. Eight of the 10 students in the two rows closest to the teacher’s desk tested positive (attack rate = 80%), while 4 in 14 in the three back rows tested positive (attack rate = 28%). Fourteen additional infections could be traced back to the class, bringing the total to 27 (26 individuals in addition to the teacher). Of the 27 individuals, 3 were fully vaccinated and 22 (81%) reported symptoms.13
While children are at risk of infection, the role they play in community and household transmission remains poorly defined. Zhu and colleagues conducted a meta-analysis that examined 213 household SARS-CoV-2 transmission clusters and found that only 8 (3.8%) included a pediatric case, and that secondary attack rates in households with a confirmed pediatric case were significantly lower than secondary attack rates in households with confirmed adult cases.14 Of course, there were numerous limitations with this study; chief among them was the fact that it was not clear what role, if any, asymptomatic pediatric cases played in secondary attack rates within households.
Far more surprising is the fact that an Ontario study involving more than 6000 households found that younger children (aged 13 years and
under) are actually more likely to spread SARS-CoV-2 within a household than older children (between the ages of 14 and 17 years), even if older children were more likely to be primary household case.15 Moreover, children aged 0 to 3 years were more likely than the study’s other three age groups (4-8, 9-13, and 14-17) to transmit SARS-CoV-2 infection.15 While this seems counterintuitive at first, it could be explained by several factors. Some have hypothesized that younger children carry a larger viral load than older children or adults. Others have noted that younger children are most likely to be asymptomatic than any age group and because younger children are incapable of self-isolating even if symptomatic. Furthermore, as anyone who has had a teenager or can remember being one can tell you older children tend to demand more of their own personal space than younger children.
under) are actually more likely to spread SARS-CoV-2 within a household than older children (between the ages of 14 and 17 years), even if older children were more likely to be primary household case.15 Moreover, children aged 0 to 3 years were more likely than the study’s other three age groups (4-8, 9-13, and 14-17) to transmit SARS-CoV-2 infection.15 While this seems counterintuitive at first, it could be explained by several factors. Some have hypothesized that younger children carry a larger viral load than older children or adults. Others have noted that younger children are most likely to be asymptomatic than any age group and because younger children are incapable of self-isolating even if symptomatic. Furthermore, as anyone who has had a teenager or can remember being one can tell you older children tend to demand more of their own personal space than younger children.
The Pandemic’s Impact on Children
While children infected with COVID-19 may have a favorable prognosis when compared to adults, the same cannot be said for their mental health. Throughout the pandemic, children have faced the same kinds of stresses that adults have been forced to confront, and they have also felt trapped, bored, anxious, or afraid. The data have shown that they have responded in much the same way as adults to these stressors. However, children have also faced unique difficulties that clinicians should appreciate if they are to act with empathy and fully understand the specific circumstances that children have endured throughout the COVID Era.
Anxiety, Depression, and Defiance
The COVID-19 Era is simply not sustainable for the mental health of anyone, children included. As noted throughout Chapter 5, Psychosocial and Economic Impact of COVID-19—A Nation Under Siege, humans are not blank slates, and their adaptability can only go so far until their physical and mental health begin to suffer. Children are no different and the elevated rates of symptoms associated with mental health difficulties support this position.
A meta-analysis from the University of Calgary examined 29 individual studies from around the world that included 80,879 children and found that depression and anxiety symptoms had doubled from prepandemic averages among similar cohorts—from 12.9% and 11.6% to 25.2% and 20.5%, respectively. This means approximately one out of every four children globally are experiencing depression symptoms while one in five report clinically elevated anxiety symptoms.16 A Norwegian study involving 2536
adolescents—1621 of whom were surveyed prior to the pandemic and 915 of whom were surveyed during the pandemic—showed a stronger connection between high pandemic anxiety and not only depression symptoms but also poor physical health. Of the 915 adolescents surveyed during the pandemic, 158 (17.3%) experienced high pandemic anxiety and were significantly more likely to have experienced depressive symptoms and poor physical health.17
adolescents—1621 of whom were surveyed prior to the pandemic and 915 of whom were surveyed during the pandemic—showed a stronger connection between high pandemic anxiety and not only depression symptoms but also poor physical health. Of the 915 adolescents surveyed during the pandemic, 158 (17.3%) experienced high pandemic anxiety and were significantly more likely to have experienced depressive symptoms and poor physical health.17
This should sound reminiscent of the positive feedback loops discussed in previous chapters. Though it may not provide proof of directionality, it does suggest that COVID-19, anxiety, and depressive symptoms, as well as poor physical health, may reinforce one another. Furthermore, these can be compounded by poverty, housing precarity, food insecurity, and other factors common among households of low socioeconomic status. What is important to remember, however, is that these studies suggest that COVID-19 anxiety may be relatively common among children but that it is far from universal. The majority of children will prove to be resilient in the face of COVID-19 stress, and parents and guardians can increase the likelihood that their children will process the experience in an appropriate way by fostering an environment of love and support.
Similar approaches should be taken with children who have developed oppositional defiant disorder. Evidence is starting to emerge that more children are becoming more defiant and aggressive during the pandemic, particularly among younger children. A study involving 5823 children from three age groups (1-6 years, 7-10 years, and 11-19 years) across Germany, Austria, Liechtenstein, and Switzerland revealed that the youngest age group had the most notable increase in defiant behaviors (43% of the group), the middle group showed moderate increases in emotional and behavioral problems, while the oldest group reported higher rates of anxiety than the middle group (but lower than the youngest) and complained of “being overtired, underactive, and nervous.”18
Yet another Canadian study that surveyed 587 children between 5 and 18 years of age with attention deficit hyperactive disorder also found moderately higher levels of anxiety and depression (14.1% and 17.4%, respectively) among the participants but that 38.6% of participants displayed behaviors indicative of oppositional defiant disorder.19 Given oppositional defiant disorder is estimated to have a prevalence rate between 1% and 11%, and that DSM-V estimates that the average prevalence to be 3.3%, this seems like a worrisome observation that warrants more study.20
There are numerous potential reasons for these kinds of phenomena. While it is certainly a possibility that the child’s homelife may have deteriorated, as they may live with a caregiver or relative who is negligent, struggling with substance abuse, or abusive, not all pediatric mental health problems can be traced back to mistreatment. Like many adults, some
children may feel socially isolated because their ability to see people from outside of their household has been severely disrupted. Others may not be able to feel comfortable because of the lack of stability in their life or the fact that they have a new awareness of their own mortality, possibly brought on by the death of someone close to them. Still others may simply feel overburdened by the multiple stresses of the pandemic.
children may feel socially isolated because their ability to see people from outside of their household has been severely disrupted. Others may not be able to feel comfortable because of the lack of stability in their life or the fact that they have a new awareness of their own mortality, possibly brought on by the death of someone close to them. Still others may simply feel overburdened by the multiple stresses of the pandemic.
Many older children and teenagers will likely also feel they have missed major life milestones and coming of age moments due to pandemic restrictions. They may also be frustrated by the fact that they cannot physically be with their peers for friendship and support or that the pandemic has also severely reduced opportunities for intimacy. Platonic and romantic relationships are integral parts of separation-individualization from the family unit, and the creation of social bonds within peer groups often supplant the family unit as the individual’s primary source of social support. As the pandemic has arrested this process, it has likely led to feelings of angst or potentially depression, as well as significant friction between children attempting to assert their independence and parents attempting to maintain their authority at a time when they could expect neither consistency nor predictability from the world outside their homes. Meanwhile, those who stand on the precipice of adulthood but have been unable to leave the proverbial nest due to COVID-19 restrictions may experience an even greater sense of indignation and resentment. Those who obsess over these perceived injustices will likely find themselves searching for a specific culprit to blame for their predicament and may be especially vulnerable to demagogues and social media campaigns designed to exploit this need to assign blame.21
It is difficult to speculate how long these types of negative emotions will persist and even the most educated guess about how long rates of anxiety and depression will remain elevated among children and late adolescents cannot account for unforeseen variables. In addition, there is a lack of available data as to how epidemics or pandemics have historically impacted children’s growth and development or how widespread masking and social isolation will affect different age groups. For example, some have speculated that widespread masking may interfere with the development of speech and nonverbal language among young children, but there are not enough data to support this claim or to completely refute it.22
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