Mental health effects of school closures during COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic—and the social distancing measures that many countries have implemented—have caused disruptions to daily routines. As of April 8, 2020, schools have been suspended nationwide in 188 countries, according to UNESCO. Over 90% of enrolled learners (1·5 billion young people) worldwide are now out of education. The UNESCO Director-General Audrey Azoulay warned that “the global scale and speed of the current educational disruption is unparalleled”.

For children and adolescents with mental health needs, such closures mean a lack of access to the resources they usually have through schools. In a survey by the mental health charity YoungMinds, which included 2111 participants up to age 25 years with a mental illness history in the UK, 83% said the pandemic had made their conditions worse. 26% said they were unable to access mental health support; peer support groups and face-to-face services have been cancelled, and support by phone or online can be challenging for some young people.

School routines are important coping mechanisms for young people with mental health issues. When schools are closed, they lose an anchor in life and their symptoms could relapse. “Going to school had been a struggle for [some children with depression] prior to the pandemic, but at least they had school routines to stick with”, said Zanonia Chiu, a registered clinical psychologist working with children and adolescents in Hong Kong, where schools have been closed since Feb 3. “Now that schools are closed, some lock themselves up inside their rooms for weeks, refusing to take showers, eat, or leave their beds.” For some children with depression, there will be considerable difficulties adjusting back to normal life when school resumes.

Children with special education needs, such as those with autism spectrum disorder, are also at risk. They can become frustrated and short-tempered when their daily routines are disrupted, said psychiatrist Chi-Hung Au (University of Hong Kong, Hong Kong, China). He advised parents to create a schedule for their children to reduce anxiety induced by uncertainty. With speech therapy sessions and social skills groups suspended, he cautions that stopping therapy can stall progress, and children with special needs might miss their chance to develop essential skills. He points out that creative ways, such as online speech and social skills training, are needed to make up for the loss.

Many countries are postponing or cancelling university entrance exams. In Hong Kong, the authorities made a last-minute decision on March 21 to push back the Diploma of Secondary Education (DSE) exams, which were scheduled to start on March 27, by a month to April 24. According to a poll by the student counselling group Hok Yau Club in March, 2020, over 20% of the 757 candidates surveyed said their stress levels were at a maximum 10 out of 10, even before the postponement was announced. 17-year-old DSE candidate Yoyo Fung has been experiencing loss of appetite and sleep problems, and said she found the uncertainties of whether the exams could be delayed further stressful. “I have a huge wave of fear that I might contract the virus and thus cannot make it to the exams. Staying healthy has become another stressor”, she said.

Meanwhile, college and university students are stressed about dormitory evacuation and cancellation of anticipated events such as exchange studies and graduation ceremonies. Some lost their part-time jobs as local businesses closed. Students in their final years are anxious about the job market they are going to enter soon. “College students […] are more vulnerable than we think, especially with the current academic and financial burden”, said Chiu.

Social distancing measures can result in social isolation in an abusive home, with abuse likely exacerbated during this time of economic uncertainty and stress. Jianli County in Hubei province, China, has seen reports of domestic violence to the police more than triple during the lockdown in February, from 47 last year to 162 this year. Increased rates of child abuse, neglect, and exploitation have also been reported during previous public health emergencies, such as the Ebola outbreak in west Africa from 2014 to 2016.

However, not much is known about the long-term mental health effects of large-scale disease outbreaks on children and adolescents. While there is some research on the psychological impact of severe acute respiratory syndrome (SARS) on patients and health-care workers, not much is known about the effects on ordinary citizens. Evidence is especially scarce in children and adolescents. “This is an important gap for research”, Au said. COVID-19 is much more widespread than SARS and other epidemics on a global scale. As the pandemic continues, it is important to support children and adolescents facing bereavement and issues related to parental unemployment or loss of household income. There is also a need to monitor young people's mental health status over the long term, and to study how prolonged school closures, strict social distancing measures, and the pandemic itself affect the wellbeing of children and adolescents.

This online publication has been corrected. The corrected version first appeared at thelancet.com/child-adolescent on April 17, 2020