Dr. Loades and Prof. Reynolds Reply.

It is heartening to see that our rapid systematic review1 is stimulating others to highlight the needs of particular subsets of vulnerable children and adolescents. We found evidence that loneliness in children and adolescents is associated with increased depression and anxiety symptoms both cross-sectionally and longitudinally. We agree with Dr. Morrissette2 that children and adolescents with social phobia merit additional consideration in the 2019 novel coronavirus disease (COVID-19) pandemic. Speculatively, we suggest that many children and adolescents who did not have social phobia before the pandemic may begin to experience worries about social situations as schools reopen. Furthermore, we hypothesize that a range of mental health symptoms including social phobia are likely to become more obvious as many pupils return to school.

It is heartening to see that our rapid systematic review is stimulating others to highlight the needs of particular subsets of vulnerable children and adolescents. We found evidence that loneliness in children and adolescents is associated with increased depression and anxiety symptoms both cross-sectionally and longitudinally. We agree with Dr. Morrissette that children and adolescents with social phobia merit additional consideration in the 2019 novel coronavirus disease (COVID-19) pandemic. Speculatively, we suggest that many children and adolescents who did not have social phobia before the pandemic may begin to experience worries about social situations as schools reopen. Furthermore, we hypothesize that a range of mental health symptoms including social phobia are likely to become more obvious as many pupils return to school.

Social phobia, also known as social anxiety disorder, describes an extreme distressing and disabling fear of being judged by others. Those who struggle with social anxiety worry about situations in which they may be observed by other people, including having a conversation, doing a presentation, and eating or drinking in public. Social anxieties often emerge during adolescence as the peer group becomes an increasingly important source of identity and approval. During the COVID-19 pandemic, disease containment measures have meant that most children and adolescents have had minimal or no in-person social interaction with their friends and peers. This means that they will be out of practice, and all will need time to reconnect with others, who may have developed at different rates and in different ways during the break in contact. For some children and adolescents, including those who were socially anxious before the pandemic, their fears of negative evaluation and resultant anxiety may prevent them from being able to reengage socially without extra support.

Some children and adolescents may have been able to keep in touch with their friends via digital means such as social media and video conferencing. However, children and adolescents with social phobia may have avoided these methods of contact or struggled to use digital communication. For instance, frequent delays and disruptions in communication may be (mis-) attributed to others being unfriendly or uninterested, and seeing oneself on screen during a video call may increase negative, self-focused attention.

There are several reasons why mental health problems are likely to become evident as children and adolescents return to school. As Dr. Morrissette points out, the lack of exposure to feared situations has meant that anxious children and adolescents have not been facing their fears, which is likely to have further amplified and reinforced them. Core beliefs, such as “the world is dangerous,” may have been triggered or heightened by the threat of an invisible virus and associated public health messaging. Public health messages and coverage in the mainstream media may have increased attention to physical symptoms and thus anxiety about health and well-being in children and their parents. For children and adolescents for whom absence from school has been a positive experience, returning to school may be extremely challenging. Finally, some children and adolescents will find it very difficult to adapt to a new socially distant school environment, where many familiar and welcome routines have been changed. Given these multiple pathways to new mental health problems as well as the likely amplification of preexisting difficulties, it is highly likely that school staff will observe elevated rates of distress and behavioral challenge. Schools and mental health services therefore need to be prepared for this prospect.