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COVID-19Children & Young People's Mental Health Restoration & Recovery PlanningSummary of Relevant Literature & Emerging EvidenceDr Gavin LockhartConsultant Clinical Psychologist: Clinical Lead CYP Mental Health NHS England South East Clinical Delivery Network/Mental Health CellHealth Education England, Kent, Surrey & SussexVictoria SoppResearch AssistantUniversity of Sussex/Sussex Partnership Foundation TrustVersion 2.024th July 2020Overview This paper attempts to collate key findings from relevant pre-existing and emerging literature in relation to the current and predicted impact of the COVID-19 pandemic and associated safety measures on Children and Young People's (CYP) psychological wellbeing/mental health (MH). The paper seeks to identify themes across the available evidence with regards to specific presenting difficulties that we might anticipate, and groups of young people who may be most affected, considering the implications of these for both predictive modelling and restoration and recovery planning in CYP MH and emotional wellbeing services. This is intended to be used alongside the Public Health England (PHE) Evidence Pack and local data/intelligence. The review in this paper is not fully exhaustive, nor has it been possible to employ the robust methodology of a meta-analysis or systematic review. Limitations in the representativeness and generalizability of studies are acknowledged throughout however. The literature base is rapidly evolving and many others are undertaking similar reviews at present. The paper will therefore be updated as new findings or literature emerges. If you are aware of any other key reviews, reports, research, or data please send these to Gavin.Lockhart1@.A Note on Predictive ModellingThe current crisis is unprecedented and ongoing, and there is likely to be a longer term societal impact, so we cannot reliably make forecasts on the overall impact on CYP psychological wellbeing and mental health at this point. It should be noted that not all studies outlined in this paper would be considered robust enough to base predictive modelling on. However, the authors of this paper are part of a collaborative of clinical leads, researchers and health economists seeking to identify the most robust studies, and develop predictive modelling formula and tools based on these. For further information on this please contact Dr Gavin Lockhart on the email above.A contents page, including hyperlinks to each section of the paper, can be found on the next page. An overall synthesis and summary of findings can be found on pages 15-16, with suggested next steps on pages 17-19. Full references and web-links/DOIs are provided at the end of the paper. An annex document containing a table with more detailed description of studies is available on request. Contents (skip to relevant section by holding "Ctrl" key & clicking on page number)Revisiting Pre-COVID-19 CYP MH Prevalence Rates (page 4)Potential Impact of COVID-19 on Psychological/Mental Health of CYP* (pages 5-14)Research from prior pandemics (page 5)Research into the impact of social isolation/quarantine and loneliness (page 5)Research following natural or man-made disasters (pages 5-6)Research on bereavement (page 6)Research post-ICU (pages 6-7)Research on media exposure and health messaging (page 7)Research on school absence and distance learning (page 7)Emerging findings from ongoing COVID-19 CYP MH studies (pages 8-14)A note on interpreting emerging findings (page 8)Referral rates (pages 8-9)Altered MH support and access (page 9)Worsening of pre-existing MH symptoms (page 10)Common mental health problems - overall, anxiety, depression & a note on loneliness (pages 10-11)Other mental health difficulties - PTSD, eating disorders, psychosis (pages 11-12)COVID-19 related anxiety, somatic concerns or health anxiety (page 12)Behaviour difficulties (page 12) CYP with life-limiting conditions (pages 12-13)A note on family functioning, adverse experiences, work/finances & parental wellbeing (pages 13-14)Parent/carer requests for support (page 14)Synthesis & Summary (pages 15-16)Suggested Next Steps (pages 17-19)* CYP affected by potential COVID-19 generated psychological/mental health issues are likely to include both those already known to, and those new to, MH and emotional wellbeing servicesPre-COVID prevalence dataPre-COVID prevalence figures for the specific MH disorders described in the literature throughout this report are outlined below, to provide a baseline to compare against. Although referral rates for other conditions such as psychosis and eating disorders are discussed in the emerging findings section, prevalence figures for these are not given below as there are no specific studies directly evaluating the impact of COVID-related factors on these conditions. We are aware of a UK-based study into the impact of COVID on young people with SMI, although this is longitudinal and no findings are currently available. The most up to date prevalence figures for England (NHS Digital, 2018) suggest:12.8% (1 in 8) 5-19 year-olds have at least one MH disorder - this was 11.7% in the South East5% (1 in 20) 5-19 year-olds have two or more MH disordersEmotional disorders are most prevalent (8.1%) and have risen from previous figures7.2% experience an anxiety-based disorder; 2.1% a depressive disorder22.4% girls aged 17-19 have an emotional disorder4.6% of 5-19 year-olds have a behavioural or conduct disorderGroups with higher prevalence rates of MH disorders are listed below (% prevalence rates are shown in parenthesis). CYP may fall in more than one of these groups. Figures on the total number of CYP in each group within the population can be found on the NHS Digital, Children's Commissioner, or Department for Education websites:CYP with special educational needs (47.1%)CYP in the care system (45-46% any disorder; 12% emotional disorders – Ford et al. 2007; Meltzer et al, 2002) - note that these figures are significantly out of date but NHS Digital (2018) data did not look specifically at this group of CYPCYP with parents experiencing MH difficulties (38.9%)CYP in less healthy functioning families (38.2%)CYP with poor general health (35.7%)Studies have suggested prevalence rates of 19-24% for anxiety and 13-15% for depression in CYP with life-limiting conditions, although often these are based on small samples and a narrow range of life limiting conditions (Barker et al. 2019; LaGrant et al., 2020)Those who identify as lesbian, gay or bisexual (34.9%)Females (23.9%)Older CYP (5.5% in 2-4 year-olds; 16.9% in 17-19 year-olds)Those in the lowest income households (16.2%)Higher rates were found in CYP of White British (14.9%) or Mixed Race (12.1%) ethnicity, whilst lower rates were found in those of Black (5.6%) or Asian (5.2%) ethnicityA Specific Note on Post-Traumatic Stress Disorder (PTSD)The baseline prevalence rate for PTSD in the UK is approximately 3-4% (Fisher et al. 2015; Royal College of Psychiatry, 2013)Approximately 16% of CYP exposed to a traumatic event develop PTSD, rising to 25.2% for those experiencing an interpersonal trauma such as physical or sexual abuse/attack (Alisic et al. 2014)CYP with lower levels of social support, peri-trauma fear, social withdrawal, and poor family functioning post-trauma are at greater risk of developing PTSD (Trickey et al. 2012)Comorbidity of PTSD with other MH disorders is high - around 55% also experience depression, 48% self-harm or suicidal behaviour, 27% conduct disorders, and 26% substance misuse (Lewis et al. 2019)Potential Impact of COVID-19 on psychological/mental health in CYPResearch from Prior PandemicsThere is surprisingly little research regarding the impact of prior pandemics on CYP MH. Sprang and Silman (2013) studied 398 parents and CYP in the worst affected areas of the US during the Avian Flu Pandemic. This was a self-selecting sample and based on parental report only. It is unclear how long quarantine or social distancing lasted for those in the study.1/3 CYP in social isolation or quarantine required MH services during or after the pandemic - 6.2% of these were diagnosed with PTSD but the most common diagnoses were acute stress, adjustment disorder, or bereavement (all 16.7%)30% CYP in social isolation or quarantine scored above cut-off on PTSD measures - average scores were four times higher than those not in isolation/quarantineParent and CYP PTSD symptoms were significantly associated with one anotherResearch into the Impact of Social Isolation and LonelinessLoades and colleagues (2020) have undertaken a rapid review of 63 studies into social isolation, quarantine, and loneliness, covering 51,576 CYP. Conditions of social isolation/quarantine varied.At the time of isolation and lonelinessCYP were 5.8-40 times more likely to score over clinical cut-offs for depression and 1.63-5.49 times more likely to score over clinical cut-offs for anxiety - rates were higher for females and older CYP Isolation/loneliness was also associated with suicidal ideation, self-harm, and eating disorder-related risk behavioursLonger-termThere is a clear association between social isolation/loneliness and MH up to nine years later - strongest association with depressionLength of isolation was a predictor of later MH difficulties in one of the studiesCYP in enforced isolation/quarantine were up to 5 times more likely to require a MH serviceThere is some tentative evidence that sleep may moderate the link between social isolation and general anxiety, social anxiety and depression (Richardson et al. 2019), and that family connectedness reduces suicidal risk in socially isolated CYP (Hall-Lande et al. 2007). However, these studies were not in the context of a pandemic or enforced quarantine/social isolation and the way social isolation was measured was limited.Research into Natural or Man-Made DisastersWhilst not entirely generalizable to the current context, there may be some learning from studies into natural or man-made disasters.Risk & Protective FactorsRisk factors for poorer MH outcomes in CYP following a natural disaster include poor MH prior to the crisis, prior trauma, bereavement, injury to self/family, threat to life, separation from family, apprehension and emotional disturbance in relation to the event, and dose-response effect (Lazarus, Jimerson & Brock, 2002; Slone & Mann, 2016; Tang et al. 2014)There is some evidence that relationships with teachers and good social support serve a protective function against development of MH difficulties post-disaster (Hong & Efferth, 2016; Tang et al. 2014) - conversely, perceived teacher distress has been associated with higher levels of PTSD (Yeung et al. 2018) PTSD Following DisastersRates of PTSD may vary between around 35-55% following natural or man-made disasters (e.g. Goenjian et al. 2020; McDermott, Duffy & McGuiness, 2004)For adolescents exposed to the Spitak earthquake in Armenia, 14.3-28.3% of those who did not receive treatment at the time experienced PTSD 25 years on, depending on the level of destruction their home area was categorised as experiencing (Goenjian et al. 2020)In a 6-month follow-up study of 1696 school-aged children bereaved as a result of the 9/11 disaster bereavement was associated with PTSD and depression but not once grief was controlled for - authors suggest heightened grief reactions should be targeted through tailored interventions to reduce risk of subsequent depression or PTSD (Geronazzo-Alman et al. 2019)Depression Following DisastersEstimated rates of depression in CYP following a disaster are highly variable, ranging from 1.6 to 44.8% (Lai et al. 2014; Tang et al. 2014; Wang et al. 2013)A meta-analysis by Tang et al. (2014) suggested those CYP who are bereaved as a result of disasters are 0.81-6.29 times more likely to develop depression than those who are not bereaved from the disasterResearch into BereavementAt present we do not have figures on the number of CYP likely to have been affected by bereavement during the current pandemic. Social distancing measures are likely to have affected CYP experiencing bereavements of any kind, not solely those related to COVID-19 (see Winston's Wish website).A large-scale longitudinal study in the Netherlands found the majority of CYP experiencing a family bereavement (parent/sibling) showed acute grief reactions including sleep problems, anger, irritability, and behavior problems - however, 75-80% did not go on to develop MH problems (Stikkebroek et al. 2016)In the above study, there were 22% new cases of internalizing disorder post-bereavement compared to 5.5% in the non-bereaved groupA study comparing CYP experiencing the sudden death of a parent with non-bereaved CYP found high rates of PTSD and depression two-years post-bereavement even when pre-death factors were controlled for - no effect was found on anxiety (Pham, Porta & Beismesser, 2018)Interestingly, a small-scale study of CYP who had experienced parental death around three-months prior to the study found that CYP experiencing a sudden death showed lower levels of post-traumatic stress or maladaptive grief than those where the death was expected (Kaplow, Howell & Layne, 2014)A smaller scale study of 8-18 year olds who had experienced the death of a parent, sibling or other close family member on average three years before the study found around 3.4% met criteria for prolonged complicated grief/bereavement disorder, although this was a biased sample as CYP were recruited from services so already seeking help for their difficulties (Boelen et al. 2019)As noted above, bereavement was found to significantly increase the likelihood of experiencing depression following a disaster (Tang et al. 2014)Research Post-ICUThere are currently no figures on the number of young people who have been in hospital or ICU as a result of COVID-19, although these may be relatively low. In May it was reported that there had been 2486 confirmed cases in 0-18 year-olds in England, with 8 deaths across England and Wales (HM Government COVID-19 Dashboard, May 2020).A review by Nelson & Gold (2012) of 9 articles suggested rates of PTSD symptoms (not diagnosis) in CYP post-ICU was between 35-62% A small scale study suggested around 26% of CYP developed post-traumatic stress (Stowman, Kearney & Daphtary, 2015)Prevalence rates of PTSD itself may be around 5-28% in CYP post-ICU (Nelson & Gold, 2012)There is some preliminary association between CYP and parent PTSD symptoms (Nelson & Gold, 2012)Research on Media Exposure & Health MessagingResearch into the effects of post-incident media exposure on CYP MH show mixed resultsA longitudinal study of 3577 CYP (10-17 years) following an earthquake in China, who were unlikely to have experienced direct exposure to the earthquake, found prevalence rates of PTSD based on validated screening measures were 16.9% at baseline and 11.1% at 6-month follow up - CYP frequently exposed to distressing imagery in the first month were 1.48 times more likely to experience PTSD at six months, although baseline post-traumatic stress was not controlled for so causality is not certain (Yeung et al. 2018)A meta-analysis of 47 studies including over 40,000 adults and youth found a small but significant association between exposure to TV coverage and post-traumatic stress - however, no studies controlled for prior trauma, and most were cross-sectional so again cannot infer causality (Pfefferbaum, Nitiema & Newman, 2019)A study of 451 young adults following the Paris terror attack found social media consumption was significantly associated with anxiety, depression and somatic symptoms, although again causality cannot be inferred - those indirectly exposed to the event through social media did not meet PTSD criteria one-month after (Monfort & Afzali, 2017) We were unable to find any studies directly evaluating the impact of health messaging on CYP MH.Research on School Absence & Distance Learning Studies have shown a significant association between school absence and common MH disorders such as anxiety and depression, and substance misuse (e.g. Finning et al. 2020; Goldman-Mellier et al. 2016). However, these are often cross-sectional so it is not possible to state with confidence whether school absence is the cause of mental health difficulties, a consequence, or a combination of both. The latter is perhaps most likely. These studies are also in the context of CYP absence outside of the context of pandemic or enforced quarantine/social isolation for some sections of society so not directly translatable to the current context.There are a paucity of studies into the relationship between distance learning and CYP MH.Emerging findings from ongoing COVID-19 CYP MH studiesInterpreting Emerging FindingsAlthough it is acknowledged that studies into the impact of the current pandemic on CYP MH have had to develop at pace, the following limitations should nonetheless be taken into account when interpreting emerging findings: Studies below are taken from the UK, Europe, and Asia, although it is acknowledged that there will be cultural and geographical differences in the impact of COVID-19 and associated safety measures Most studies use self-selected samples so are often not representative in terms of the demographics of the general population, and are unlikely to represent or capture the experience of many vulnerable or minority groupsAlmost all studies employ self or parental report, and use of validated measures of MH is variable between studies. Where validated measures of MH are utilized symptoms are only reported over a short period of time, often at the peak of the infection and death rate. The emerging findings therefore cannot be taken as definitive evidence of longer-lasting or diagnosable MH difficulty at this stageVery few studies have baseline pre-COVID measures for the CYP in their sample, making it difficult to track direct impact of the pandemicWhere mean scores are reported these provide an average for the sample (or subgroup within the sample) but do not show the range of scores nor how many CYP fall at the more clinically significant extremes of the measures usedSome studies are starting to report change in scores on MH measures over time. However, these are often based on the mean scores for the sample and do not track changes in mental health for individual CYP. At times these studies are reporting "significant changes" in MH scores but these mean scores often still fall within the same range on measures at both time points (e.g. "mild") so change may not be clinically meaningful or significant Referral Rates Specialist CAMHSReferral rates to specialist CAMHS services have largely reduced during the current pandemic, likely representing "suppressed demand". A report from the Health & Social Care Select Committee (2020) cites reductions of 30-40% in referrals to CAMHS during the first few months of the pandemic, although figures from some individual services indicate a more substantial decrease:Sussex Partnership NHS Foundation Trust reported a 53% reduction in referrals to Hampshire CAMHS between March & April 2020In May, Lancashire and South Cumbria NHS Foundation Trust reported an 88% reduction in referrals to CAMHS since the start of lockdownServices across the South East are reporting a gradual increase in referrals although these have not yet reached pre-COVID levelsEating DisordersServices across the South East are reporting referrals of eating disorders have returned to, or significantly exceeded, pre-COVID levels. There is particular concern regarding complexity, acuity, levels of risk and the need for re-feeding in these referrals. In one all-age community eating disorder service urgent referrals have increased to around five times the levels seen in the same period of 2019 and routine referrals have increased by around 2/3rds. These referrals are often new to the service. Psychosis Information on referral rates to Early Intervention in Psychosis services is mixed. Whilst the Eye 2 Project (Greenwood, May 2020) identified a 40% increase in monthly referral rates to early intervention in psychosis services March to May 2020 compared to rates between June 2019 and February 2020, figures from teams across the South East are variable, ranging from a 186% increase to a 4.5% decreaseVoluntary & Community SectorAnecdotal reports from voluntary and community sector organisations (ARC-KSS, May 2020) are mixed. Some report reductions in referrals, whilst others report a significant increase in general referrals (e.g. a 30% uplift) and an increase in safeguarding referrals. This is mirrored in data from Kooth (April 2020) in relation to increased use of their online platform.There are significant concerns over continued funding streams for many VCS organisations at present, particularly those reliant on charity contributions.Altered MH Support & AccessMany services have rapidly mobilized around remote provision of care but anecdotal reports suggest take up has been variable and not all families/CYP have been able to access this medium of service delivery. There is emerging evidence of a general reduction in the support CYP with pre-existing MH difficulties and their families may have been able to access through the current pandemic. Large-scale surveys (N > 1000) of CYP with pre-existing MH difficulties have found 52%-68% report disruptions to their MH support (not exclusively from CAMHS), with 64% reporting that this has affected their MH (Healthwatch Suffolk, June 2020; Crosby et al., June 2020; YoungMinds, March 2020)In a survey of 2531 parents of CYP with disabilities or serious illness, 60% reported their CAMHS support had declined (Family Fund, May 2020)Studies have also suggested that other support for CYP and their families has reduced - initial findings from the UK-based Co-Space Study (Waite et al., May 2020; Waite & Creswell, April 2020) with 5000 parents of 4-13 year-olds note 80% of those whose child received educational, social care, or MH support reported this has stoppedService-based data from Hampshire CAMHS (July 2020) provides a helpful insight into potential variations in care:Numbers of initial assessments are broadly similar to pre-COVID levels but the number of CYP allocated for treatment is lower than averageThis is attributed to routine work being disrupted for business critical functions - there has been an increase in duty timeNumber of contacts remain the same but the duration of contact has reduced (i.e. check-ins) - it is unclear whether contacts are with the same volume of CYP across the full service caseloadDischarges have significantly reduced - anecdotal feedback suggests clinicians are reluctant to discharge CYP they are seeing remotelyGiven the reduction in discharges it is too early to establish if the number of sessions required to discharge has changedThis is consistent with a Royal College of Psychiatry survey (May 2020) of 1300 psychiatrists (all-age), where 45% reported a reduction in their routine caseload (although urgent caseloads had increased)Worsening of Pre-Existing MH DifficultiesIn a recently published editorial, Jefson et al. (July 2020) describe a review of the clinical notes of 4879 CYP open to MH services in Denmark. Notes for 94 CYP (2%) specifically mentioned additional MH difficulties directly related to COVID-19, most commonly anxiety (35%), followed by OCD (15%) and self-harm (5%). The authors note that this is likely to be a significant underestimate of the impact of COVID-19 on CYP with pre-existing MH difficulties. It is unclear whether the findings noted above led to prolonged or more intensive service need in those individuals.Emerging evidence from several surveys suggests the MH of CYP with pre-existing MH concerns may have worsened. It is unclear if this represents worsening of existing symptoms or emergence of new symptoms, nor whether this will be a sustained deterioration. 83% of CYP in the YoungMinds (March 2020) survey noted above reported their MH symptoms had worsened (32% "much worse")89% parents of CYP with disabilities or serious health concerns reported COVID-19 and social distancing measures had impacted negatively on their child's behavior and emotions - 82% reported negative impact on their child's MH (Family Fund, May 2020)In the Co-Space study noted above (Waite et al., May 2020; Waite & Creswell, April 2020), CYP behavior or wellbeing was the highest stressor for parents of CYP with pre-existing MH or neurodevelopmental difficulties and 50% parents of CYP with SEN reported CYP behavior as a frequent stressorNeurodiversity and breakdown of family relationships have been noted in a number of CYP suicides during the pandemic, although it should be noted that numbers are too small to infer significance or a causal themeCommon Mental Health DifficultiesA Note on LonelinessSeveral UK-based studies and surveys of CYP identify high level of reported loneliness, feelings of disconnection, and concerns about being unable to socialize, as high as 67% of the sample in some reports (Children's Parliament, May 2020; Etheridge & Spantig, June 2020; Girlguiding, May 2020; Healthwatch Suffolk, June 2020; Street Games, May 2020). This is of significance in light of the Loades et al. (2020) systematic review noted in the pre-existing literature above showing the immediate and long-term consequences of social isolation and loneliness. OverallA longitudinal study by the Institute for Fiscal Studies reported on changes in MH difficulties as a result of the pandemic (Banks & Xu, June 2020). Data was available for 16-18 year olds but represented two different samples before (N = 404) and during COVID (N = 348). Comparison of General Health Questionnaire-12 (GHQ-12) scores for the two samples suggested a slight worsening for 16-18 year-old males but higher increases for 16-18 year-old females in average GHQ scores (12.5 vs. 15.2), number of GHQ conditions (2.6 vs. 4.4) and the proportion of those scoring at least one condition "much more than usual" (18% vs. 41%). Measures were taken during the peak COVID-related death rates.Report 4 of the Co-Space study of 2890 4-13 year-olds outlines changes in MH as measured by the Strengths and Difficulties Questionnaire (SDQ) over a one month period in lockdown, although changes often still fell within the same clinical banding on the SDQ (Pearcey et al., June 2020). Average scores for both emotional and behavioural difficulties in the sample were on the threshold between the close to average and slightly raised category, whilst restlessness and inattention scores were in the close to average category. Emotional symptoms were slightly higher for females and those from low income households, and markedly higher for CYP with SEN. Pre-COVID baselines were not available and neither was data available on the number of CYP falling into the different clinical bandings at each time point.See also the section below on CYP with pre-existing health conditionsAnxietyIn an axillary study to the UK-based COVID-19 Psychological Research Consortium (C19PRC) research, of the 1001 13-18 year-olds in their sample, 47% females and 60% males had anxiety scores over clinical cut-off on validated MH measures (Levita, May 2020)Rates in European and Asian studies are somewhat lower, ranging between 10-30% (Chen et al. May 2020; Orgiles et al. April 2020; Xie et al. April 2020; Zhou et al. May 2020), although not all used standardized MH measuresIn a self-report study of 1036 6-15 year-olds in China risk of anxiety was higher for adolescents, females, CYP not doing regular physical exercise, or CYP who were alone on weekdays (Chen et al. May 2020)Report 3 of the Co-Space study found that 44.2% of the 611 parents surveyed expressed concerns about their child returning to school, whilst only 18.8% believed their child was concerned, although these responses may well be normative and not indicative of clinical anxiety (Pearcey et al., May 2020) DepressionIn the C19PRC study (Levita, May 2020), 20% of 13-18 year olds had depression scores over clinical cut-off on validated MH measures - CYP of black or mixed ethnicity scored significantly higher - particularly pertinent given pre-COVID prevalence figures for CYP of black ethnicity found significantly lower rates of MH disorderRates of reported sadness or depression are similar in European and Asian studies (Orgiles et al., April 2020; Xie et al., April 2020; Zhou et al., May 2020) Kooth (April 2020) report that self-reports of depression and sleep problems have shown the sharpest rise, with reports of depression rising by 170%, although it is not clear how depression was categorised, the baseline, how many CYP this represented or whether these were new or pre-existing difficultiesIn the study by Chen et al. (May 2020) noted above, depression was higher for adolescents, females, CYP whose parents had a lower level of education, CYP not doing regular physical exercise, and CYP who were alone on weekdays.Other Mental Health DifficultiesPTSDThe C19PRC study noted above (Levita, May 2020) utilized the CRIES-8, a validated screening tool for PTSD. Questions were worded to assess for COVID-19 related trauma, although this wording was in generic terms rather than specific to an indexed COVID-19 related traumatic incident. The CRIES-8 is not diagnostic in its own right.53% females and 44% males aged 13-18 scored over the clinical cut-off for COVID-related PTSD - this was highest in females and the children of keyworkers - of note, DfE data shows only 5% of school-aged children of keyworkers have attended school during the lockdown periodEating DisordersNo current research is reporting on eating disorders related to COVID-19, although changes in the nature and number of referrals are noted above. Kooth (April 2020) report a 49% increase in self-reports relating to eating difficulties (including ARFID) although again it is unclear how this was categorised, the baseline, how many CYP this represented or whether these were new or pre-existing difficulties.PsychosisThere is ongoing place-based longitudinal research into the effects of the pandemic on young people with pre-existing psychosis although no data is available from this study as yet. We are not aware of any research investigating the impact of the current pandemic on first-episode psychosis. Changes in referral rates to early intervention services are noted above. Kooth (April 2020) report a 13% increase in self-reports of psychotic symptoms although again it is unclear how psychotic symptoms were defined, the baseline, how many CYP this represented or whether these were new or pre-existing difficulties.COVID-19 Related Anxiety, Somatic Symptoms & Health AnxietyStudies in the UK, Europe, and Asia evidence COVID-19 related anxiety and somatic symptoms in CYP, although these have not been compared against pre-COVID baselines nor tracked over time. It is therefore not possible to say whether these are normative or not.8-10% CYP have moderate to high somatic symptoms (Levita, May 2020; Liu, Liu & Liu, May 2020) A UK based axillary study of 1001 13-18 year-olds by the COVID-19 Psychological Research Consortium (C19PRC - Levita, May 2020) found rates of somatic symptoms are highest in the children of keyworkers - of note, DfE data shows only 5% of school-aged children of keyworkers have attended school during the lockdown periodA survey of 23,779 CYP by the Children's Commissioner for Wales identified 37% were not worried about catching COVID-19, whilst 38% reported "consistent worry" about catching COVID-19 (Children’s Commissioner for Wales, June 2020)20-53% CYP are reported to experience worries about themselves, friends, or family catching COVID-19, or passing it on to others (Liu, Liu & Liu, May 2020; Orgiles et al., April 2020; Waite et al., May 2020; Waite & Creswell, April 2020; Healthwatch Suffolk, June 2020)In the Healthwatch Suffolk survey 15% of the 2572 CYP reported worries about catching COVID-19 on return to school Kooth (April 2020) report a 164% increase in self-reports of health anxiety although it is unclear how health anxiety was defined, the baseline, how many CYP this represented or whether these were new or pre-existing difficultiesEuropean and Asian studies identify dependence, clinginess, and fear of others leaving the house as amongst the highest reported symptoms (Jiao et al., June 2020; Orgiles et al. April 2020) Behavioural Difficulties, Irritability & AngerAs noted above, parents in the Co-Space study reported their child's behavior was a frequent stressor, and this was highest for parents of CYP with a SEN (50% vs. 2% - Waite et al, May 2020; Waite & Creswell, April 2020), mirroring the Family Fund (May 2020) surveyAlthough the Co-Space study has utilized the SDQ there are currently no reported figures for conduct disorders scores or the number of CYP falling in each of the clinical bandings for conduct disorders on the scaleIn a study investigating the immediate effects of quarantine with 1143 parents of 3-18 year olds in Spain and Italy, 85.7% parents report changes in their child's emotional state and behavior (Orgiles et al. April 2020)30-40% report irritability (mirrored in a small-scale study in Asia by Jiao et al., June 2020), whilst 20-30% report their child is angrier (Orgiles et al. April 2020)CYP with Life Limiting ConditionsIt has not been possible to find data on the number of CYP in the UK who have needed to shield. However, guidance suggests risks of COVID-19 for many with pre-existing health problems are low (see )In a study of 97 10-25 year-olds with diabetes in India, although 5.2% reported severe stress scores, perceived stress scale scores were not significantly different from a control group. However, those with worse glycemic control had higher PSS scores - those with higher PSS scores tracked pandemic updates less frequently (Agarwal et al. June 2020)A study in China compared 252 young people from 15 years of age up (average age of sample 23 years) with epilepsy to a control group, finding that both attending to COVID-19 updates and epilepsy independently predicted severe psychological distress, which included symptoms of anxiety and depression (Hao et al. April 2020)The SHARE study (Marino et al, July 2020; Darlington et al, June 2020; Together for Short Lives, June 2020) reported that CYP and their families were requesting COVID-19 information specific to their health condition A Note on Family Functioning, Adverse Experiences, Work/Finances, & Parental WellbeingTo contextualize some of the emerging evidence below, DfE data from March showed only 14% of school-aged children classed as "children in need" had been attending school during lockdown, and attendance at SEN schools had been 8%. In the Born in Bradford study, only 16% of CYP eligible to attend school were (Dickerson et al., June 2020)Family Functioning & Adverse ExperiencesAlthough there are widespread concerns that CYP will have been at heightened risk of adverse experiences during the pandemic and lockdown it is hard to accurately quantify this. Concerns relate to both newly vulnerable CYP and families and to an increased vulnerability for those with known safeguarding concerns.In a UCL study, Iob et al. (July 2020) note that reports of abuse have been amongst the highest in people living with CYPA Centre for Mental Health report by Allwood and Bell (June 2020) notes a 20% increase in phone calls to Childline and Kooth (April 2020) report child sexual abuse as amongst three issues showing the sharpest rise in self-reports and a 51% increase in self-reports of being the victim of violence in the home although it is unclear how many CYP either of these reports refer to, what the baseline was, or whether these were CYP already identified in the safeguarding system A sharp decrease in referrals to the police, children's social care, and for Child Protection Medical Assessments was noted in the initial months of lockdown, with concerns that many more children may have been living with abuse over a prolonged timescale without support or intervention (Association of Directors of Children's Services, July 2020; Royal College of Paediatrics and Child Health, May 2020)ADCS report a more recent acceleration in referrals, identifying a cohort of newly vulnerable CYP and families, alongside a rise in homelessness and harmful behaviour in young males We are currently not directly aware of any emerging evidence regarding the mental health of children in care, care leavers, or those in the criminal justice system during the pandemicA number of emerging studies and surveys have included questions about family functioning Surveys have found between 31% and 47% of CYP report a strain on family relationships during the pandemic and the samples in these surveys are unlikely to represent the most vulnerable CYP (Thomas et al., May 2020; Girlguiding, May 2020)Thomas et al. found reports of family functioning was linked with poor family experiences and a negative outlook of the futureThe You Cope study (Crosby et al, June 2020) of 1274 16-24 year-olds found reports of changes to living situations were higher (30%) in those with anxiety or depression than those without a MH difficulty (20%) Orgiles et al (April 2020) found that parental perception of how easy it is for the family to live together predicted some CYP emotional wellbeing symptoms, and parents perceiving the COVID-19 situation as more serious rated their CYP more anxious, sad and lonelyWork & FinancesAccurate calculations of unemployment or financial hardship as a result of the pandemic are difficult to ascertain, partly due to the complexities of zero hours contracts and furlough. HMRC figures indicate 649,000 less people are on a company payroll since the start of the pandemic, and Job Centre figures show an increase from 1.24 million to 2.6 million people receiving job seekers allowance. It is unclear how many of these are parents/carers.Work and finances are reported as the most frequent stressor by many parents in UK surveys (Family Fund, May 2020; Waite et al., May 2020; Waite & Creswell, April 2020) and the Family Fund (May 2020) survey of parents of CYP with disabilities or serious illness found 50% reported loss of income due to unemployment or having to give up work, with 77% reporting household costs have increased.Parental Mental HealthThe Born in Bradford study of 1146 parents found 40% of parents met the clinical cut off for depression and 40% met the cut-off for anxiety (Dickerson et al., June 2020). The sample was from a largely deprived area and had a high BAME representation. It was unclear how many had pre-existing mental health problemsParent/Carer Requests for Support Although not representative, a range of surveys have provided some insight into the type of support requested by some parents/carersIn the Co-Space study many parents reported that they would like support and advice around managing their child's emotions, behaviours and education via written or video material available online, or personalized online contact with a professional (Waite et al., May 2020; Waite & Creswell, April 2020)A supplementary report identified parents trusted information from schools (67%), GPs (59%) or NHS England (58%) the most (Shum et al. June 2020)When parents had accessed support this had most frequently been related to their child's emotions (77%), behaviour (47%) or educational demands (41%), with the internet (62%) or school (48%) being the main points of accessIt is worth noting that the YoungMinds (June 2020) survey of school/college staff found 78% felt additional pastoral support would be helpful on CYPs return to school, although 24% did not feel confident or equipped to provide this. 67% indicated they would appreciate a good practice guide to supporting MH. The authors concluded that staff training and a list of support available to students would be most usefulSynthesis & SummaryEvidence from previous studies into pandemics and social isolation or quarantine has indicated an increase in demand for CYP MH services. Figures showed a third of CYP required MH services, or CYP were five times more likely to require MH services, following a pandemic and/or social isolation or quarantine. We might therefore reasonably anticipate an increase in overall demand for CYP MH support. There is some evidence to suggest that difficulties peak within a year or two, although there are also studies that have shown a much longer-lasting impact on CYP MH several years later. Despite the above, service-level data shows a significant reduction in routine referrals to CAMHS since the start of lockdown but uplift in urgent referrals and work. We might assume the "suppressed routine demand" will emerge in time, in addition to any COVID-generated demand. Referrals to CAMHS are beginning to increase and it is reasonably anticipated that there may be a surge in both COVID-suppressed and COVID-generated demand from September, as some CYP are re-exposed to triggers for their MH and others who have developed MH difficulties over the lockdown period are identified and referred on. Service level data shows that referrals in different parts of the system are increasing or even surpassing pre-COVID levels at different rates. Eating disorders are a particular area of concern, with a surge in complex, high risk/acuity CYP, who are new to services. Data on whether referrals to VCS or online support have increased is mixed. However, many VCS services are reporting concern over financial stability.There is evidence to suggest that a number of CYP with pre-existing MH difficulties have seen formal support for them or their families reduce, stop, or been unable to take up digital/remote delivery offers. Both CYP and parent-report suggest that the MH of CYP with pre-existing MH difficulties may have worsened since the start of the pandemic. It is unclear at this stage whether any worsening of symptoms is temporary, nor whether it represents worsening of existing symptoms or emergence of additional/new difficulties and symptoms. However, this may impact on throughput of CYP already open to MH services/support. Service-level data suggests that discharges have reduced throughout the pandemic although it is unclear whether this is due to a clinical need for extended support or other factors (e.g. difficulties discharging when working remotely).There is compelling evidence that family functioning is crucial as both a risk and protective factor. Pre-COVID prevalence studies show 3-4 times higher rates of MH difficulties in CYP living in less healthy functioning households and with a parent experiencing their own MH problems. There is emerging evidence that incidents of family/parental stress (particularly work & financial), domestic violence, and child abuse during the lockdown period may have increased, along with reductions in family income. Evidence from previous studies has suggested that family functioning reduces risk of CYP developing MH difficulties following a disaster; PTSD following trauma or loss; and suicide risk during social isolation. Parents in UK surveys are requesting support and advice via online mediums and both utilise, and trust, schools as a main source of this advice and signposting. There is some evidence from pre-existing research that teachers also serve an important protective function against the development of MH problems in CYP following a disaster.There is evidence that social isolation can increase concurrent anxiety. Emerging evidence indicates that anxiety in CYP is elevated at present (e.g. COVID-related, somatic, health & separation anxiety) and may be particularly high in children of keyworkers and males. However, there is less clear evidence this will be long-lasting from either current or previous studies. We might reasonably anticipate a spike in anxiety-related difficulties and need for support at the point of lockdown measures easing and CYP returning to school. In adults based in the UK there is some evidence that anxiety may have reduced over the duration of lockdown.Evidence from prior studies of social isolation, quarantine, bereavement and disasters all suggest a likely increase in depression that could be longer lasting. An ongoing current study of older adolescents has suggested those of black or mixed ethnicity report significantly higher depression symptoms.There is some evidence that sleep difficulties have increased for CYP at present, and there is some very tentative evidence that sleep may moderate the impact of social isolation on other MH difficulties although this might not be directly translatable to the current context. Emerging evidence suggests that a lack of physical exercise may also be associated with MH problems during COVID-19. The majority (approximately ?) of CYP experiencing a family bereavement show grief reactions but do not go on to develop MH difficulties. However, CYP who have experienced family bereavement are more likely to develop internalizing MH difficulties than peers (particularly depression, which may be up to four times more likely). They are also more likely to develop PTSD, particularly where grief reactions are heightened. Risk factors for complex or prolonged grief reactions are higher at present.CYP experiencing disasters, interpersonal trauma, and ICU are at increased risk of developing PTSD (potentially between 25-50% - or higher if including those with "clinically important symptoms"), which is often comorbid with other MH difficulties. Reports of current COVID-19 related PTSD symptoms are at similar levels, and children of keyworkers may be particularly vulnerable. Risk factors that increase the likelihood of CYP developing PTSD after traumatic incidents are likely to be higher at present. Ongoing studies across the UK, Europe and Asia suggest potential increases in irritability, anger and behavioural difficulties in children, with particularly high levels in CYP with SEN.There is some evidence that social isolation or quarantine increases risk of self-harm, suicidal ideation/attempts and eating disorder risk behavior.Given the current context, multiple risk factors outlined in this paper may be present for any given CYP.There is very little currently reported or known regarding vulnerable groups or those with severe mental illness, beyond those with SEN. 86% CYP classed as a "child in need" are not currently attending school. Pre-COVID prevalence data clearly identifies vulnerable groups and there is some evidence to suggest that these groups continue to be more at risk of experiencing MH difficulties as a result of the pandemic. It is also likely that greater numbers of CYP will fall into some of these groups now than previously (e.g. low income, less healthy functioning families). Suggested Next StepsSuggested next steps are outlined below and have been organized under headings from the THRIVE model. These are not intended to be definitive nor absolute and they should be considered alongside local data, intelligence, and other national evidence/guidance (e.g. PHE evidence pack).Advice & Getting HelpThe role of professionals in education, social care, school nursing, primary care and the VCS is likely to be crucial in restoration and recovery. They will have a critical role in identifying CYP who may be experiencing emerging MH difficulties, signposting or referring to appropriate support and advice, and providing some aspects of early intervention: Additional training and support may be required to help professionals in these settings: a) identify potential signs and symptoms of MH difficulties in CYP, particularly heightened grief reactions, depression, acute stress disorder, and PTSD; b) understand when watchful waiting or active monitoring is, and is not, recommended; c) know how and when to refer on and what the evidence-based/ NICE recommended treatment would be for specific difficulties. The PHE evidence pack is anticipated to include evidence-based guidance on screening.Effective mechanisms for monitoring the emotional wellbeing and MH of vulnerable groups will be crucial, particularly those not returning to school. This should include CYP with SEN or health concerns, whose parents have MH difficulties, in less healthy functioning families, in the care system or care leavers, and asylum seekers/refugees. Evidence would also suggest that monitoring of females, recently bereaved CYP, those from BAME groups, and children of keyworkers is important at present. All bereavements should be considered, not just those as a direct result of COVID. Activities that increase CYP's experience of "connectedness" may well serve a protective or moderating function on their MH, for both those returning to school and those not. Wider peer and community support may serve an important role with this.Support and advice to families is likely to improve MH outcomes of CYP. This may include:Signposting to existing online support and advice on managing CYP emotions and behavior, for example Anna Freud ()Schools in Mind (Anna Freud) advice for parents and carers ()MindEd for families ()Schools will be a crucial and trusted hub for this information, and support should be given to schools in providing this functionSignposting to personalized online advice (e.g. Family Lives) and existing local formal and informal parenting support Support and onward referral of parents experiencing their own mental health difficultiesFinancial support and adviceCommunity and peer supportSpecialist support to families of CYP with SENProvision of education and support to CYP/families around sleep hygiene and other lifestyle factors (exercise & diet) conducive to emotional wellbeing and MH is likely to be beneficial. Raising awareness that VCS and specialist CYPMH services remain "open for business" and facilitating referrals to appropriate evidence-based MH support where needed.Training in psychologically-informed practice with regards to managing and supporting CYP experiencing acute stress and acute grief reactions may be beneficial as this can moderate development of later MH difficulties. It is worth noting that the National Bereavement Alliance have produced a guide on commissioning of bereavement services, which includes reference to CYP.Wellbeing for staff across sectors should be a central consideration in any restoration and recovery planning.Getting Help, Getting More Help & Risk SupportPredictive modelling, and restoration and recovery planning in specialist MH services would benefit from including consideration of: a) suppressed demand; b) impact of worsening symptoms or altered care on throughput of existing CYP known to services; c) potential increased demand (as outlined in synthesis & summary section); d) impact of staff who are unwell, shielding, or with caring responsibilities on service capacity. In calculating (b) above, discharge rates, allocations for treatment, and average numbers of sessions to discharge may be a more reliable measure than monthly service contacts as these have remained relatively stable in some services but consist of "check-in" calls that may not be as impactful in moving towards discharge. Both predictive modelling and restoration and recovery planning will need to be a dynamic and iterative process as more evidence and service-level data becomes available and circumstances regarding the pandemic change. Where discharge rates have fallen, or the number of sessions to discharge have increased, it will be useful to monitor whether this is a sustained change and to understand the factors behind this to inform forward planning.Restoration and recovery planning is likely to require consideration of how to meet surges in demand that may emerge in different areas of the service at different times, and how to manage any increase in high risk, high acuity, complex referrals whilst also addressing a potential uplift in MH difficulties such as PTSD, depression and anxiety. It may be beneficial to review robustness of systems to monitor and review the MH and risk of CYP and families already open to services that have been uncontactable or unable to continue with care/support, and those with higher risk presentations or life circumstances. Some services have begun to develop decision-making tools regarding face-to-face or digital sessions to enable timely reinstatement of face-to-face sessions where clinically indicated.Given the potential increased risk of PTSD, it would be advisable for CYP to be screened for acute stress reactions and PTSD when presenting with other MH difficulties or sleep problems (see box below). It may also be beneficial to include questions regarding bereavement and signs of heightened grief reactions. Staff training may be required to support this.It will be important to routinely enquire as to the mental health and wellbeing of parents/carers, and to family functioning, which are likely to be of increased importance and impact at present.It will be important to identify the number of staff trained to an appropriate level of competency in the therapy modalities outlined in the box below, taking into account the likely volume of demand for these therapies across different clinical presentations. It is worth noting that the therapies below often have a good evidence-base for complex and high acuity presentations. All guidelines emphasize the importance of working with and supporting families, and sufficient numbers of staff trained in adaptations/augmentations for CYP with LD or neurodevelopmental disorders appears particularly important given emerging evidence around this group. This review of skill mix may highlight workforce training needs for working with specific difficulties or therapeutic modalities.As with other services, monitoring and support of staff wellbeing will be crucial to prevent burnout if facing a surge in demand.It would be useful for professionals providing psychological wellbeing support for keyworkers to be aware of the potential heightened vulnerability of the children of keyworkers to MH difficulties. It would be beneficial to include enquiry as to the emotional wellbeing or MH of children of keyworkers as a standard part of psychological support provided to these workers. Ideally any wellbeing hubs being developed will screen for and integrate both adult and CYP MH.center0The literature reviewed for this paper suggests that there may be a particular, but not exclusive, rise in depression and PTSD in CYP. NICE guidelines for depression in CYP () recommend:Watchful waiting for two weeks in CYP presenting with symptoms of mild depressionDigital CBT (see NICE website for suggested packages), group CBT, group non-directive supportive therapy or group interpersonal therapy (IPT) as a first-line intervention for mild depressionDelivered in schools, colleges or primary careDelivered by professionals trained in child and adolescent MH and with an appropriate level of competency in the specific therapeutic modalityAfter two months, or for moderate to severe depression, referral to CAMHS and first line treatment with individual CBT for 5-18 year-olds, or family based IPT, family therapy (see website for specific approaches), or psychodynamic psychotherapy for 5-11 year-olds. Where individual CBT is not preferred or deemed suitable for 12-18 year-olds, IPT-A, family therapy, brief psychosocial intervention or psychodynamic psychotherapy.Conceptual models underpinning behavioural activation (a subset of CBT for depression) and IPT may be particularly applicable and helpful in the current circumstances.NICE guidelines for PTSD () recommend:Active monitoring within one month of the traumatic eventTrauma-focused CBT as the first line treatment if CYP are showing clinically important symptoms of PTSD or acute stress disorder (i.e. do not have to meet full diagnostic criteria), which could be group TF-CBT for CYP 7-17 years following a large scale shared traumaIndividual Eye Movement De-sensitization Reprocessing (EMDR) as a second line treatment. Of note, University College London are currently compiling a competency framework for EMDR, including prerequisites to undertake EMDR training (due September 2020)NICE guidelines for anxiety-based disorders recommend group or individual CBT for CYP00The literature reviewed for this paper suggests that there may be a particular, but not exclusive, rise in depression and PTSD in CYP. NICE guidelines for depression in CYP () recommend:Watchful waiting for two weeks in CYP presenting with symptoms of mild depressionDigital CBT (see NICE website for suggested packages), group CBT, group non-directive supportive therapy or group interpersonal therapy (IPT) as a first-line intervention for mild depressionDelivered in schools, colleges or primary careDelivered by professionals trained in child and adolescent MH and with an appropriate level of competency in the specific therapeutic modalityAfter two months, or for moderate to severe depression, referral to CAMHS and first line treatment with individual CBT for 5-18 year-olds, or family based IPT, family therapy (see website for specific approaches), or psychodynamic psychotherapy for 5-11 year-olds. Where individual CBT is not preferred or deemed suitable for 12-18 year-olds, IPT-A, family therapy, brief psychosocial intervention or psychodynamic psychotherapy.Conceptual models underpinning behavioural activation (a subset of CBT for depression) and IPT may be particularly applicable and helpful in the current circumstances.NICE guidelines for PTSD () recommend:Active monitoring within one month of the traumatic eventTrauma-focused CBT as the first line treatment if CYP are showing clinically important symptoms of PTSD or acute stress disorder (i.e. do not have to meet full diagnostic criteria), which could be group TF-CBT for CYP 7-17 years following a large scale shared traumaIndividual Eye Movement De-sensitization Reprocessing (EMDR) as a second line treatment. Of note, University College London are currently compiling a competency framework for EMDR, including prerequisites to undertake EMDR training (due September 2020)NICE guidelines for anxiety-based disorders recommend group or individual CBT for CYPAcknowledgementsWe are extremely grateful to the following people for signposting, sharing of resources and perspectives, and bespoke analyses, without which this paper would not have been possible.Professor Robin Banerjee, University of SussexProfessor James Banks, University of ManchesterProfessor Samantha Cartwright-Hatton, University of SussexDr Timothy Clarke, NHS England East of England Clinical Delivery NetworkProfessor Cathy Creswell, University of OxfordProfessor Peter Fonagy, Kings College LondonProfessor David Fowler, University of SussexProfessor Kathryn Greenwood, University of SussexDr Katrina Lake, NHS England South East Clinical Delivery NetworkDr Liat Levita, University of SheffieldDr Maria Loades, University of BathBecca Randell, Kent, Surrey & Sussex Academic Health Science Network & Applied Research Consortium (KSS-AHSN/KSS-ARC)Dr Lydia Turner, University of SussexXiaowei Xu, Institute for Fiscal StudiesReferencesAgarwal, N., Harikar, M. 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