Children's Experiences of Death Anxiety and Responses to the Covid-19 Pandemic

Abstract

The aim of this study was to explore children's experience and responses to the Covid-19 pandemic through their illustrations and short narrations. During October 2020 and January 2021 data was collected from thirteen children aged 9–10 years old in a primary school in the North-West of England. Children were asked to draw their thoughts and feelings about the pandemic and to write a short narration to accompany the drawing. Thematic analysis of data revealed that during the pandemic children at this age have an understanding of death, experience death anxiety and are able to use creative expression to facilitate meaning of the impact of lockdown on their lives such as feeling isolated, lonely, sad and bored. Creative expression also facilitated adaptive coping mechanisms derived from being able to spend more time with family. The data on primary school children is part of a larger study which involved surveys and interviews with children aged 12–16 years in secondary schools.

Keywords

children death anxiety emotional responses Covid-19 drawings loss bereavement

Introduction

In December 2019, a novel coronavirus was first detected in Wuhan, China. Within a few months, the virus had been named Covid-19 and, having dominated global headlines was recognized by the World Health Organisation as a dangerous pandemic that was capable of sweeping the globe (WHO, 2020). The resulting lockdown in the United Kingdom has been linked with mental health problems such as prolonged grief disorder, post-traumatic stress, loneliness, and death anxiety (Copper et al., 2021; Menzies & Menzies, 2020; Selman et al., 2020). Risks of the existing United Kingdom child health crisis, such as rising levels of anxiety and safeguarding concerns, have already been recognized (Green, 2020). However, there has not been any consideration of the impact on death anxiety or other emotional responses in children.

In addition to the impact of the pandemic on physical health, Covid-19 has also resulted in increased stress, anxiety and depression (Varma et al., 2021). Anxiety and stress may have been particularly high among children during the pandemic (Ford et al., 2021). Such stressors may have been further exacerbated by the continuous reporting of death rates in the media (Jones et al., 2021; Joubert & Wasserman, 2020; Sowden et al., 2020).

During the worst periods of Covid-19, family members were unable to be at the bedside or funeral or their loved ones, leading to sadness, guilt, and a sense of failure, especially if the dying person had to die alone (Kontoangelos et al., 2020; Varma et al., 2021). These experiences can generate feelings of depression because of the inability to shape, and participate in, funeral and after-death rituals (Selman et al., 2020). Potential implications for children in terms of mental health and social determinants have been highlighted further by the pandemic (Basu, 2021; Bonoti et al., 2021; Copper et al., 2021). Such feelings may negatively impact sleep, memory and concentration, and a difficulty to accept the death and can even lead to complicated grief (Varma et al., 2021). Moreover, research undertaken by Idoiaga et al. (2020) during the pandemic in Spain demonstrate that the lockdown produced conflicting emotions among children aged 3–12 years. While children reported feeling scared, lonely, bored, sad, angry and nervous they also felt happy to be able to spend more time with their family (2020: 1).

Prior to the pandemic an understanding of death under traumatic circumstances has been shown to negatively influence behavior and school achievement, as well as potentially increase mortality rates (Dyregrov & Dyregrov, 2015). Moreover, children's sense of the world following death is often compromised (Schuurman, 2015). Evidence suggests that children as young as seven years old understand something about the loss of someone through death (Webb, 2010). However, Dyregrov (2008) suggests children's understanding of death mirrors their cognitive development.

Webb (2010) applied Jean Piaget's’ theories concerning children’s cognitive development on children’s understanding of death and the different ways children grieve compared to adults. While children of all ages understand a sense of loss; younger children (those aged 12 and under)are less likely to understand the permanent and irreversible nature of death compared to adults. Indeed, experience of death can influence a young child's maturity of understanding compared to their peers and some may avoid the topic altogether (Schuurman, 2015; Webb, 2010). Children may also be more sensitive to pain than adults, which may create anxiety if the cause of death involves suffering (Webb, 2010).

Death anxiety has been characterized by various features: an awareness of one's own death and the resulting anxiety and depression caused by the realization that self-actualization is restricted (Farahi & Khalatbari, 2020); and ‘emotional distress and insecurity aroused by reminders of mortality, including one's own memories and thoughts of death’ 2020; Jones et al., 2021). Reactions of children to traumatic events are thought to be similar to those of adults: depression, regression, and physical and mental health problems, including post-traumatic stress disorder (PTSD) (Chachar et al., 2021; Panagiotaki et al., 2015). Misunderstanding the feelings of children and adults inadvertently communicating their stress to younger children may further complicate death anxiety in children (Webb, 2011).

Due to their age children are also considered disenfranchized grievers, according to Doka (1989, 2001) who argues that since adults consider children too young understand the finality of death they remain unsupported. While children may not be able to fully verbalize fully due to developmental stages, children do have emotional responses, thus, Art and Play therapy can be critical to expressing emotion and adaptive coping strategies (Webb, 2010).

Qualitative approaches have been widely used to study responses to death among children through art-based: techniques (Anderson et al., 2014; Bonoti et al., 2013; Byrne & Grace, 2009; Idoiaga et al., 2020). Using drawings and verbal descriptions to explore death Tamm and Granqvist (1995) identified three broad categories in children aged 9–18. Firstly, drawings were related to biological death (death of the body, violence and the moment of death. Secondly, children provided illustrations which depicted psychological aspects of death (emotions, feelings about death such as sorrow and emptiness). Thirdly, children identified metaphysical death (expressing religious/spiritual or metaphysical such as heaven and hell).

More recently, Green et al. (2021) conducted a study involving six art therapy sessions with thirteen CYP aged 5–18. The findings demonstrated an increase in positive affect and a significant decrease in negative effect. The implication of the study is such, that art therapy can assist children impacted by death as it permits an exploration of feelings thereby reducing stress which is a factor in influencing mood such as anger, anxiety and sadness (Green et al., 2021). Moreover, it demonstrates a way in which adults can recognize and actively support children's’ death and grief literacy.

Method

In our study, we explored the experiences of children aged 9 – 10 as well as young people aged 11–16 years of age (through surveys and interviews). Here, we report on the findings from data collected with children aged 9–10 years of age based in a primary school in the North-West of England.

The research aimed to provide new insights into the impact of Covid-19 on death anxiety and emotional stressors experienced by children in year 6 and any coping mechanisms adopted. To meet this aim, the project had two main objectives:

To explore the perspectives of children about death and dying because of the Covid-19 pandemic.

To explore children's lived experience and response to the Covid-19 pandemic.

Children aged 9 to 10 years attending one primary school were invited to participate through convenience sampling. The final sample consisted of 13 children, which is outlined in Table 1 by gender and by age.

Table 1.

Demographic Details of Children Included in the Study.

Participant Cohort and age	Male	Female	Totals
9 years old	3	4	7
10 years old	3	3	6
Totals	6	7	13

Ethics

The ethically sensitive nature of this study as well as the challenges of conducting research during a pandemic were recognized (and as such data collection took place by the school and sent to the researchers) as well as the potential for strong emotions to emerge. An opportunity to reflect on any strong emotions and responses during classroom-based activities was offered to participants on completion of drawings and short narratives with an additional check on their welfare (via text, email or phone) in the days following the activity with the Deputy Head Teacher who facilitated the activity. Approval by the authors University ethics committee was sought to collect anonymised classroom-based activity from primary schools to reflect the social distancing measures during the pandemic. Approval from the ethics committee was granted (HREC 3777). Students' caregivers were given participant information sheets which reassured their child's anonymity and the right for their child to withdraw at any time as well as the opportunity to clarify any questions or concerns and provided verbal as well as written informed consent. Written informed consent was sought from caregivers due to their ability to fully understand the nature of the research and data collection. A letter detailing supportive organizations was also provided to parents.

Classroom Based Activity

In line with previous research (Anderson et al., 2014; Bonoti et al., 2013) into the concept of death with children of this age, the children were asked to draw pictures as part of a classroom based activity relating to Covid-19 and which represented their thoughts, feelings, and experiences and to give a short narrative explanation of their picture. This approach has been used in other studies with children and young people to explore to explore different emotional experiences Kalantari et al., 2012; Bonoti et al., 2013). As this research was undertaken during the pandemic, it was not possible to conduct class observations or to conduct face-to-face interviews with children. The data gathered were the illustrations drawn by the students and which were accompanied by short written narrations.

Prior to the lesson, the deputy head teacher was briefed for drawing elaboration to provide each child with a blank sheet of paper, a pencil, eraser and colored pencils. The deputy head teacher was briefed to ask the students to draw about their feelings in relation to the pandemic including home schooling and to write a sentence or a short paragraph to describe the illustration as well as to ask: ” How did you feel during the activity we have just done.” It was emphasized by the deputy head teacher that there were no wrong or right answers. The drawings took place during a single lesson on personal and social development.

Data Analysis

Firstly, deductive analysis was carried out using Tamm and Granqvist (1995) interpretation of concepts of death in children which describes three subordinate categories and 10 subordinate categories. These include Biological death of drawing relating to:

(a) a violent death event, (b) the moment of death, and (c) the dead person, the funeral or grave.

Psychological death includes drawings of:

(d) the emotional reaction to death, (e) thoughts and anxieties associated with death, and (f) the notion of emptiness.

Metaphysical death includes drawings of:

(g) near-death experiences, (h) the mystery of death, (i) personification of death, and (j) heaven and hell.

Drawings were analyzed using a phenomenographic approach whereby 3 superordinate and 10 subordinate qualitative categories were created. Using deductive analysis, the researchers assigned each participant, using the combination of the two main sources of information at the same time (drawing and short written commentary), to one of the three superordinate categories (Biological concept of death in children, Psychological death, and Metaphysical death), and to the different subordinate categories described above (i.e. a – j). There were no discrepancies found with regards to the source of information (drawing, and written commentary).

Some drawings did not match the subordinate categories previously established. In these instances, an inductive approach included the generation of the psychological death superdordinate and subordinate categories with the addition of a new categories of experiences as outlined in Figure 1.

Figure 1.

Generation of categories.

Two authors (xx,xx) participated in the coding generation and modification. In cases of disagreement, a review of the literature and discussions were conducted to ensure that each new code matched the participant's experience. This strategy was used to maintain the rigor and trustworthiness of the findings. We utilized manual coding prior to employing thematic analysis (Braun & Clarke, 2006).

Results

The qualitative analysis identified one main category, Psychological death which was the most frequently represented category and depicted by the number of drawings. While there were no drawings which conveyed a Biological death or Metaphysical death concept, the drawings relate to the psychological death concept and only the subordinate category emotional responses of which six 9- year olds and seven 10-year-olds conveyed emotional responses. Further categories were developed to depict the themes emanating from the drawings: i. death anxiety; ii. loneliness and isolation; iii. sadness and boredom; and iv. positive experiences of the pandemic/lockdown.

Psychological Death Concept

Drawings in the super ordinate category represented emotions associated with dying such as fear, anxiety, and sadness. The most represented subordinate category was anxiety associated with death during the Covid-19 pandemic. The mental imageries subordinate category was developed by Tamm and Granqvist (1995) to express negative feelings associated with death. However, children expressed not only imaging anxieties but also their own fears through the drawings. Therefore, this subordinate category was replaced by death anxiety. None of the children identified in their drawing the subordinate category of emptiness, so this was not represented in this study. The verbal description of the drawing as well as drawer's gender and age are indicated by each drawing: pseudonym, gender, and age.

Death Anxiety

Several children of primary school age expressed their anxiety through the illustrations they drew and accompanying short description. For example, Josh aged 9, associated his anxiety with his parent's physical ailments (Figure 2):

‘My dad couldn't taste or smell so I fought [sic] he had covid. My mum, she has asma [sic] so it will be hard for her if she had covid.

Figure 2.

Josh, boy, aged 9 years.

Josh's picture indicated an emotional response because he mentioned being worried or fearful of his parents being ill with Covid. He also described not being able to play outside or see his family, which meant he felt imprisoned during the pandemic.

Others such as Tom expressed fears about the possibility of parents contracting Covid-19 and as a consequence was very worried that they might die:

‘I had a worrie that my mum or dad was going to get it [Covid] and die, or me, and I did not want that to happen [sic]’

(Tom, boy, aged 10 years)

While Tahlia was worried that older members of the family such as grandparents might die, or indeed friends, the toll of lockdown was seen as something that was never ending:

‘Yes I did and I still do. They mainly were about if any of my older family members were ill. Or my friends. And if were ever going to come out of lockdown.’

(Tahlia, girl, aged 10 years)

Death anxiety was prevalent among other primary school aged children, particularly concerns that they could themselves contract the virus or those they loved (Figure 3):

‘ I was worried that I would die from covid or someone I knew would die’

Figure 3.

Aeisha, girl, aged 9 years.

Similarly, Aeisha worried that Covid would result in either her or someone in her family becoming ill. This heightened anxiety was also shown by three of descriptive words, which were ‘worried,’ ‘nervous,’ and ‘anxious.’ Something more about the picture – 3 happy faces a huge gap in the middle and Aeisha hands spread out with distress and sadness with a vid separating her from those she cherishes.

‘I did have some worries of getting covid or anyone in my family.’

(Aeisha, girl, aged 9 years)

However, alongside death anxiety, and feeling isolated, there were other consequences associated with lock down for Simone:

‘[What affect me most during the pandemic] was being isolated and anxious of what may happen and I didn’t have any motivation to get up or do anything.’

(Simone, girl, aged 9 years)

As well as experiencing death anxiety, primary school aged children also demonstrated that the pandemic also brought about loneliness and boredom due to being isolated from friends and other family members.

Another subordinate category was created and this was named loneliness and isolation

Loneliness, and Isolation

Primary school aged children described the impact of lock down such as not as being able to see or have close contact with family or friends and engaging in play. Ollie, for example likened his sense of isolation to being imprisoned:

‘Imprisond because I coudn’t see my famaly, only my dad [sic]’

(Josh, boy, aged 9 years)

Others, such as Tahlia demonstrated the sense of isolation that was felt and which is exemplified in the following picture she drew (Figure 4):

Figure 4.

Tahlia, girl, aged 9.

Tahlia drew the world as a germ, with a rainbow bridging over to a cloud which hung over her and her family. She also used the words ‘anxious,’ ‘sad,’ ‘upset,’ ‘isolated,’ and ‘lonely’ to describe her feelings about the pandemic. This indicates an emotional response to death through a personification of the pandemic because she views it as having an objective to kill her and her family.

Similarly, Zainab expressed a sense of loneliness as a consequence of not being able to be with family members and friends (Figure 5):

‘ The thing that affected me most was not seeing my sister and friends. ‘I felt very lonely.’

Figure 5.

Zainab, girl, aged 9 years.

Zainab provided a very powerful statement of ‘No people allowed,’ which possibly represented her fearful emotional state. Rather than being a peaceful and calm situation, Zainab appeared to view the pandemic as an upsetting period which created division between loved ones. This interpretation is supported by her use of ‘scared,’ ‘sad,’ and ‘angry’ to explain her feelings and the large pool of tears at her feet in the picture. However, she also used the word ‘happy’ which appears to be an unexplained contrast to both her picture and the rest of her written explanation.

The illustrations provided by children as part of their primary school classroom-based activity, powerfully represent feelings that it wasn’t always possible to give a voice too, demonstrating that drawing pictures and illustrating the impact of an unpredictable situation is powerfully evoked with feelings of loneliness and isolation manifesting through drawings. Similarly, such means of exploring other feelings evoked as a result of Covid-19 also revealed children of this age experienced a great deal of sadness and boredom which was created as a third new subordinate category.

Sadness and Boredom

Notwithstanding the impact that lockdown had on children's death anxiety, loneliness and sense of isolation, many children were not able to attend school or mix with peers and play with friends. Consequently, many children expressed being sad, depressed or bored.

Indeed, the following narrative parts described by Ruby about her experiences (Figure 6):

Figure 6.

Ruby, girl, 9 years of age.

Ruby's picture shows three people separated by solid walls and the neutral expression on their faces, as well as on the sun in the sky, may indicate they are less than pleased at being parted. This is supported by the Ruby describing her feelings during the pandemic as ‘bored’ and ‘sad’. For Ruby, the separateness imposed by social distancing, meant that she was unable to engage with her peers in the usual way through play and was confined in such a space which resulted in boredom due to lack of interaction and activity with peers, resulting in boredom.

Sadness was a recurring theme throughout children's illustrations and most notably by Tom's picture (Figure 7):

Figure 7.

Tom, boy, 10 years of age.

Tom's picture of a sad, crying face suggests the pandemic caused a significant emotional response. The words he used to describe his feelings were ‘sad,’ ‘upset,’ and ‘depressed,’ and coupled with the relative size of the tears and sad mouth in his picture, Tom seemed to find life very difficult during the pandemic.

The data showed that all of the primary school children gave a largely emotional response to death, with a heightened awareness of death and emotional responses to it. Death anxiety was a significant theme which indicated children's awareness of their own mortality as well as the mortality of people around them, and this made them feel worried and fearful of death.

The pandemic also created feelings of loneliness and isolation. As the lockdowns continued, the majority of children felt separated from their friends and wider family, and some also mentioned not being able to see parents they did not live with. Again, this added to the sadness they felt during the pandemic because they weren’t able to socialize and play with others. This situation also led some children to feel bored because they were confined to their homes. However, there were also some positives which came from the pandemic and the lockdown, with children able to spend more time with their family.

Children's drawings and descriptive words matched and showed their levels of awareness of the seriousness of the pandemic. Children were sometimes worried about their own health but appeared to be more concerned about the health and wellbeing of those around them. They were also negatively impacted in terms of emotional and psychological health.

While the majority of children experienced a number of consequences during the pandemic, others were able to explore the more positive aspects of lockdown such as spending more time with family

Positive Experiences

Finally, another subordinate category was created which related to positive experiences during the Covid-19 pandemic. Indeed, while for many children lockdown meant having to spend time away from peers and friends, it also brought about the opportunity to spend more time with family as a result of parents having to work from home or being furloughed:

‘[S]ometimes I would feel happy because I got to see my family more than usual.’

(Zainab, girl, aged 9 years)

‘Without covid I woldnt [sic] have been able to conect [sic] with my family and get to know them better.’

(James, boy, aged 9 years)

‘ It wasn’t that bad for me because I got to bond with my house family.’

(George, boy, aged 10)

Moreover, for one child, the pandemic helped to normalize what was an unusual situation and for them had become the ‘new normal:

‘It felt crazy and a bit unusual, but it became more normal.’

(Sophie, girl, aged 10 years)

Most of the feelings of children were negative and focused on the difficulties of the pandemic, the worry, and the anxiety. However, there were some positive aspects of the pandemic where children identified the benefit of being able to spend time with family and this situation becoming more normalized. This has implications in the way in which children are often supported. While some children may well be caught up in the stressors of being confined to home during lockdown along with their care givers, for these children, it brought about a greater bonding experience and with it the opportunity to develop adaptive coping strategies and approaches as they become accustomed to a ‘new normal.’

Discussion

The main objective of this research was to explore children's experiences to and responses to the Covid-19 pandemic and understanding of death through drawings using a deductive and inductive qualitative analysis. Psychological aspects of death were the most frequently represented superordinate category in keeping with other studies (Bonoti et al., 2013; Tamm & Granqvist, 1995). While there were no biological or metaphysical representations, psychological conceptions were evident in the subordinate category of emotional responses. Modifications were performed on the original model of Tamm and Granqvist (1995) with emotional responses being a subordinate category to include further categories of death such as anxiety, loneliness and isolation, sadness and boredom and positive experiences.

As this study focused specifically on death and dying associated with Covid-19, other causes of death were not reported by children as in other studies (Bonoti et al., 2013; Panagiotaki et al., 2015).

While this study asked children to simply draw and describe their experiences and thoughts about Covid-19 they spontaneously brought up other themes related to the pandemic. Similarly, Idoiaga et al.'s (2020) study asked children to describe their thoughts and feelings about Covid-19. Their analysis classified children's responses to categories which related to the virus and others to the lockdown imposed by the pandemic. These findings support the assumption that meaning -making of Covid-19 involves not only the scientific but also social, cultural and emotional information (Joubert & Wasserman, 2020). Thus, children don’t just receive information about Covid-19 but directly experience many aspects of the health crisis, attributing it to social and emotional dimensions. Moreover, our results imply that in the midst of the pandemic children responded to the threat by conceptualizing Covid-19 as life threatening and associated with death and also through the changes that the pandemic imposed on their psychological and social world as suggested by other studies (Bonoti et al., 2021; ChacharI et al., 2021). Indeed, children spontaneously depicted a variety of psychological items with specific references to the illnesses, transmission, threat of death and the social restrictions imposed.

In addition, the drawings and associated short narratives which accompanied them suggest that children experience Covid-19 as a highly emotional phenomenon. Indeed, negative emotions were expressed by the children such as death anxiety, loneliness, isolation and sadness, indicating that children share similar emotional reactions in response to the pandemic as adults. Aside from these negative emotions, some children expressed positive emotions citing that they were able to spend more time with their family. One child described the pandemic situation as a ‘crazy and unusual’ one that one had to adjust to a ‘new normal’, sentiments often described in media accounts of Covid-19. However, it is not clear if this can be attributed to a tendency of children to produce happier pictures or to associate the positive emotion with Covid-19 (Idoiaga et al., 2020). Interviews would have permitted further exploration. What we do know is that children tended to verbalize the positive dimensions and graphically on the psychological ones. Indeed, the drawings facilitated the representation of emotional expression, in response to a psychologically laden situation, a strategy developed by these children for displaying emotions in their graphic representations (Bonoti et al., 2013).

The findings of this study has implications for raising awareness of the experiences of children of a pandemic and in supporting them in addressing certain risks in the future. Scaffolding children in coping such crises requires simple, clear and timely information to support their understanding alongside emotional expression and awareness of children age related needs. Indeed, while children may not be able to fully verbalize their emotions, and their expression of grief may differ to adults, the level of children's death awareness and anxiety is apparent and it is this which adults need recognize in order to adequately support a child.

Moreover, this study as in others (Joubert & Wasserman, 2020; Tamm & Granqvist, 1995) suggests that visual modalities can be a powerful and valuable tool in enabling expression in response to a crisis.

Limitations

This research has some limitations. First the sample size among primary school age children should be increased in future research by increasing the age range of children perhaps enabling a greater representation of the biological superordinate category. Second the convenience sampling adopted in this study may reduce the transferability of the findings.

It was not possible to interview the children due to social distancing measures which would otherwise have illuminated the illustrations and feelings of the children further. Future studies may benefit from exploring experiences of previous deaths as well as any differences mediated by cultural factors.

Conclusion

In conclusion, four central aspects of children's experiences were outlined in the present study and the reflections that children made about the pandemic: death anxiety, loneliness and isolation, sadness and boredom along with more positive responses. Further investigation is required to identify socio cultural variations impact on children's experience of the pandemic and their response to the crisis. The data derived from this study will be useful to parents, teachers and health professionals to support children during their development and in the intervention in dealing with death, dying and bereavement as well as psychological responses to crisis.

Footnotes

Acknowledgments

The authors would lie to acknowledge the children who took part in this study and the teaching staff who facilitated this.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

K. Jones

Author Biographies

K. Jones' research and teaching focus are on death, dying grief and bereavement, and end-of-life care across the life course. Kerry has published and presented her research on men's experience of loss, stillbirth neonatal death, parental bereavement, paediatric palliative care, brain injury, dementia, and suicide. More recently, her focus has turned to the impact of loss during the Covid-19 pandemic, in particular to men's grief, death anxiety among children and young people and healthcare workers' experiences. In addition to research and teaching at the OU, she was an Academic consultant on death and dying for programmes for national television: ‘A Time to Live’, BBC 2, which was broadcast in May 2017 and for BBC 3 radio.

Ben Hughes, after studying at university, has spent most of the last 20 years teaching in higher education. He has brought a multi-disciplinary approach to teaching across Health and Social Care and Nursing programmes. His PhD research focused on advance care planning with young people and he has a particular interest in the experiences and engagement of young people in their advance care planning process. He is also interested in research that explores and informs policy around vulnerable groups, marginalised populations, socially excluded populations, young people, health, and education. He is a member of the Lancashire and South Cumbria Children and Young People's Palliative Care Zonal Network and the Palliative and End of Life Care Research Group.

References

Anderson

J. L.

Ellis

J. P.

Jones

A. M.

(2014). Understanding early elementary children’s conceptual knowledge of plant structure and function through drawings. CBE Life Sciences Education, 13(3), 375–386. https://doi.org/10.1187/cbe.13-12-0230

Basu

(2021). Prioritize systemic approaches for young people’s mental health. Nature Human Behaviour, 5(October), 1264–1265. https://doi.org/10.1038/s41562-021-01185-7

Bonoti

Christidou

Papadopoulou

(2021). Children’s conceptions of coronavirus. Public Understanding of Science, 31(1), 35–52. https://doi.org/10.1177/09636625211049643

Bonoti

Leondari

Mastora

(2013). Exploring children’s understanding of death: Through drawings and the death concept questionnaire. Death Studies, 3(1), 47. https://doi.org/10.1080/07481187.2011.623216

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa

Byrne

Grace

(2009). Using a concept mapping tool with a photograph association technique (CoMPAT) to elicit children’s ideas about microbial activity. International Journal of Science Education, 32(4), 479–500. https://doi.org/10.1080/09500690802688071

Chachar

A. S.

Younus

Ali

(2021). Developmental understanding of death and grief among children during COVID-19 pandemic: Application of Bronfenbrenner’s bioecological model. Frontiers in Psychiatry, 12(September), 654584. https://doi.org/10.3389/fpsyt.2021.654584

Copper

Hards

Moltrecht

Reynold

Shum

McElroy

Loades

(2021). Loneliness, social relationships, and mental health in adolescents during the COVID-19 pandemic. Journal of Affective Disorders, 289(June), 98–104. https://doi.org/10.1016/j.jad.2021.04.016

Doka

(1989). Disenfranchised grief: Recognising hidden sorrow. Lexington books.

10.

Doka

(2001). Disenfranchised grief: New directions, challenges and strategies for practice. Research Press Publishers.

11.

Dyregrov

(2008). Grief in children: A handbook for adults (2nd ed.). Jessica Kingsley Publishers.

12.

Dyregrov

(2015). Teachers’ perception of bereaved children’s academic performance. Advances in School Mental Health Promotion, 8(June), 187–198. https://doi.org/10.1080/1754730X.2015.1051888

13.

Farahi

Khalatbari

(2020). Effectiveness of acceptance and commitment therapy on the life expectancy, resilience and death anxiety in women with cancer. International Journal of Applied Behavioral Sciences, 6(3), 9–19. https://doi.org/10.22037/ijabs.v6i3.21470

14.

Ford

John

Gunnell

(2021). Mental health of children and young people during pandemic. BMJ, 372(June), N6. https://doi.org/10.1136/bmj.n614

15.

Green

Karafa

Wilson

(2021). Art therapy with grieving children: Effect on affect in the dual-process model. Art Therapy, 38(4), 211–215. https://doi.org/10.1080/07421656.2020.1823197 To link to this article: https://doi.org/Hards, E. et al. (2021) Loneliness and mental health in children and adolescents with pre-existing mental health problems: A rapid systematic review. British Journal of Clinical Psychology, pp. 1–22. https://doi.org/10.1111/bjc.12331

16.

Green

. (2020). Risks to children and young people during covid-19 pandemic. BMJ, 369. https://doi.org/10.1136/bmj.m1669

17.

Idoiaga

Berasategi

Eiguren

Picaza

(2020). Exploring children’s social and emotional representations of the COVID-19 pandemic. Frontiers in Psychology, 11(August), 1952. https://doi.org/10.3389/fpsyg.2020.01952

18.

Jones

Mallon

Schnitzler

(2021). A scoping review of the psychological and emotional impact of the COVID-19 pandemic on children and young people. Illness, Crisis & Loss, (November), 1–25. https://doi.org/10.1177/10541373211047191

19.

Joubert

Wasserman

(2020). Spiky blobs with evil grins: Understanding portrayals of the coronavirus in South African newspaper cartoons in relation to the public communication of science. Journal of Science Communication, 19(7), A08. https://doi.org/10.22323/2.19070208

20.

Kalantari

Yule

Dyregrov

Neshatdoost

Ahmadi

S. J.

(2012). Efficacy of writing for recovery on traumatic grief symptoms of Afghani refugee bereaved adolescents: A randomized control trial. OMEGA - Journal of Death and Dying, 65(2), 139–150. https://doi.org/10.2190/OM.65.2.d

21.

Kontoangelos

Economou

Papageorgiou

(2020). Mental health effects of COVID-19 pandemia: A review of clinical and psychological traits. Psychiatry Investigation, 17(6), 491–505. https://doi.org/10.30773/pi.2020.0161. Epub 2020 Jun 15. PMID: 32570296; PMCID: PMC7324731.

22.

Menzies

R. E.

Menzies

R. G.

(2020). Death anxiety in the time of COVID-19: Theoretical explanations and clinical implications. The Cognitive Behaviour Therapist, 13(June), 1–24. https://doi.org/10.1017/s1754470x20000215

23.

Panagiotaki

Hopkins

Nobes

Ward

Griffiths

(2015). Children’s and adults understanding of death: Cultural and developmental influences. Journal of Experimental Child Psychology, 33(1), 31–44. https://doi.org/10.1111.bjdp.12064

24.

Schuurman

(2015). Never the same. Coming to terms with the death of a parent. Springer.

25.

Selman

L. E.

Sowden

Marshall

Chamerlain

Offman

J. K.

(2020). ‘Bereavement support on the frontline of COVID-19: Recommendations for hospital clinicians. Journal of Pain and Symptom Management, 60(2), e81–e86. https://doi.org/10.1016/j.jpainsymman.2020.04.024

26.

Sowden

Selman

Borgstrom

(2020). ‘Saying goodbye during COVID-19: UK media representations of relatives’ experiences of end of life, grief and bereavement at the peak of the pandemic. Unpublished. Available at: https://www.ccscheme.org.uk/ultrasite/why-is-this-important/.

27.

Tamm

M. E.

Granqvist

(1995). The meaning of death for children and adolescents: A phenomenographic study of drawings. Death Studies, 19(August), 203–222. https://doi.org/10.1080/07481189508252726

28.

Varma

Junge

Meaklim

Jackson

M. L.

(2021). Younger people are more vulnerable to stress, anxiety and depression during COVID-19 pandemic: A global cross-sectional survey. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 109(July), 110236. https://doi.org/10.1016/j.pnpbp.2020.110236

29.

Webb

N. B.

(2010). The child and death. In Webb

N. B.

(Ed.), Helping bereaved children: A handbook for practitioners (pp. 3–21). The Guilford Press.

30.

Webb

N. B.

(2011). Play therapy for bereaved children: Adapting strategies to community, school, and home settings. School Psychology International, 32(2), 132–143. https://doi.org/10.1177/0143034311400832.

31.

WHO (2020) Timeline of WHO’s response to COVID-19. https://www.who.int/news-room/detail/29-06-2020-covidtimeline.