Abstract
The mental health impact of the coronavirus disease 2019 (COVID-19) pandemic on PK–12 youth is likely an urgent and enduring concern, yet research on this topic is still emerging. To synthesize current knowledge, the researchers conducted a systematic review of empirical studies exploring the mental health impacts of COVID-19. Five themes emerged across 104 included studies: (a) the pandemic proved widely disruptive to PK–12 youth; (b) there was a clear connection between the mental health of caregivers (e.g., parents) and children; (c) the pandemic broadly increased levels of stress, anxiety, and depression in PK–12 youth; (d) students were particularly affected on the basis of age, gender, race/ethnicity, socioeconomic status, and previous mental health or disability diagnosis; and (e) youth demonstrated negative and positive coping strategies and even saw some positive mental health outcomes during the pandemic. Implications for research, practice, and policy are discussed.
Keywords
Likely Mental Health Impacts of COVID-19 on PK–12 Students
Preexisting literature suggests that the emotional well-being of PK–12 students has been affected by COVID-19. To explore this we drew from research related to the mental health challenges associated with school closures during natural disasters and the psychological impacts of quarantine.
Mental Health Challenges During Natural Disasters
After Hurricane Katrina, nearly 200,000 Louisiana students from kindergarten through 12th grade were displaced (Jaycox et al., 2007), and an estimated 34% experienced symptoms of posttraumatic stress disorder (PTSD) or depression (Katoaka et al., 2009). Students commonly navigated secondary stressors such as separation from family or friends or parental unemployment (Overstreet et al., 2010). Such stressors often compound emotional distress related to a traumatic event and may manifest in disengagement from school (Sims et al., 2015), disruptive behavior (Coombe et al., 2015), or substance abuse (Brock & Cowan, 2004). When students returned to school, there was often high demand for mental health support, particularly in higher poverty contexts (Madrid et al., 2008). Compounding this increased demand, educators across the PK–12 spectrum reported higher levels of emotional distress when they returned to work (Burnham & Hooper, 2012). Taken together, this suggests that schools might expect an increased demand for mental health support during and after COVID-19 with an educator workforce that is similarly overwhelmed.
Psychological Impact of Quarantine
Brooks et al. (2020) reviewed research on the psychological impacts of quarantine and found that it was associated with feelings of anxiety, exhaustion, and demotivation, which could persist after quarantine has ended. Quarantining can also negatively affect resilience and relationships, and research has shown that students who experienced quarantine following a natural disaster were more likely to show symptoms consistent with PTSD (Sprang & Silman, 2013). Although the majority of U.S. PK–12 students have now returned to in-person instruction, there was considerable variability at the start of the 2020–2021 academic year, with some remaining fully remote (Hoffman et al., 2021), with corresponding mental health consequences (Duckworth et al., 2021). Regardless, all students likely experienced some level of mandated quarantine (Stevens, 2020) and may have lingering distress as a result.
Particularly Affected Student Groups
It is important to understand developmental differences between children and adolescents when considering how they experience stress. Preschool-aged children may show regression in previously learned behaviors, while elementary children might present as more easily agitated (Murray, 2010). Adolescents may show increased difficulty concentrating, poorer school performance, and higher rates of school absenteeism (Jaycox et al., 2006). Furthermore, research suggests that quarantine might be particularly disruptive for adolescents, who tend to particularly need interaction with peers to support mental well-being (Brooks et al., 2020).
Students with existing mental health challenges may experience an increase in maladaptive symptoms that adversely affects social and academic functioning (Powell & Bui, 2016). Moreover, students with physical and cognitive disabilities may experience elevated symptoms associated with their disabilities or have difficulty adhering to safety protocols (Peek & Stough, 2010). Furthermore, students with existing substance abuse issues may see their addictions amplified (Overstreet et al., 2010).
The experiences of families who were directly affected by COVID-19 can have profound and direct consequences for students. Comer et al. (2010) explained that a child’s mental health tends to be negatively affected by familial experiences like job loss, food insecurity, and physical health challenges. Moreover, parent and child well-being tends to be correlated, and parental capacity to meet the mental health needs of their children can be compromised in the wake of a disaster (Lowe et al., 2012).
The pandemic has had a disproportionately negative impact on students of color and students living in poverty (Naff et al., 2020), including higher hospitalization rates and exposure to COVID-19-related environmental stressors (Centers for Disease Control and Prevention, 2020). Additionally, undocumented students may experience particular stress during the pandemic because of its impact on their financial security (Enriquez et al., 2021). Only approximately 20% of low-income youth received the mental health support they needed in the year following Hurricane Katrina (Madrid et al., 2008), further emphasizing the need to prioritize this during and after the pandemic.
The Need for Mental Health Supports in Schools During COVID-19
Schools play an essential role in the psychological, social, and academic development of children (Fazel et al., 2014) and employ the largest number of youth mental health providers (Jaycox et al., 2006). This is perhaps why approximately 80% of school-aged children with mental and behavioral health needs rely on school-based services (Masonbrink & Hurley, 2020). Research suggests that schools are often the first institutions to open after a natural disaster (Overstreet et al., 2010), which places them in a position to address immediate trauma (Jaycox et al., 2006). A lack of adequate support for children’s mental health can lead to attention difficulties, behavioral concerns, and lower academic achievement (Powell & Bui, 2016). In a mixed-methods study by Savitz-Romer et al. (2021), school counselors reported adapting their practices to meet the needs of their students during COVID-19 and that it was more important than ever to focus their energy on student mental health.
Research suggests that students need emotional support during online learning (Literat, 2021; Kim et al., 2021). Early identification and interventions for mental health concerns can therefore lead to higher academic and social success, as well as less psychological distress (Naff et al., 2020). Concurrently, it is important to be mindful of how the pandemic has affected the mental health of educators, who have reported navigating their own emotional exhaustion while attending to student needs (Collie, 2021). Considering the imperative role that schools play in supporting students socially and emotionally, disrupted access to school-based providers has likely exacerbated the deleterious mental health impacts of the pandemic.
Purpose Statement and Research Questions
It is clear that COVID-19 has likely affected the mental health of PK–12 students in acute and enduring ways, but research in this area is still emerging. In this paper, we discuss the results of a systematic literature review focused on empirical studies exploring the apparent impact of the pandemic on the mental health of PK–12 students. Our purpose is to aggregate key findings that inform the work of PK–12 educators, mental health providers, and policy makers and to identify future research opportunities. Two research questions guided our review:
Research Question 1: How has the COVID-19 pandemic affected the mental health of PK–12 students?
Research Question 2: Which students have seen their mental health particularly affected during the COVID-19 pandemic?
Method
We conducted a systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Moher et al., 2009), searching PsycInfo, CINAHL Complete, Education Research Complete, ERIC, Psychology and Behavioral Sciences Collection, Social Sciences Abstracts, and Social Work Abstracts after using exemplary studies to develop search terms. Table 1 summarizes keywords and Boolean operators used for the search, which included gray literature and international studies.
Search Terms
Selection Process
Four researchers reviewed titles and abstracts of 550 studies published by December 11, 2020, marking articles for exclusion that were not (a) related to mental health, (b) related to COVID-19, (c) related to PK–12 school-aged youth outcomes, (d) empirical studies (including research questions, methods, and findings), and (e) written in English. On the basis of these criteria, the research team identified 76 relevant studies, divided them for full review, and excluded 35 by consensus decision. This process also included a quality appraisal using the Mixed-Methods Appraisal Tool (Hong et al., 2018). Articles scoring 3 on a 5-point scale were rated as “medium” quality, while those rated 4 or 5 were rated “high” quality. Any article scoring less than 3 was excluded.
We then replicated the first literature pull on May 12, 2021, resulting in an additional 532 studies divided evenly for title and abstract review. We discussed articles for which inclusion or exclusion was ambiguous and came to a consensus on 103 additional studies for full-text review. After replicating the first round process, we eliminated 40 additional articles, ultimately including 104 studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram (Figure 1) depicts the combined search process.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart.
Of the resulting articles, 26.0% were from the United States, 22.1% were from China, and 29.8% were from European countries (primarily Italy and the United Kingdom). Although most studies included more than one mental health focus, anxiety (47.1% of studies) and depression (44.2% of studies) were most commonly explored. The vast majority (91.3%) used survey or questionnaire methods for data collection. Full frequencies are included in Table 2.
Frequencies
Most studies included more than one mental health focus.
Table 3 offers key information about the studies included in the systematic literature review that informed our findings section. This includes details about the sample, date and methods of data collection, measure(s) used, mental health focus area(s), and quality appraisal results. Researchers reviewed articles carefully and met monthly over approximately 1 year to determine emergent themes, as discussed in the following section.
Included Studies
Note. ADHD = attention-deficit/hyperactivity disorder; ASD = autism spectrum disorder; CDC = Centers for Disease Control and Prevention; COVID-19 = coronavirus disease 2019; ED = emergency department; HIV = human immunodeficiency virus; NDD = neurodevelopmental disorder; OCD = obsessive-compulsive disorder; ODD = oppositional defiant disorder; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress syndrome; TD = typically developing.
Findings
There were five themes that emerged from the literature. Theme 1 highlighted the disruptive nature of COVID-19 on the lives of PK–12 students, including the corresponding mental health impacts. Theme 2 explored the connection between caregiver and student mental health. Theme 3 revealed the broad mental health impacts of the pandemic on PK–12 students. Theme 4 investigated student groups who saw their mental health particularly affected by the pandemic. Finally, Theme 5 explored resilience and coping during the pandemic, including positive mental health outcomes and strategies for supporting student mental health identified in the literature.
Theme 1: The Disruptive Nature of the COVID-19 Pandemic for PK–12 Students
A prevailing theme was the pronounced disruption of the pandemic on students’ daily lives, including the impacts on their physiological health and increased use of technology. Each of these disruptions corresponded with impacts on student mental health.
Disruption to Daily Life and Routine
Adolescents in Magson et al.’s (2021) study reported lower life satisfaction during lockdown if they strictly adhered to stay-at-home orders rather than leaving their homes periodically. Buzzi et al. (2020) similarly found that the overall concern of Italian teenagers in their study increased during lockdown orders, and decreased after the restrictions were loosened. Raviv et al. (2021) found that nearly all of the U.S. K–12 students and caregivers in their study reported prolonged disruptions to daily routines, including decreased peer support and academic enrichment. Similarly, Dewa et al. (2021, p. 668) found that 93.1% of their U.K. adolescent participants reported a “moderate to severe” impact on their routine. Research showed similar challenges following routine for pre-K (Di Giorgio et al., 2021) and elementary students (Cellini et al., 2021).
Disruption to Schooling
Research repeatedly showed that disruption to schooling was the highest concern for students. More than half of the Chinese children and adolescents in Duan et al.’s (2020) study reported that the pandemic had affected their learning. Similarly, Asanov et al. (2021) found that more than half of the Ecuadorian adolescents in their sample saw school disruption as their main concern. Students were particularly concerned with online learning, including time management and motivation (Scott et al., 2021) and lack of access to support from teachers (Magson et al., 2021). Li, Beames, et al. (2021) found that more than 95% of the Chinese secondary school students in their sample participated in online learning and most indicated a negative impact on their overall well-being, including increased loneliness. Haffejee and Levine (2020) found that stress associated with online learning was compounded by disrupted access to high-speed Internet or reliable devices.
Access to Information About COVID-19
Receiving ambiguous information about the pandemic was associated with greater fear in youth (Al Omari et al., 2020; Buzzi et al., 2020). Qin et al. (2021) found that students (M = 12.04 years) with fewer ways of finding information about the pandemic tended to have higher odds of distress. However, research suggests the age of the student relates to how they respond to information about COVID-19. For example, Nissen et al. (2020) found that elementary-aged students were old enough to understand media reports, leading them to worry about their family becoming sick or dying. Yue et al. (2020) found that media exposure was a risk factor for PTSD and anxiety in their sample of “school-aged” children but served as a protective factor against anxiety and depression for their parents.
Physiological and Mental Health Connection
There were several documented physiological impacts of the pandemic on PK–12 students, including diet (Sama et al., 2020; Scott et al., 2021; Zengin et al., 2021), weight (Adibelli & Sümen, 2020; Sama et al., 2020), and exercise (Scott et al., 2021). Research also showed that the pandemic exacerbated existing physiological and neurological issues in students, including headaches (Papetti et al., 2020) and epilepsy (Pasca et al., 2021). Li, Beames, et al. (2021) found that more than half of their participants reported worsening physical health during the pandemic, and 75% reported negative impacts on their mental health.
Sleep
A prominently documented physiological issue associated with COVID-19 that had an impact on student mental health was disrupted sleep patterns (Cellini et al., 2021; Di Giorgio et al., 2021; Liu, Tang, et al., 2021). Liu, Chen, et al. (2021) found that adolescents who slept less than 6 hours per day during the pandemic also reported higher levels of anxiety. Moulin et al. (2021) found that emotional difficulties in children were significantly associated with difficulty sleeping during the pandemic. Cellini et al. (2021) similarly found that lower sleep quality was associated with increased emotional difficulties and boredom. Disrupted sleep during the pandemic was also associated with lower optimism (Dewa et al., 2021). Contrarily, Penner et al. (2021) reported positive changes to sleeping routines in U.S. adolescents. Overall, Di Giorgio et al. (2021) concluded that the factor that had the biggest impact on the psychological well-being of the mothers and children in their study during lockdown was the quality of their sleep.
Increased Technology, Internet, Device, and Social Media Use
In Zengin et al.’s (2021) study, 71.8% of children reported increased Internet use. The vast majority (69.3%) of parents in Adibelli and Sümen’s (2020) study reported increased Internet use by their children, whose self-esteem and emotional well-being scores were negatively associated with higher Internet use. Duan et al. (2020) found that 29.6% of children and adolescents in their sample reported spending more than 5 hours online daily (an increase from prepandemic), with 6.03% reporting use to the point of Internet addiction. Increased Internet use was significantly associated with clinical depressive symptoms. Al Omari et al. (2020) similarly found that adolescents in their sample reported spending an average of 5.64 hours on the Internet prepandemic, which increased to 9.74 hours after its onset, and that depression, anxiety, and stress were significantly associated with the amount of time spent online.
Salzano et al. (2021) found that their adolescent sample spent an average of 6 hours per day on devices for educational purposes and 4 to 6 hours for recreation after the outbreak. Tso et al. (2022) found that the amount of time spent on devices for recreation increased, particularly for children 6 to 12 years of age, by approximately 1 hour after school closures. Additionally, they found that the emotional benefits of exercise were curbed by lowered physical activity associated with increased screen time. Parents in Omer et al.’s (2021) study considered increased screen time for their children to be “a matter of great concern” (p. 50). Chen et al. (2021) found an increase in Internet gaming addiction after the beginning of the pandemic, which was significantly correlated with rates of depression, anxiety, and stress. Moulin et al. (2021) found that increased screen time was associated with higher risk for depression, anxiety, inattention, and suicidal thoughts in children and adolescents.
Lockdown measures led adolescents in particular to increase their use of social media to stay connected with their peers (Buzzi et al., 2021; O’Brien et al., 2021; Salzano et al., 2021). Drouin et al. (2020) found that parents reported heightened social media use for their adolescent children and themselves, although this was less pronounced for higher socioeconomic status (SES) families. They also found that children with higher levels of anxiety used social media more frequently. Adolescents in Murata et al.’s (2021) study who spent more time on social media were more likely to report moderate to severe symptoms of depression and anxiety. Chen et al. (2021, p. 4) found a significant association between “problematic social media use” and stress, depression, and anxiety.
Cauberghe et al. (2021) found that adolescents with higher reported loneliness were more likely to use social media, but that use was not significantly associated with their levels of happiness, suggesting it was not a sufficient substitution for in-person interactions. Still, the authors noted that it tended to show positive coping effects for participants with higher reported initial levels of anxiety during the pandemic. Their findings suggested that peer connection through social media use was the most beneficial strategy for adolescents to emotionally self-regulate. Similarly, Li, Zhang, et al. (2021, p. 9) found that although increased screen time tended to be associated with psychological distress, this relationship tended to no longer be evident when screen time was used to connect with family and friends, and was instead associated with lower levels of loneliness and higher well-being. These findings suggest that social media use, although potentially detrimental to student mental health, can also be a positive coping strategy when used in moderation.
Theme 2: Connections Between Caregiver and PK–12 Student Mental Health
Similar to PK–12 students, caregivers saw their lives disrupted by the pandemic. This included loss of childcare (Jansen et al., 2021), stresses associated with employment disruptions (Akinsanya et al., 2021; Moulin et al., 2021), and concerns about the threat to their children and themselves (Bailey et al., 2021). Generally, caregivers who were more directly affected by COVID-19 were found to experience higher levels of parenting stress (Bentenuto et al., 2021) depression (Feinberg et al., 2021), and anxiety (Lee, Ward, Lee, et al., 2021), leading to harsher parenting practices (Chung et al., 2020; Feinberg et al., 2021). During the pandemic, the mental health of caregivers worsened when they encountered economic stress (Ares et al., 2021; Patrick et al., 2020; Tierolf et al., 2020), which corresponded to lower responsiveness to the mental health needs of children (Akinsanya et al., 2021). Caregivers felt overwhelmed by home schooling during lockdown, causing exhaustion, stress, and anxiety (Greenway & Eaton-Thomas, 2020; Patrick et al., 2020). Parents had to adjust to working from home or stop working completely to help take care of children, negatively affecting their mental health (Egan et al., 2021; Lee, Ward, Chang, et al., 2021; Spinelli et al., 2021). Additionally, research showed that the mental health of caregivers of children with special needs was particularly affected by the pandemic, including increased feelings of anxiety, depression, and defeat due to disrupted access to support (Tso et al., 2022; Willner et al., 2020).
Parent-Child Relationships
Research showed that challenges associated with lockdown, home-schooling, and economic stressors may have impacted the nature of interactions between caregivers and their children, both positively and negatively (Tang et al., 2021).
Negative Changes in Family Relationships
Pandemic-related stress led to a diminished ability by caregivers to respond to the emotional needs of children (Spinelli et al., 2021). Bérubé et al. (2020) found that this was particularly true of caregivers of teenagers. Caregivers in Chung et al.’s (2020) study also reported increased parenting harshness and decreased closeness with children. Raviv et al. (2021) found significant correlations between mental health decreases in caregivers and children.
Similarly, the lockdown led to perceived increases in family conflict (Li, Zhang, et al., 2021; Ravens-Sieberer et al., 2021; Raviv et al., 2021; Scott et al., 2021; Tardif-Grenier et al., 2021). Research showed that LGBTQ youth expressed particular concerns about conflict with parents, especially if they had not disclosed their gender identities or sexual orientations, leading them to be more likely to disregard physical distancing to meet social needs during lockdown (Nelson et al., 2020). Perceived increases in familial conflict was related to higher depressive symptoms and loneliness (Rogers et al., 2021) and increasing externalizing behavior (Ravens-Sieberer et al., 2021) in youth. Rogers et al. (2021) found that adolescents with depressive symptoms were more likely to perceive their social relationships as negative if they experienced family conflict during the pandemic. However, O’Brien et al. (2021) found that peer support buffered the effects of negative family relationships.
Lee, Ward, Chang, et al. (2021) conducted a cross-sectional survey in the United States, finding that one fifth of parents in their sample had spanked or hit their children, and had done so more often since the pandemic. Parent job loss and depression increased the likelihood of reported emotional or physical abuse and verbal aggression. Parents also reported that social isolation was a factor for their increased use of discipline, yelling, and leaving children alone or using physical punishment. Lawson et al. (2020) similarly found that job loss, depression, and prior maltreatment were associated with increased probability of physical and psychological abuse during the pandemic.
Positive Relationship Outcomes
Research also showed that lockdown measures provided an opportunity for increased family relationship building (Penner et al., 2021), leading to reduced psychosocial problems in children (Tso et al., 2022). Tierolf et al. (2020) found that PK–12 children who had previously experienced tension at home reported that conflict with caregivers and siblings had either maintained or decreased during the pandemic. Additionally, Buzzi et al. (2020) found that adolescents in their sample reported higher levels of communication with parents during the pandemic. Parents in Greenway and Eaton-Thomas’s (2020) study reported enjoyment in supporting home schooling during lockdown. Research also showed caregivers spending more time playing games with their children (Lee, Ward, Lee, et al., 2021) or eating meals as a family (Jansen et al., 2021). Children with strong familial ties saw their family as a source of support and comfort during COVID-19 (Cao et al., 2021; Penner et al., 2021). In addition, Lawson et al. (2020) found that strong family connections could mitigate the negative effects of caregiver job loss on the mental health of their children.
Caregiver Perceptions of Child Mental Health
Caregivers often reported that their children’s emotions changed since the pandemic (Ares et al., 2021; Raviv et al., 2021). Parents in Tambling et al.’s (2021) study reported that their children felt bored, afraid, depressed, and stressed. About 18% of parents in Sama et al.’s (2020) study reported that their children showed symptoms of depression and anxiety, and 75% reported increased signs of irritation, attributing the mental health changes to shifts in diet, sleep, and technology use. These findings suggest broad mental health impacts of the pandemic on PK–12 students, as explored in the following section.
Theme 3: The Broad Impacts of the COVID-19 Pandemic on PK–12 Student Mental Health
Research showed that the pandemic led to widespread increases in fear, anxiety, depression, loneliness, and behavioral issues in PK–12 students. In a longitudinal study, Hussong et al. (2021) found that although only 3.3% of young adolescents demonstrated “problematic symptoms” related to mental health before COVID-19, that number increased to 22.9% during the pandemic. Similarly, 47.5% of adolescents in Pisano et al.’s (2021) study reported experiencing some level of anxiety, 14.1% reported experiencing depression, and 26.7% experienced some level of general psychopathology. Dewa et al. (2021) also found that 30% of adolescents in their U.K. sample reported poor anxiety and worsening mood. Leeb et al. (2020) found that the number of mental health–related emergency department visits among U.S. children increased from March to October 2020 compared with the same time span in 2019. In a study by Qin et al. (2021) using survey data from 1.2 million Chinese students, 10.5% of children and adolescents reported psychological distress. The increased prevalence of youth mental health challenges during the pandemic was pronounced across contexts and cultures.
Depression and Suicidality
Between 14% and 33% of samples reported experiencing symptoms above the threshold for clinical depression (Asanov et al., 2021; Duan et al., 2020; Gazmararian et al., 2021; Pisano et al., 2021; Zhang, Ye, et al., 2020). Al Omari et al. (2020) found that 64.8% of their sample in Saudi Arabia experienced depression. Contrarily, Xiang et al. (2020) found that depressive symptoms were lower during lockdown compared with prepandemic in their elementary and adolescent-aged sample. Murata et al. (2021) found that 37% of the adolescents in their sample reported suicidal ideation and 1.7% had attempted suicide during COVID-19. Contrarily, Penner et al. (2021) found a decline in suicide rates during stay-at-home orders. O’Brien et al. (2021) found that sexual-minority adolescents were more likely to report suicidal ideation than cisgender youth.
Anxiety
Numerous studies noted increased anxiety. Almost half the adolescents from Al Omari et al.’s (2020) and Pisano et al.’s (2021) studies reported clinically relevant symptoms of anxiety. Other studies reported increased anxiety levels from pre-COVID-19 with prevalence rates around one fifth of the samples (Cheah et al., 2020; Waselewski et al., 2020). Researchers found that anxiety was related to negative attitudes about COVID-19 (Xue et al., 2021), negatively associated with happiness (Cauberghe et al., 2021), and positively correlated with depression (Duan et al., 2020). Additionally, youth reported higher anxiety than their parents (Cheah et al., 2020; Yue et al., 2020). Fear of COVID-19 also posed a unique mental health challenge for youth (Dewa et al., 2021; Di Giorgio et al., 2021; Ravens-Sieberer et al., 2021; Scott et al., 2021; Seçer & Ulaş, 2021; Shek et al., 2021). Students feared that contracting COVID-19 would be “extremely or very serious” (Gazmararian et al., 2021, p. 358). However, student concerns were often more focused on family members becoming ill rather than themselves (Gazmararian et al., 2021; Pisano et al., 2021).
Loneliness
Research clearly indicated that the pandemic-related social isolation had negative implications for youth mental health. Magson et al. (2021) found that isolation was the most distressing issue for adolescents in their sample. Similarly, 70.2% of adolescents in Salzano et al. (2021, p. 2) study reported that self-isolation “strongly influenced” their everyday life, whereas only 6.8% indicated that they were unaffected. They also widely reported feelings of fear, anxiety, and discouragement. Similarly, adolescents in Rogers et al.’s (2021) study considered social isolation to be “distinctly challenging” (p. 48). Oosterhoff et al. (2020) found that the majority of their U.S. sample indicated prosocial motivations for isolation, including social responsibility (78.1%) and not wanting to infect others (77.9%). The 57.8% who were motivated to protect personal health also tended to report higher anxiety. In addition to peers, students missed contact with caring adults (Idoiaga Mondragon et al., 2021). Although the mental health effects of social isolation may be particularly pronounced for adolescents, parents also perceived feelings of loneliness and missing peers in their pre-K through elementary-aged children (Egan et al., 2021).
Research indicated that social isolation had several corresponding mental health impacts, including greater conflict with siblings (Magson et al., 2021) and peers (Rogers et al., 2021), as well as depression (Chen et al., 2020; Rogers et al., 2021; Scott et al., 2021), stress (Cost et al., 2021; Li, Beames, et al., 2021; Tambling et al., 2021), and anxiety (Idoiaga Mondragon et al., 2021). Drouin et al. (2020) found that 86.2% of parents in their U.S. sample felt that social distancing measures had some negative impact on the mental health of their children. Social isolation was associated with stress and decreased mental health in two thirds of the child and adolescent participants in Cost et al.’s (2021) study. Similarly, Magson et al. (2021) found that feelings of disconnection were associated with increasing depressive symptoms, anxiety, and life satisfaction. Murata et al. (2021) found that loneliness was the most salient predictor of all psychiatric outcomes for adolescents.
Behavioral Issues
Research commonly showed behavioral changes during social distancing. For example, in Sama et al.’s (2020) study with 400 parents in India, a majority reported that their children quarreled more often and appeared more irritable, anxious, and depressed. Several studies found that children were much more likely to externalize behavior during the pandemic (Bentenuto et al., 2021; Feinberg et al., 2021; Ravens-Sieberer et al., 2021). This included “acting out, throwing objects, and hitting,” more commonly in boys than girls (Browne et al., 2021, p. 70). Moulin et al. (2021) conducted a longitudinal study assessing the emotional difficulties and symptoms of hyperactivity and inattention of children living in France during lockdown. One fourth of parents reported an increase in hyperactivity and inattention in their children. Although the preceding evidence of the broad mental health impacts of the pandemic is striking, research also highlighted students who will be in need of particular support, as discussed in the following section.
Theme 4: Students Whose Mental Health Was Particularly Affected by the COVID-19 Pandemic
Research noted differential mental health impacts by age, gender, race and ethnicity, culture, and SES, as well as considerations for students with existing mental health challenges or disabilities.
Age Differences
Although the pandemic has affected children and adolescents alike, research noted age differences. Cost et al. (2021) conducted a cross-sectional study with 1,013 parents of children aged 2 to 18 years and found that 66.1% of children aged 2 to 5 years and 70.2% of those aged 6 to 18 years reported deterioration across at least one domain (depression, anxiety, irritability, attention, hyperactivity, or obsessive-compulsive behavior), which was strongly associated with social isolation. Children younger than 5 years experienced the lowest rate of deterioration and the highest rate of improvement, indicating that the mental health impacts of the pandemic were strongest for school-aged children. Parents in Egan et al.’s (2021) study reported that younger children were significantly more likely to miss school than children older than 6 years, although they also had significantly lower scores for missing their friends than the older children.
Even with the ability to connect with others virtually, adolescents reported a decrease in emotional connection and support with friends, which was highly distressing (Magson et al., 2021; Mensi et al., 2021; O’Brien et al., 2021; Rogers et al., 2021). In Cost et al.’s (2021) study, adolescents were most likely to experience higher inattention, hyperactivity, obsession, and compulsion. Leeb et al. (2020) found that youth aged 12 to 17 years had the highest prevalence of mental health–related emergency department visits during the pandemic. Adolescents in Murata et al.’s (2021) study reported higher symptoms of depression, anxiety, PTSD, stress, and sleep problems than adults. The majority (75.9%) of the approximately 400 adolescents in Rogers et al.’s (2021) study reported feeling challenged by their inability to interact in person with friends and some family members, with corresponding significant increases in depression, anxiety, and loneliness.
Zhang, Ye, et al. (2020) found that anxiety symptoms were slightly higher for high schoolers (28.4%) than junior high schoolers (25.4%). Zhou et al. (2020) found that grade level was increasingly predictive of depression and anxiety in high school in their survey of more than 8,000 Chinese adolescents. Similarly, fourth-year high school students in Scott et al.’s (2021) qualitative study reported more concerns about the future than students in lower grades. Conversely, Gazmararian et al. (2021) found that high school students in lower grades reported higher incidences of feeling anxious, depressed, and stressed than students in higher grades.
Gender Differences
Research consistently showed that female students experienced higher levels of depression and anxiety than male students during the pandemic (Asanov et al., 2021; Chen et al., 2020; Gazmararian et al., 2021; Liu, Yue, et al., 2021; Magson et al., 2021; Pisano et al., 2021; Qi et al., 2020; Tardif-Grenier et al., 2021; Xiao et al., 2020). Male students in Scott et al.’s (2021) study were most concerned with issues related to academics, work habits, and their future, while female students reported the most concerns with friends and family. Sexual minority youth reported particular challenges with mental health (Hawke et al., 2021; Nelson et al., 2020; Scott et al., 2021). Similarly, O’Brien et al. (2021) found that sexual minority youth were at greater risk for disturbance in their overall well-being, social isolation from peers, disconnection from supportive resources, and confinement with unsupportive family members with corresponding increases anxiety, depression, and suicidal ideation.
Racial, Ethnic, and Cultural Differences
Research showed that youth from minoritized racial and ethnic groups are at increased risk for mental health issues related to COVID-19. Gazmararian et al. (2021) found that Black and Latinx high school students from Georgia were significantly more likely than White students to feel very or extremely worried about the pandemic. Similarly, Black, Latinx, and low-income families reported disproportionately high rates of COVID-19 stressor exposure in Raviv et al.’s (2021) study. Yet Black, Latinx, and low-income families also demonstrated resilience as they were less likely to report mental health concerns and more likely to report positive adjustments than White and more affluent households. Similarly, Penner et al. (2021) found that Latinx adolescents often demonstrated resilience during COVID-19, as collectivistic cultural norms may have served as protective factors.
Systemic racism also likely contributed to disproportionately high COVID-19 stressors for minoritized communities (Raviv et al., 2021). Cheah et al. (2020) explored the mental health impacts of pandemic-related racism toward Chinese Americans through a survey of 543 parents and their children. They found that 31.7% of parents and 45.7% of youth reported experiencing direct racial discrimination at least once online, and more than 50% of each reported experiencing in-person discrimination. Anxiety and depressive symptoms were significantly associated with all types of discrimination.
Socioeconomic Differences
Children from low-SES backgrounds may be at greater risk for experiencing psychological distress during the pandemic (Ravens-Sieberer et al., 2021). Research suggests that this may be related to greater challenges from lower-income families to meet the social and safety needs of children (Akinsanya et al., 2021). Students in Rogers et al.’s (2021) study from urban low-income households perceived greater overall impacts of COVID-19 on their lives. Qin et al. (2021) and Gazmararian et al. (2021) found that lower SES students reported higher levels of pandemic-related distress. Moulin et al. (2021) found that emotional difficulty, hyperactivity, inattention, and anxiety were more pronounced during the pandemic for students from lower SES backgrounds. Similarly, Al Omari et al. (2020) found that students from less wealthy families reported higher levels of depression, anxiety, and stress. In a study by Ares et al. (2021), low-SES parents were more likely than higher SES parents to report that their children were more demanding and experienced greater mood changes during social distancing.
Connection With Existing Disabilities or Mental Health Issues
Youth with preexisting mental health disorders may be at greater risk for depression, anxiety, PTSD, and suicide during the pandemic (Moulin et al., 2021; Nissen et al., 2020; Penner et al., 2021; Pisano et al., 2021; White et al., 2021). The majority of youth in Li, Beames, et al.’s (2021) study reported worsening mental health during the pandemic, including higher levels of depression, anxiety, technology use, loneliness, and distress, as well as less exercise and sleep. This was more pronounced for those with previous mental health diagnoses. Nonweiler et al. (2020) found that children with neurodevelopmental disorders, particularly autism spectrum disorder and attention-deficit/hyperactivity disorder (ADHD), showed particular increases in conduct and emotional regulation issues during the pandemic. In a similar study by Greenway and Eaton-Thomas (2020), U.K. parents who chose to home-school their children with special needs (primarily autism spectrum disorder and/or ADHD) reported worsening behavioral, emotional, and social problems associated with the disability. Research also showed that youth with ADHD experienced exacerbated inattention and hyperactivity (Werling et al., 2021), which was mitigated by maintaining routines (Becker et al., 2020) and healthy sleeping patterns (Çetin et al., 2020).
Trauma
Adolescents with histories of trauma may find those challenges compounded, particularly if they experienced a scarcity of accessible resources during the pandemic (Guo et al., 2020). In a cross-sectional study of Chinese adolescents during quarantine, Guo et al. (2020) collected data about their prior adverse childhood experiences. Those who had experienced maltreatment prior to COVID-19 reported higher levels of posttraumatic stress symptoms and anxiety during the data collection period. Encouragingly, Yang et al. (2020) found that psychological trauma caused by lockdown in the COVID-19 pandemic was mediated by resilience and positive emotion regulation of students.
Obsessive-Compulsive Disorders (OCD)
Nissen et al. (2020) found that children and adolescents with a diagnosis of OCD who had a connection to mental health support during the pandemic experienced less distress than those who did not, whereas social isolation worsened OCD behaviors. They also found that media coverage about COVID-19 increased anxiety in children with OCD who grew concerned that a loved one would become ill or die. In their adolescent sample, Seçer & Ulaş (2021) found that the effect of fear of COVID-19 on OCD symptoms was mediated by emotional reactivity, experiential avoidance, and depression-anxiety.
Theme 5: Resilience and Coping in Response to the COVID-19 Pandemic
Research showed that PK–12 youth used different coping strategies for dealing with the pandemic and its associated stressors, which were sometimes maladaptive but other times beneficial.
Negative Coping Strategies
Dewa et al. (2021) found in their mixed-methods study with U.K. adolescents that poor mental health was negatively associated with positive reframing and acceptance but positively associated with self-blame, substance use or abuse, venting, denial, and disengagement as forms of coping. Similarly, Duan et al. (2020) found that emotion-focused coping was associated with depression symptoms, and O’Brien et al. (2021) found that adolescents reported negative coping mechanisms, including alcohol, drugs, and social isolation.
Dumas et al. (2020) found in their sample of Canadian adolescents that the number of participants who used alcohol did not increase significantly from before to during COVID-19, but that frequency of use did (similar for cannabis use). Of the respondents indicating substance use during the pandemic, 49.3% did so alone, while 31.6% used substances during online video-conferencing with friends and 23.6% did so face to face despite social distancing requirements. Adolescents with higher reported fears of COVID-19 and depressive symptoms were significantly more likely to use substances alone.
Positive Coping Strategies
Several studies explored positive coping strategies and evidence of resilience in students in the face of pandemic-related adversity. For example, Zhang, Lee, et al. (2020) found that positive coping and resilience were associated with decreased symptoms of depression, anxiety, and stress for adolescents, stating that these strategies “can enhance mental health by promoting an individual’s sense of control over a chaotic environment” (p. 753). They also found that students from higher SES backgrounds were more likely to use positive coping strategies. Research showed that humor and problem-focused coping had positive mental health benefits for students (Cauberghe et al., 2021; Duan et al., 2020). Qualitative results from Dewa et al.’s (2021) study showed that participants used positive coping strategies such as self-distraction, talking to people, exercising, sticking to routine, and focusing on school work.
Positive Mental Health Outcomes
Although the literature overwhelmingly showed that PK–12 student mental health suffered during COVID-19, some studies highlighted positive outcomes. Students reported that they appreciated time at home with parents and having autonomy over their day (Rogers et al., 2021; Xiang et al., 2020). Research showed that virtual learning was sometimes associated with positive mental health effects. For example, peer stressors related to in-person instruction that were removed during virtual instruction sometimes corresponded with lower academic pressures (Penner et al., 2021; Xiang et al., 2020). Jones et al. (2021) found that removal of social pressure to conform to gender norms was especially important for gender diverse students.
Strategies for Addressing Mental Health Concerns During COVID-19
Many of the reviewed studies examined current practices for addressing mental health or made suggestions for interventions based on the findings. Because none were intervention studies, these suggestions should be interpreted with that limitation in mind.
Exercise
Physical exercise proved to be a protective factor against depression, anxiety, and psychiatric disorders during the pandemic (McGuine et al., 2021). Qin et al. (2021) found that students who exercised more reported lower psychological distress. Parents also reported that their children engaged in exercises such as yoga, bicycling, dancing, and running as positive coping strategies (Tambling et al., 2021; O’Brien et al., 2021). Lindell-Postigo et al. (2020) found that social isolation negatively affected adolescents by decreasing self-concept but that physical activity helped mitigate this impact. Similarly, Chen et al. (2020) found that physical exercise showed a significant negative relationship with depression and anxiety, suggesting a protective effect for youth mental health during the pandemic.
Strategic Use of Technology and Social Media
During the pandemic, youth sought information, social connection, and emotional support through social media (Drouin et al., 2020; Tambling et al., 2021; Tardif-Grenier et al., 2021). Students in Gazmararian et al.’s (2021) study reported that using social media helped them cope with stress. Zhou et al. (2020) found that using technology to stay informed about the pandemic was a protective factor against depression and anxiety. However, several studies found that excessive exposure to media coverage about the pandemic could be harmful for youth mental health (e.g., Ares et al., 2021; Duan et al., 2020; Magson et al., 2021; Yue et al., 2020).
Adaptation of Routine
Tambling et al. (2021) found that daily routine and engagement in new activities at home were helpful for stress management. Similarly, Spinelli et al. (2021) found that familiar routines were highly important for fostering positive interactions between parents and their children during the lockdown. Additionally, Tardif-Grenier et al. (2021) found that adolescents reported fewer sleeping problems, as well as lower depression and loneliness when completing schoolwork, serving as a protective factor against boredom and ruminating.
Creative Outlets
Studies showed several types of creative activities that children engaged in during the lockdown, including art, listening to music, reading, and playing freely (Idoiaga Mondragon et al., 2021; O’Brien et al., 2021; Tambling et al., 2021, Zengin et al., 2021). All were found to be related to emotional and physical benefits for children.
Social and Family Support
Qi et al. (2020) found that “adolescents with low social support showed 4.2 times greater risk of depression symptoms and 3.2 times greater risk of anxiety symptoms than those with high social support” (p. 517). Relatedly, Magson et al. (2021) found that life satisfaction during the pandemic was supported through social connections. Interestingly, Tierolf et al. (2020) found that decreased availability of support systems such as social workers or daycare led to some parents increasing their own emotional regulation and improving family connections. Research showed that early detection of potential mental health challenges in youth and offering corresponding support was beneficial in reducing severity (Qin et al., 2021; Ravens-Sieberer et al., 2021).
Conclusion
The themes across the synthesized literature illustrate how the pandemic has had broad and profound impacts on the mental health of PK–12 youth, making this an urgent priority for schools to address. The following section discusses the implications of these findings, including considerations for school-based mental health professionals and other educators as well as recommendations for future research in the emergent field of COVID-19-related mental health challenges in students.
Discussion
The literature is clear that the pandemic proved massively disruptive to youth and their families in nearly every facet of their lives, with corresponding physical (e.g., Adibelli & Sümen, 2020; Sama et al., 2020) and mental health consequences (e.g., Magson et al., 2021; Raviv et al., 2021). Furthermore, research offered a direct link between the mental health of caregivers and their children during the pandemic (e.g., Ares et al., 2021; Tambling et al., 2021), suggesting that any youth interventions should be mindful of the well-being of caregivers as well. Evidence of crescendoing anxiety and depression levels in students (e.g., Pisano et al., 2021; Rogers et al., 2021) suggests that schools not only need to be considerate of the extra psychological burdens their students may be experiencing but also ensure they are adequately staffed to meet those needs.
At the same time, the literature showed that adolescents seemed to be more susceptible overall to the mental health impacts of the pandemic (Cost et al., 2021; Magson et al., 2021; O’Brien et al., 2021), as were female students (Asanov et al., 2021; Chen et al., 2020; Gazmararian et al., 2021; Liu, Yue, et al., 2021; Xiao et al., 2020), and low-SES students (Akinsanya et al., 2021; Moulin et al., 2021), as well as students with preexisting disabilities (Greenway & Eaton-Thomas, 2020; Nonweiler et al., 2020), mental health disorders (Nissen et al., 2020; Penner et al., 2021), and histories of substance abuse (Dumas et al., 2020). Research also showed that communities of color navigated disproportionate exposure to COVID-19-related stressors (Cheah et al., 2020; Raviv et al., 2021). Encouragingly, although the literature showed some students engaging in maladaptive coping strategies (Dewa et al., 2021; Duan et al., 2020), they often found ways to remain resilient (Cauberghe et al., 2021; Duan et al., 2020; Zhang et al., 2020). School and district leaders must keep these trends in mind and remain committed to prioritizing student mental health as they work to regain some sense of normalcy in educational settings. Furthermore, researchers must continue to attend to the issues identified in the emerging literature on this topic. In the following sections we explore practical and theoretical implications.
Practical Implications
Although we will not fully understand the long-term impact for years to come, the synthesized literature to date offers important implications for educational practice and policy.
Teachers and School Leaders
Educators and district leaders should be mindful of the general prevalence of stress, anxiety, loneliness, behavioral issues, and depression brought on by the pandemic (Asanov et al., 2021). They should also recognize that student groups that have been particularly affected are also often the ones who experience enduring inequities that manifest in academic (Naff et al., 2021) and disciplinary disparities (Siegel-Hawley et al., 2019). The pandemic therefore presents a clear opportunity to prioritize the mental health of students, with particular attention to supporting the needs of marginalized student groups. Programs such as Positive Behavioral Interventions and Supports (Bal et al., 2012), restorative practices (Gregory et al., 2016), and trauma-informed care (Azeem et al., 2011) that help reduce exclusionary discipline (particularly for low-income students of color; Siegel-Hawley et al., 2019) could also prove useful in providing mental health support to students who have experienced renewed or compounding trauma during the pandemic. For example, restorative practices often focus on community building and emotional check-ins as a Tier 1 support for all students (Kervick et al., 2019). These strategies could prove advantageous in meeting the unique mental health needs of students during and after COVID-19. To that end, teachers and administrators should be mindful of how the pandemic has exacerbated behavioral challenges in students with prior diagnoses (Asanov et al., 2021) when making disciplinary decisions.
Although schools use school-based mental health providers (Jaycox et al., 2006) and often partner with community mental health supports (Naff et al., 2020), the preceding findings make it clear that the needs of students during and after COVID-19 may exceed the capacity of existing support systems. Thus, it will be critical for teachers to receive training in brief mental health supports like mindfulness (Belen, 2022) that help address the needs of students when counselors and other mental health personnel in schools are overwhelmed. However, training teachers to be prepared to offer these supports should not deter from granting students ready access to school and community-based mental health providers.
School-Based Mental Health Providers
School counselors, social workers, and psychologists receive graduate-level training in mental health interventions. However, they often spend their time focused on other tasks such as academic advising (Fitzpatrick, 2020), testing (Hilts et al., 2019), truancy prevention (Rhodes et al., 2018), and psychological assessment (Benson et al., 2019). Consequently, they commonly report not having sufficient time to meet the mental health needs of their students (Hilts et al., 2019). Considering the clear and widespread psychological impact of the pandemic on PK–12 youth and the disrupted access that students had to counseling services during school closures, principals and district leaders should protect the limited time of school-based mental health providers so that they can prioritize student social and emotional support. They can do this by not assigning extraneous duties and setting district expectations that prioritize time spent in direct student mental health support.
Policy Implications
School boards and state legislatures will need to support policies that produce comprehensive mental health programs in schools in the wake of the pandemic. This includes providing funding for additional school-based mental health support personnel as well as contracted partnerships with community mental health providers who can respond to referrals. These policy-making bodies can also set guidelines for how much time school-based mental health providers such as counselors are allowed to spend on tasks that are extraneous to direct student support. Schools will need these professionals to maximize their availability as students continue to navigate stressors associated with COVID-19. Furthermore, it will be imperative that district leaders implement policies centered on prioritizing issues related to mental health. This could include incorporating breaks into the school calendar for students and staff to focus on personal needs. It could also include aforementioned professional development for teachers focused on strategies for addressing the mental health needs of their students during and after the pandemic. Finally, districts should establish policies and practices that support the mental health of educators who are struggling with their own pandemic-related challenges while continuously meeting the needs students, potentially leading to compassion fatigue (Yang, 2021). Although this literature review focused on the mental health impacts of COVID-19 on PK–12 students, educators have undoubtedly been affected as well and merit similar attention.
Theoretical Implications and Recommendations for Future Research
COVID-19 provided a natural comparison point to measure how traumatic disruptions to schooling affected PK–12 students’ mental health. Correspondingly, the research covered in this review offered insights into the unique challenges associated with the pandemic either by comparing student outcomes prior to and after the outbreak (e.g., Magson et al., 2021) but more commonly to explore their experiences after its onset, thus limiting the ability to draw inferences about change over time. There is a clear need for additional longitudinal research spanning pre- and postpandemic to gain sufficient empirical evidence of the mental health impacts of COVID-19.
Additionally, the overwhelming majority of studies included in this review used survey methods, which is reasonable given the need to conduct rapid research at the onset of the pandemic. Future research should prioritize qualitative and mixed-methods studies that offer nuanced insights into the lived experiences of students and their perceptions of the impact of the pandemic on their mental health. This could also lead to deeper exploration of the experiences of students of color and low-income students who research suggests had disproportionate exposure to COVID-19-related stressors, but there is yet limited research evidence of how the pandemic has uniquely affected their mental health. Researchers should also seek opportunities to conduct experimental studies, not only by leveraging the pandemic as a natural comparison point, but also by exploring which interventions appear to be most beneficial for offering mental health support for students, particularly those most affected as identified in this review. Regardless of the methods used, it will be critical for researchers to continue to explore the mental health impacts of COVID-19, as they are likely to endure, and schools will be in need of evidence-based practices to respond in kind.
Limitations
In addition to the limitations discussed in the collected literature, there are a few others to note related to the methods used in this review. First, the final literature pull in this systematic review was conducted in mid-May 2021, excluding any relevant studies published since that date. Second, several studies in this review were based on parental perceptions of their children’s mental health. Although these offered valuable insights into the connections between caregiver and student well-being, their perspectives likely included some biases or inaccuracies. Third, the research included in this review skewed toward offering insights about the experiences of adolescent students, perhaps because of the overwhelming reliance on survey methods that were often administered with secondary students. There are therefore relatively little insights gleaned about the experiences of pre-K and elementary-aged youth outside of parent perspective. Finally, this review was intentional about excluding studies that did not focus specifically on PK–12 aged youth, omitting literature about the experiences of college students as well as PK–12 educators. Both of these populations are worthy of their own systematic literature reviews to offer evidence of how to best respond to their needs in unprecedented times.
Conclusion
Although the research on the mental health impacts of COVID-19 on PK–12 students is still emergent, the evidence presented herein is clear that the pandemic has proved massively disruptive and is likely to continue its influence for the foreseeable future. Those tasked with meeting this rising need will require an understanding of current trends that clearly illustrate the problem to properly ameliorate it. This review is intended as a starting point for future inquiry into this enduring issue, as well as an opportunity for policy makers and educational leaders to leverage empirical evidence when making decisions about how to best offer support. Perhaps most importantly, it is intended to guide the practice of school-based mental health providers as well as teachers who will be tasked with rising to the challenge of meeting this growing need in their students during and after COVID-19.
Footnotes
Authors’ Note
Ms. Williams, Dr. Furman-Darby, and Dr. Young are co–second authors.
Authors
DAVID NAFF is the associate director of the Metropolitan Educational Research Consortium and an assistant professor of foundations of education in the School of Education at Virginia Commonwealth University. His research focuses on equitable access and support for advanced coursework across K–12 education, supporting mental health in schools, and promoting research use through researcher-practitioner partnerships.
SHENITA WILLIAMS is a PhD candidate in educational leadership, policy, and justice at Virginia Commonwealth University and a school social worker for Henrico County Public Schools. Her research focuses on developing school-based mental health systems that meet the unique cultural needs of Black students.
JENNA FURMAN-DARBY is the research and evaluation specialist for Chesterfield County Public Schools in Virginia. Her research focuses on K–12 teacher preparation for using trauma-informed practices in K–12 schools and supporting research to promote equitable education and student success in her division.
MELISSA YEUNG is the student services coordinator for the School of Physical Therapy at Bowling Green State University. Her research focuses on equitable access to health care education for students across all education levels and supporting mental health in schools.