School Closures During the COVID-19 Pandemic: Psychosocial Outcomes in Children - a Systematic Review

Unintended Consequences of School Closures

The school environment provides by far more than mere education. Children rely on school as a “safe haven” nurturing them with safety, social activities, healthy meals, a place to establish positive relationships with peers and educators, and as a resource to strengthen competencies. In school children find opportunities for contribution and participation. While in quarantine, children struggle with emotional, social, and cognitive impairments due to psychosocial risk factors overweighing protective factors, which are represented by the social system “school”. The ongoing social deprivation and disruption from education, peer and teacher relations emphasizes the importance of school as an optimal environment in which children can flourish and attain competencies in order to master the challenges of life.

There is a growing body of research stating detrimental effects of school closures on children’s mental health and development (Araújo et al., 2021; Lee, 2020; Xie et al., 2020). Due to social isolation children experienced increased levels of loneliness by lacking contact with peers and teachers, which is normally catered by the school’s environment. For instance, in a rapid systematic review by Loades et al. (2020), a link between loneliness and depression among children and adolescents was found. Overall, the longer the duration of loneliness, the more the prediction for future mental health problems (Loades et al., 2020). Generally, mental health problems in children and adolescents show a poor prognosis and can result in conduct disorders, depressive disorders, and anxiety disorders (Ihle & Esser, 2002), which potentially threatens the academic (McLeod & Kaiser, 2004; Miller-Lewis et al., 2014), social and emotional functioning of a child (Thomson et al., 2019). Another important chief concern is the psychosocial impact of the domestic environment and the familial system children find themselves in during lockdown, while in-person instruction remains disrupted. While schools are closed, certain risk factors existent in a family environment may moderate psychosocial outcomes in children and influence their mental health as well as their development. In times of COVID-19, families are additionally burdened with drastic lifestyle changes, ranging from stressors such as job loss, reduced income, to fulltime childcare and home schooling, which decreases the level of family well-being and life-satisfaction among parents (Huebener et al., 2021). School closures also contributed to a greater level of family stress due to the balancing of employment demands such as working hours and home schooling. Female caregivers, especially, with school aged children bear the responsibility of childcare, experience the brunt of reduced working hours or job losses during the pandemic (Collins et al., 2021). As a consequence, these temporary stressors cascade down to children, which may show reciprocal and unintended effects in behavior, well-being, and mental health. Wickens et al. (2021) reported depressive symptoms to occur more likely in households with 4+ persons as well as in households with children age six to 12 years during lockdown. Clearly, the COVID-19 pandemic outlines the contextual risk families have to face, which impedes family functioning, adding a newfound struggle to family-life. Furthermore, certain environmental risk factors are pre-existent, highlighting inalterable parameters which shape the upbringing of a child, and at the same time shed light on a child’s socio-emotional development. Key findings from several studies suggested an association between poor mental health in a child and psychosocial risk factors, such as parental psychopathology (Hammen et al., 1990; Rutter & Quinton, 1984), interparental conflicts (van Eldik et al., 2020), low socio-economic status (SES) (Bradley & Corwyn, 2002), parental alcoholism (Raitasalo et al., 2019), poor housing quality (Rollings et al., 2017), or domestic violence (Holt et al., 2008) - to name a few of the most studied risk factors. Under COVID-19, children might be at the mercy of various risk factors with no social support outside of their familial microsystem. To sum it up, pandemic related school closures may exponentiate childhood adversity both by the loss of an essential social framework and the climax of familial and social difficulties while being in remote learning.

Situation Prior to and During the COVID-19 Pandemic: Results From Longitudinal Studies

Studies that examined the same children before and after or during the COVID-19 pandemic provide insight into the impact of the pandemic on children’s mental health. On the basis of the representative BELLA study, mental health issues related to psychosocial risk factors were found in German children prior to the pandemic (Otto et al., 2020; Ravens-Sieberer & Kurth, 2008; Ravens-Sieberer et al., 2015). According to the longitudinal data (n = 1.556 families) collected during the fourth BELLA follow-up study (2017), the prevalence of noticeable mental health issues in children was 9.9 % (Otto et al., 2020). Along with biological risk factors, psychosocial risk factors account for a great proportion in mental health in children. For instance, Wille et al. (2008) reported twice as many children (26 %) with mental health issues came from families with a low socio-economic status (SES) compared to children from households with high SES (10 %). Children with psychopathological burdened parents were more vulnerable towards mental health problems (38 %) vs. children with parents with no psychopathological burden (13 %) (Wille et al., 2008). The COVID-19 pandemic clearly enhances the severity of risk factors and the percentage of mental health issues in children. The representative longitudinal COPSY study conducted in Germany during the two waves of the pandemic in May and June 2020 (n = 1.586 families) (Ravens-Sieberer et al., 2021b) and in December 2020 and January 2021 (n = 1.625) (Ravens-Sieberer et al., 2021a) measured mental health and risk factors for mental health problems in children (age 7–17) during the pandemic. Data revealed 17.8 % of children in the first wave and 20.3 % of children in the second wave suffered from noticeable mental health problems (Ravens-Sieberer et al., 2021a). Specifically, children from families with a low SES, scarce living spaces, or from a migrant background were more severely affected by the burden of the pandemic in comparison to peers in low-risk environments (42.5% vs. 26.7%) (Ravens-Sieberer et al., 2021b). Parents of at risk reported more emotional symptoms, poorer mental health and conduct problems in their children. This illustrates existing disparities between individuals who are exposed to deprived environments and optimal familial environments. The mentioned findings before and during the pandemic are in line with results of non-representative studies (Gassman-Pines et al., 2020; Jiao et al., 2020; Ormel et al., 2012; Posserud & Lundervold, 2013).

The Interrelation of Development and Mental Health Within the School Setting

A positive school climate, a social support system by educators and peers promotes mental health in children and adolescents at risk (Plass et al., 2016). A good mental health status is intertwined with the successful accomplishment of developmentally appropriate tasks via developmental competencies. School provides a social context in which academic achievements, following rules for appropriate behavior and the development of positive peer relations are established (Masten & Coatsworth, 1995) as well as resilience –the ability to cope with adversity (Masten et al., 2005). Pandemic related school closures may invoke failures in developmental competencies and contribute to negative psychosocial, also emotional outcomes and psychopathology. In his Developmental Tasks Theory (Havighurst, 1956), Havighurst posited a successful accomplishment of developmental tasks aimed to prepare “subsequent levels of maturity and provides mental and socio-emotional tools to face life’s challenges” (Bowler & Weinraub, 2018, p. 596). According to this theory, school plays a key role during childhood. At school, children acquire social, emotional, and other skills (e.g. computational skills) via developmental tasks. The concept of developmental tasks approaches socio-cultural standards individuals should reach to guarantee social functioning. The positive impact of the school environment on children’s mental health, as well as their psychosocial and emotional development, is of importance. As a protective factor, the microsystem “school” can buffer risk factors threatening positive psychosocial outcomes and thus mental health.

Aims of the Present Systematic Review

According to current data and knowledge, no review has systematically collected quantitative data regarding pandemic-related school closures and psychosocial outcomes in children contingent on potential psychosocial risk factors; which may harm children’s mental health and their emotional and psychosocial development. The international prospective register of systematic reviews “Prospero”, has been checked for previous and ongoing systematic reviews which probe the interplay of pandemic- related school closures and psychosocial outcomes in children. Zhang et al. (2020) exclude impacts of pandemic-related school closures and instead take a wider look at mental health outcomes in children amidst COVID-19 and past pandemics. In another ongoing systematic review Packer et al. (2020) synthesize data of the impact of school closures on (1) physical and mental health in children and (2) differentiated between long-term and short-term effects. Apart from the Prospero research, a previous systematic review by Berger et al. (2021) was found on Pubmed. According to this systematic review, risk factors such parental mental health concerns were taken into account, resulting negatively in children’s mental health. For instance, if parents in quarantine showed clinical features of post-traumatic stress disorder (PTSD), children most likely developed PTSD symptoms as well. However, Berger et al. (2021) waive COVID-19 related school closures and refer to various infection outbreaks as SARS, COVID-19, Middle East Respiratory Syndrome (MERS) and influenza.

Therefore, the present study aims to systematically review quantitative observational studies (i) to present an overview of the interrelation between pandemic-related school closures and psychosocial outcomes in children, (ii) to examine whether the empirical evidence supports or contradicts the theoretical hypothesis.

Method

Process of Study Selection

The articles retrieved from the database search (n = 2,195) were exported into endnote and screened for duplicates using the remove duplicates function. A total of 456 duplicates were identified and removed. The title and abstract of the remaining 1,739 records were then screened according to the established inclusion and exclusion criteria, with a total of 47 articles that met inclusion criteria included. Of these 47 articles, eight articles were retained during the full-text screening process. The articles retrieved from databases (June and July 2021) and through other methods resulted in a total of 482 records, comprising of 419 records from both electronic database searches in June and July 2021 and 63 records from other search methods such as journals (n = 33) and a scientific platform (n = 30). Records obtained from journals (The Lancet, BMC Public Health) and the platform Science Direct were manually screened for duplicates as well as records found on electronic databases in July 2021. Additional studies were searched via the backward reference search. Ultimately, there were no additional eligible records found through reference lists of reviews and primary studies. The articles retrieved from the electronic database search in June 2021 (n = 355) were exported to Covidence (https://www.covidence.org) and automatically screened for duplicates. A total of 82 duplicates were identified and removed. In stage one of the selection process, title and - if available - abstract of the remaining 273 records were screened according to the pre-determined inclusion and exclusion criteria. Another 22 duplicate studies were removed manually from a total of 64 records generated on databases in July 2021. Ultimately, out of 315 records identified through electronic databases, 251 records were not relevant on review of the title and abstract and thus excluded. The remaining 64 reports were retrieved and assessed by examining the entire report carefully for eligibility. Based on titles and abstracts, a total of 64 reports met inclusion criteria, out of which 30 were randomly selected for further assessment of eligibility against inclusion and exclusion criteria by two independent researchers. Any disagreement regarding inclusion was discussed and resolved by consensus. To ensure reliability of the selection process Cohen’s Kappa was computed (κ= 0.84) indicating an almost perfect agreement on titles and abstracts of the selected studies between assessors (interrater reliability). Subsequently, the full text screening of potentially eligible primary studies was conducted by one reviewer and respectively decisions about their inclusion. The entire process of study screening and final inclusion, following the revised PRISMA statement (Page et al., 2021), is presented in a flow chart (Fig. 1).

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Figure 1.

PRISMA flow chart.

Of the remaining 64 references obtained from databases in June and July 2021, 14 did not include a population of subjects between age six and 13 or entirely included children with disorders such as autism; 13 reported irrelevant outcomes or measures; six were studies collecting only qualitative data; 14 were not relevant empirical studies (commentaries, letter to the editor); four were based on a wrong setting (returning to school), and finally three studies collected data from public authorities. In addition to the database identification, reports were searched in journals, one scientific platform and reference lists of a few reviews and primary studies. The search through other methods comprised 63 records, of which 14 duplicates were removed manually. A total of 42 reports were sought for retrieval and assessed for eligibility. None of the reports met the selection criteria out of various reasons presented in the PRISMA flow chart (Fig. 1).

Studies, which appeared to meet inclusion criteria were, i.e. one study by McKune et al. (2021) measuring psychosocial outcomes among K-12 students with a subsample of primary students in Florida, USA. This study was excluded, since depressive, anxiety, and OCD symptoms in children were rather associated with parental knowledge, attitudes, and practice towards COVID-19, than psychological characteristics of parents. Another excluded study by Monnier et al. (2021) used data from different child and adult cohorts generated by the French SAPRIS Project, measuring health, social interactions, and socio-economic characteristics of the general population during the COVID-19 crisis in France. In their study, Monnier et al. (2021) investigated the association between the mental health of children (age 8 to 9) and social characteristics of their families during school closure, which did not meet the present review’s pre-determined psychosocial factors and was therefore rejected. In a German nationally representative cross-sectional study by Calvano et al. (2021), the role of parental stress and mental health of parents for the pandemic-related occurrence and increase of adverse childhood events (e.g. violence, neglect, abuse against children) was analyzed; certainly with no further investigation on psychosocial health outcomes in children during school closure, which led to the exclusion of the study. In a nationally representative survey, Gadermann et al. (2021) probed the pandemic-related change of parent-child interactions within Canadian families. This cross-sectional study was excluded from reviewing, since Gadermann et al. (2021) put the focus entirely on the quality of parent-child interactions during the COVID-19 pandemic and ignored psychosocial outcomes in children as a potential result of parent-child interaction due to school closures.

Thus, the screening process resulted in a total of 10 studies included in this review (Cellini et al., 2021; Domínguez-Álvarez et al., 2020; Larsen et al., 2021; Lee et al., 2021; McMahon et al., 2021; Morgül et al., 2020; Moulin et al., 2021; Takahashi & Honda, 2021; Tang et al., 2021; Tso et al., 2020).

Results

Discussion

This systematic review is aimed to synthesize the literature examining pandemic-related school closures and emerging psychosocial outcomes in children contingent on psychosocial risk factors within the environment of families. It was assumed that implemented school closures enhance psychosocial outcomes in children, which consequently exert negative impacts on children’s mental health, as well as trajectories of psychosocial and emotional development. Findings support the interrelatedness of psychological difficulties in children and their primary caregivers as immediate socialization circle in the context of homeschooling. Across studies, children showed externalizing and internalizing symptoms referring to several common parent-related variables. Psychosocial variables identified in this review included: parental stress, psychological distress in parents with anxiety and depression, parent-child interaction, and parenting stress.

Unsurprisingly, both children and parents reported changes in distress during the period of school closure; changes in child well-being were directly and indirectly influenced by situational and permanent psychological properties of caregivers. Children experienced elevated levels of anxiety, depressive symptoms, negative emotional response, behavioral problems, and hyperactivity. These results are consistent with previous studies reporting higher levels of anxiety and depression in children during lockdown (Liu et al., 2021; Xie et al., 2020), as well as noticeable changes in children’s behavioral and emotional adjustment (Orgilés et al., 2020; Raviv et al., 2021; Tiwari et al., 2021). Parental mental health concerns and parental stress appeared to be associated with increased levels of emotional difficulties and hyperactive symptoms in children (Domínguez-Álvarez et al., 2020; Larsen et al., 2021; Moulin et al., 2021; Takahashi & Honda, 2021; Tso et al., 2020), which in turn may reflect children’s feeling of helplessness towards their unprecedented situation. Own negative emotional states, difficult behavior may be attempts of children to reduce negative effects of child perceived changes and inconsistencies in their caregiver’s behavior, interpersonal exchanges, and elevated stress levels of parents (Langrock et al., 2002) due to the pressure of lockdown and homeschooling.

With implemented school closures and other pandemic-related stressors, parents had to rapidly adapt to new daily routines, at-home education, full-time caregiving, and accordingly disrupted working hours or even job loss. Data from previous research confirm higher stress rates of parents coping with the new setting of distance-learning (Martinsone & Tzivian, 2021), and worsened parental mental health during quarantine (Furlong et al., 2021; Yamamura & Tsustsui, 2021). Interestingly, McMahon et al. (2021) found negative impacts on children’s mental health if parents were less able to support children’s learning during COVID-19 restrictions, which was mediated by parental psychological distress. Foremostly in homeschooling, children required more academic and emotional support; relied on their parents as educators, which may have been overwhelming to already overburdened parents. Consequently, it is to speculate whether children felt rejected, which was reflected in the worsening of children’s emotional and behavioral functioning.

Considering the role of mothers during school closures, results showed elevated levels of difficulties in children if mothers suffered from mental disorders (Cellini et al., 2021; Tso et al., 2020). The effect was less pronounced in the sample of Cellini et al. (2021). Compared to paternal psychopathology, a stronger association between higher rates of emotional reactions in children and poor maternal mental health was found (Tso et al., 2020). This finding may indicate children’s primary attachment to their mothers due to the biological bond. Children are particularly vulnerable to maternal psychological impairments (Goodman et al., 2011). In most cases, mothers shouldered the marked change of family routines and caregiving, which opened a discussion on gender gaps (Cheng et al., 2021). During lockdown, children’s vulnerabilities were aligned with mothers who showed difficulties in the regulation of emotions (Cellini et al., 2021). This observation was similar in an Italian sample with younger children (age 2 to 5) (Di Giorgio et al., 2021). It is possible that this review’s finding demonstrates children’s responsiveness to maternal irritability due to the reciprocal mother-child relationship (Kirby & Hoàng, 2018). Then again, Zreik et al. (2021) argued that “mothers with poor emotional regulation tend to identify their children as more problematic and symptomatic” (Cellini et al., 2021, p. 162). Interestingly, during school closure, child anxiety was not significantly affected by parental depression (Lee et al., 2021). Psychopathologies in children emerge over time as confirmed by longitudinal data from a 10- year- follow-up study (Nomura et al., 2002). In this study parental depression was proven as a strong risk factor for anxiety disorder in offspring (Nomura et al., 2002). Within the context of school closures, children were more likely to show impairments of emotional and behavioral functioning as a short-term reaction to parental depression (Morgül et al., 2020; Moulin et al., 2021; Takahashi & Honda, 2021; Tso et al., 2020). As synthesized from the literature, longitudinal data unexpectedly revealed lower odds of the link between parental depression and child maladjustment (Takahashi & Honda, 2021). In contrast, cross-sectional data of a French cohort study reported higher odds of the association between the exposure to a parent and child outcomes (Moulin et al., 2021). From a cultural point of view, it is possible that respond patterns differed in both cohorts. In Japan stigmatizing attitudes towards mental health disorders are more common than among Western countries (Griffiths et al., 2006). Bearing this in mind, parents of the Japanese cohort possibly feared the label “depression” and therefore withheld information on their (perceived) mental health status, affecting their children. On the other hand, higher odds ratios in the French cohort may have accounted for the conflictual environment of participants (Moulin et al., 2021).

With regard to parent-child interaction, results have demonstrated that the nature and a higher frequency of parent-child conversations about the disaster of COVID-19 were associated with less anxious and depressive symptoms in children (Tang et al., 2021). If children experienced quarantine negatively, they benefited from conversations with their parents resulting in fewer feelings of anxiety and depression (Tang et al., 2021). During adverse events such as the COVID-19 pandemic, involving widespread school closures, the separation from peers and educators, and the loss of learning activities, it is of utmost importance to discuss and explain the situation to children (Dalton et al., 2020). Children have more limited resources to understand the complexity of implemented restrictions and subsequent changes within their family environment; therefore, as a parent, it is crucial to ensure effective communication by providing honest information to a child (Stein et al., 2019). However, the finding by Tang et al. (2021) should be interpreted carefully. The aforementioned prevalence of children finding quarantine beneficial was relatively high compared to children disliking it. Furthermore, Chinese children growing up in a collectivist society may have responded in a more socially desirable manner according to the expected commitment towards the authority in parents (Lalwani et al., 2006). Results have shown that lacking recreational activities (e.g. physical activities and play), as well as lacking learning activities (e.g. scaffolded learning) during quarantine were associated with negative child outcomes (Tso et al., 2020). This finding is in line with studies reporting on sedentary lifestyles due to remote learning, which negatively impacted children’s mental health (Dunton et al., 2020; Xiang et al., 2020). Viewed in the light of school closures, there may be barriers to encouraging play and activities due to lacking peer contact and lower motivation in parents to engage playfully with their children. Research has shown that appropriate play and learning activities with parents and peers are an opportunity to foster the social-emotional, cognitive, language, and self-regulation skills that build executive function and a “prosocial brain” (Bodrova et al., 2013; Cheng & Mix, 2014; Hillman et al., 2014; Korczak et al., 2017; Lewis et al., 2000). The strain of distance-learning and isolation, less recreational time, less scaffolded learning through parents and educators may buffer the acquisition of social and emotional skills that are critical for academic success and positive engagement in life (Durlak et al., 2011).

The COVID-19 pandemic is an atypical scenario in which parental dispositional resilience and parental fear of future might be critical factors for child adjustment. Domínguez-Álvarez et al. (2020) found moderating effects of parental dispositional resilience and parental fear of future on the relation between child coping and psychological difficulties in children. For instance, when lower levels of parental dispositional resilience operated along with child disengagement strategies, negative child outcomes were observed; but in turn child engagement strategies produced positive child outcomes. This may seem a paradox; however, Domínguez-Álvarez et al. (2020) explained child coping strategies as compensatory actions to reduce toxic stress resulting in either positive or negative child outcomes when combined with parental factors. Coping strategies are primarily acquired through socialization processes. Literature shows that child coping responses are directly modeled by parent’s own coping, which again highlights the role of parents as socialization agents (Kliewer et al., 1996) in times of COVID-19 and beyond. In the context of school closures, parental resources appear to be overwhelmed and parents may not be aware or capable of adequate coping suggestions, which might result in negative child outcomes. Given this fact, parents are challenged to make an effort to improve their resilience skills to better cope with stress under adverse circumstances such as the pandemic.

To sum it up, this review’s findings relate to the results of the previous mentioned COPSY study (Ravens-Sieberer et al., 2021a; Ravens-Sieberer et al., 2021b): a worsening of children’s mental health, as well as their psychosocial functioning was observed across studies. Ultimately, this emphasizes the risk children have to face when exposed to unfavorable family environments.

Conclusion

In conclusion, this review provides an overview of specific family-related variables and psychosocial child outcomes during pandemic-related school closures. Furthermore, findings of this current review suggest that distance-learning showed an immediate impact on child well-being modeled by dyadic parent-child processes. Aside from risk factors, this review highlighted a few protective factors to help a child thrive under the atypical circumstance of pandemic-related school closures. How parents cope with the adverse situation of COVID-19 pandemic plays a crucial role in the social and emotional development of children, as well as children’s mental health. However, the parent-child dynamic is a complex interaction between a child and their caregiving environment. In a previous study by Raviv et al. (2021), findings underpinned the parent-child dynamic as a transactional process: children’s behavioral maladjustment during lockdown influenced parenting stress, which in turn affected parents’ “ability to regulate their own emotions” and thus “manage their children’s behavior” (Raviv et al., 2021, p. 7). This transactional mechanism may exacerbate children’s behavioral, as well as emotional difficulties and increase the risk for child maltreatment. Findings suggest that additional support should be targeted at children in vulnerable families to reduce the deepening of emotional, social, and psychological harm during school closures. From a developmental perspective, one should bear in mind that parenting cannot entirely satisfy socialization processes in a child’s life. In other words, school serves as another major agent of socialization, implementing essential learning and building relationships outside the family environment. In developmental stages of heightened sensitivity, the context of school helps children to build wholesome attitudes towards the self, to achieve personal identity, and gain independence from parents. In times of pandemic-related school closures, children may be deprived of these opportunities, which in conclusion highlights the unique role of the concept “school”. Globally, policymakers have come to terms that education is responsible for the economic and social progress of society. The thread of society’s development relies on well-balanced children and families.