Emotional and behavioral outcomes among youths with mental disorders during the first Covid lockdown and school closures in England: a large clinical population study using health care record integrated surveys

Social Psychiatry and Psychiatric Epidemiology https://doi.org/10.1007/s00127-023-02517-w RESEARCH Emotional and behavioral outcomes among youths with mental disorders during the first Covid lockdown and school closures in England: a large clinical population study using health care record integrated surveys V. Parlatini1 · L. Frangou1 · S. Zhang1 · S. Epstein1 · A. Morris1 · C. Grant1,2 · L. Zalewski3,4 · A. Jewell4 · S. Velupillai3 · E. Simonoff1,4 · J. Downs1,4 Received: 16 February 2023 / Accepted: 6 June 2023 © The Author(s) 2023 Abstract Purpose Emotional and behavioral problems in children and young people (CYP) have increased over the pandemic. Those with pre-existing mental disorders are more vulnerable but have been understudied. We investigated emotional and behavioral outcomes in this population; differences across diagnostic groups; and social, educational, and clinical determinants. Methods We invited 5386 caregivers and CYP (aged 5–17) under child mental health services pre-pandemic to complete an online survey on CYP’s emotional/behavioral symptoms and pandemic-related circumstances, and integrated responses with clinicodemographic information extracted from electronic health records. We compared four parent-rated outcomes (total emotional/behavioral scores and emotional/behavioral changes as compared to before the pandemic) across the three most common diagnostic groups in our population (Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD) and emotional disorders (EmD)). We then estimated the association of clinicodemographic and pandemicrelated characteristics with emotional/behavioral outcomes. Results A total of 1741 parents (32.3%) completed the survey. Parents of CYP with ADHD or ASD reported more behavioral difficulties (t(591) = 5.618 (0.001); t(663) = 6.527 (0.001)); greater emotional deterioration (t(591) = 2.592 (0.009); t(664) = 4.670 (< 0.001); and greater behavioral deterioration (t(594) = 4.529 (< 0.001); t(664) = 5.082 (< 0.001)) as compared to the EmD group. Those with ASD and EmD showed more emotional difficulties than ADHD (t(891) = − 4.431 (< 0.001); t(590) = − 3.254 (0.001)). Across diagnoses, poor parental mental health and challenges with education were most strongly associated with worse outcomes. Conclusions Within our clinical population, CYP with ADHD/ASD were the most adversely affected during lockdown. Enhancing clinical service provision that tackles parental stress and supports education may help mitigate the impact of future restrictions. Keywords Children and young people · Mental disorders · Covid pandemic · Remote education · Survey · Electronic health records L. Frangou and S. Zhang have contributed equally to the study. E. Simonoff and J. Downs have contributed equally to the study. * V. Parlatini 1 Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London SE5 8AF, UK 2 Department of Epidemiology and Public Health, University College London, London, UK 3 Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK 4 National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK 13 Vol.:(0123456789) Social Psychiatry and Psychiatric Epidemiology Introduction The Covid-19 pandemic has changed many aspects of the lives of children and young people (CYP) globally. Since the outbreak, the government of the United Kingdom (UK) has implemented a series of national lockdowns during which workplaces and community spaces were closed (Supplementary material, Sect. 1.1, and Fig. S1 for timeframe). Schools were also closed to pupils, unless considered vulnerable or children of keyworkers, and education was provided remotely. Although schools gradually reopened from June 2020, disruption has continued due to ongoing restrictions and local outbreaks. Quarantine measures also meant a rapid re-configuration of Child and Adolescent Mental Health Services (CAMHS), which initially suspended most routine in-person appointments to focus on emergency work and/or moved to online appointments. Concerns have grown regarding the impact of prolonged social distancing measures and school closure on the mental health of previously healthy CYP, as demonstrated by the world-wide increased rates of depression, anxiety, inattention, problematic eating and alcohol and cannabis use [1–4]. This increase has been particularly evident during the first period of lockdown [5]. Disruption of routines, family and peer relationships, education, and support from services were identified as risk factors [6, 7], while a supportive network and adaptive coping strategies as protective factors [4, 6]. There have been fewer studies on CYP with pre-existing mental disorders but the existing ones mostly reported a negative impact, with worsening of preexisting symptoms and/or emerging of new complaints, which they linked to their vulnerability and pandemicrelated reduced support from services [8–12]. However, other studies did not observe worsening but stable or improved symptoms [13–15], which suggests that distinct clinical populations may be differentially affected according to diagnosis, socio-demographic characteristics, and pandemic-related factors. Most prior studies investigating the effects of lockdown included mixed clinical samples [9, 13, 16] or only CYP with a specific diagnosis [8, 12, 17]; and the majority of them focused on neurodevelopmental disorders. Thus, it is unclear whether CYP with distinct diagnoses may have been differentially affected. Further, prior studies including clinical samples reported that age, parental mental health, and financial challenges were associated with worsening of CYP’s symptoms [9, 12, 17]. However, other potential contributing factors, such as ethnicity, housing adequacy, and the type of restrictions, were less investigated. Finally, the relationship between remote education experience and mental health in CYP with pre-existing mental disorders has received limited attention [18, 19], thus the impact of changes in education 13 provision in this vulnerable population is unclear. Addressing these questions is of importance as it may guide policy and clinical practice, and thus help mitigate the effects of this pandemic and inform the response to any future ones. For instance, child mental health services are still unclear about how to organize their limited resources, as there is considerable uncertainty over which diagnostic groups have been most affected; what pre-Covid sociodemographic and pandemic-related contextual factors conferred most risk; and what was the impact of changes in education provision. This study aims to address these questions and is part of a larger clinical population-based prospective cohort study, which survey (...truncated)